Group Number. [Group Number] Original Effective Date: [Original Effective Date] GC-1 MONTHLY DUES/PREMIUMS SCHEDULE Refer to PART V. of this Contract for additional information pertaining to the payment of Dues/Premiums. The Employer will pay to Covered California for Small Business (CCSB) the following monthly Premiums: [Legal Name] [Group Number] Dues - Subscriber / Member Rates Region [Region] Age Category Premiums Age Category Premiums Age Category Premiums Age Category Premiums 15-15 [15] 28-28 [28] 41-41 [41] 54-54 [54] 16-16 [16] 29-29 [29] 42-42 [42] 55-55 [55] 17-17 [17] 30-30 [30] 43-43 [43] 56-56 [56] 18-18 [18] 31-31 [31] 44-44 [44] 57-57 [57] 19-19 [19] 32-32 [32] 45-45 [45] 58-58 [58] 21-21 [21] 34-34 [34] 47-47 [47] 60-60 [60] 22-22 [22] 35-35 [35] 48-48 [48] 61-61 [61] 23-23 [23] 36-36 [36] 49-49 [49] 62-62 [62] 24-24 [24] 37-37 [37] 50-50 [50] 63-63 [63] 25-25 [25] 38-38 [38] 51-51 [51] 64-plus [64-120] 26-26 [26] 39-39 [39] 52-52 [52] HEALTH DUES/PREMIUMS An Employee’s Premiums will automatically increase the first day of the plan year following the plan year in which an age change that moves the Employee into the next higher age category occurs. Dependent age changes will similarly affect the portion of the premium attributed to them, if any. The Premiums set forth above do not include coverage for dental (other than pediatric dental benefits), vision (other than pediatric vision benefits), or life insurance when applicable. The Employer must be located in, and the Employee and all Dependents must live, reside, or work in, the Service Area to be eligible for this health plan.
Group Number. Employer: Policy Holder’s Name: Policy Xxxxxx’s date of birth: Policy Holder’s Address: Customer Service Phone Number on Insurance Card: PLEASE REVIEW FEE AGREEMENT CAREFULLY: I understand that payment is due in full at the beginning of the evaluation process. I understand that my insurance may not pay for Xx. Xxxxxx’ services and I agree to pay for the services, regardless of what insurance pays. I authorize the release of any information necessary to process the claim with my insurance. I agree to notify Xx. Xxxxxx of any changes in my insurance coverage.
Group Number means the group number for the insured. The label for this number is “RxGRP.”
Examples of Group Number in a sentence
Member Name: Group Number: Member ID: Address: City: State ZIP: Phone #: Account Holder Name(s): Phone #: Account Holder Address: ____________________________________________________________ Full Name of Bank or Financial Institution: Bank Account Number: 🞎 Checking OR 🞎 Savings Routing Number: I have read and accept the above agreement.
More Definitions of Group Number
Group Number. 970743 & 970744 Original Effective Date: July 1, 2013 GC-1 IMPORTANT No Member has the right to receive the Benefits of this Contract for Services or supplies furnished following termination of coverage, except as specifically provided in the Group Continuation Coverage and Extension of Benefits sections of the Evidence of Coverage and Disclosure Form. Benefits of this Contract are available only for Services and supplies as included in the applicable sections of the Evidence of Coverage and Disclosure Form, furnished during the term the Contract is in effect and while the individual claiming Benefits is actually covered by this Contract. Benefits may be modified during the term of this Contract under the applicable section in Part V. Dues, Part VIII. General Provisions, D. Changes: Entire Contract, or upon renewal. If Benefits are modified, the revised Benefits (including any reduction in Benefits or the elimination of Benefits) apply for Services or supplies furnished on or after the effective date of the modification. There is no vested right to receive the Benefits of this Contract. SHIELD SPECTRUM PPO SAVINGS PLAN
