Plan Sponsor Data

Plan Sponsor Tax ID Number:

Full Legal Business Name:

Street Address:

City:

State:

Zip Code:

Mailing Address: (If Different from Street Address)

City:

State:

Zip Code:

Phone Number:

County:

Nature of Business:

Sic:

Date Business Started:

Administrative Contact Person:

Administrative Contact Email:

Executive Contact Person:

Executive Contact Email:

Third-party administrator
United HealthCare Services, Inc.

Is your company (you) subject to COBRA?
YesNo

(Your company is subject to COBRA if you or your controlled group, as defined in 26 U.S.C.
1563, employed at least 20 full- or part-time employees on at least 50% of the typical business days during the previous calendar year. You
must include employees residing outside of the United States. Church plans and federal, state and local government plans are excluded
from COBRA.)

Give the names of persons currently under COBRA, state continuation plan or within their election period:

How many people would you like to list?
0123456

Has your company ever had a group insurance application denied by an insurer? If yes, give name of insurer, date and reason:
YesNo

Is current group medical coverage being replaced?
YesNo

List the name, address and phone number of your company’s present medical carrier or third-party administrator (tpa):

Carrier Name:