Group Number. Group Name: Sub-Group Names (if applicable): Requested Effective Date: Renewal Date: Amount Paid By Employer For: Employee Coverage: Dependent Coverage: Definition Of Subscriber (for example: “all full-time employees, all full-time and part-time employees.”): Can Employees Opt-out-of Dental/Vision Plan?: ☐ Yes ☐ No Is There A Section 125 Plan In Place?: ☐ Yes ☐ No Is This A Management Carve-Out? ☐ Yes ☐ No Number of Eligible Employees: Estimated Number of Employees Enrolling: Benefit Year: ☐ Calendar Year ☐ Policy Year ☐ Other: New Employee Waiting Period (check one): Waived At Initial Enrollment?: ☐ Yes ☐ No ☐ First of the Month Following: [ 1-90 ] Days Or ☐ First Day Following [ 1-90 ] Days Or ☐ Date Of Hire Tax Identification Number: Group Address: City: State: Zip Code: County: Telephone: Fax Number: Billing Contact: Title: E-Mail Address: Billing Address (if different from above): City: State: Zip Code: Group Administrator: Title: E-Mail Address: Previous Carrier: ☐ No ☐ Yes If Yes, Please Indicate Carrier: Delivery Method For The Group Policy, Individual Subscriber Certificate And Summary: ☐ Electronic ☐ Paper If Paper Method Is Selected, Send Materials To: By checking the electronic box, you are agreeing to receive such materials electronically pursuant to the terms for paperless delivery attached to this application form. If none selected, all materials will be sent by hard copy. Enrollee ID Cards Sent To: ☐ Group ☐ Member Home
Group Number. Phone: Group Benefits Administrator Name: For Federal COBRA and New York State Continuation of Coverage (mini-COBRA) billing, please place a check xxxx in the sections provided immediately below: Group is electing to have BlueCross BlueShield of Western New York (“BlueCross BlueShield”) directly xxxx individuals that Group identifies to BlueCross BlueShield as subscribers in Group’s COBRA/mini-COBRA coverage. (NOTE: Page 2 of this form must be completed upon selecting this option). Effective Date: Authorized by: (Authorized Group Representative Signature) Print Name: Title: If Group is exempt from Federal COBRA provisions, please explain: If Group is exempt from NYS mini-COBRA provisions, please explain: - over, please - A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association. R13264-B This Federal COBRA and NYS Continuation of Coverage Premium Billing Agreement (“Agreement”) is entered into as of the day of 20 (“Effective Date”) by and between BlueCross BlueShield of Western New York1, (“BlueCross BlueShield”) and (“Employer”). (Employer name) (Principal office location) In consideration of the terms and conditions hereof and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, Employer and BlueCross BlueShield hereby agree as follows:
Group Number. Z1281 Plan ID: CTYGM Effective Date: August 1, 2012 City of Xxxxxxx BENEFIT COPAYMENT Annual Maximum No Annual Maximum Deductible No Deductible General Office Visit $4 per Visit DIAGNOSTIC AND PREVENTIVE SERVICES Routine and Emergency Exams Covered at 100% All X-rays Covered at 100% Teeth Cleaning Covered at 100% Fluoride Treatment Covered at 100% Sealants Covered at 100% Head and Neck Cancer Screening Covered at 100% Oral Hygiene Instruction Covered at 100% Periodontal Charting Covered at 100% Periodontal Evaluation Covered at 100% RESTORATIVE DENTISTRY Fillings (Amalgam) Covered at 100% Stainless Steel Crown Covered at 100% Porcelain-Metal Crown $45 PROSTHODONTICS Complete Upper or Lower Denture $50 Bridge (per Tooth) $45 Root Canal Therapy – Anterior $30 Root Canal Therapy – Bicuspid $60 Root Canal Therapy – Molar $80 Osseous Surgery (per Quadrant) $50 Root Planing (per Quadrant) $25 ORAL SURGERY Routine Extraction (Single Tooth) Covered at 100% Surgical Extraction $50 ORTHODONTIC SERVICES Pre-Orthodontic Service $150* Comprehensive Orthodontic Service $800 MISCELLANEOUS Local Anesthesia Covered at 100% Dental Lab Fees Covered at 100% Nitrous Oxide $10 per Visit Specialty Office Visit $30 per Visit Emergency Office Visit $50 per Visit Out of Area Emergency Care Reimbursement Up to $100 Form No. 028-OR (9/11) Contract No. 001-OR (1/10R) *Fee credited towards the Comprehensive Orthodontic Service copayment if patient accepts treatment plan. Underwritten by Willamette Dental Insurance, Inc. This plan provides extensive coverage of services and supplies to prevent, diagnose, and treat diseases or conditions of the teeth and supporting tissues. Presented are just some of the most common procedures covered in your plan. Please see the Certificate of Coverage for a complete plan description, limitations, and exclusions.
Group Number means the health benefit plan group number for the insured.
Group Number. [Group Number] Age Category Premiums Age Category Premiums Age Category Premiums Age Category Premiums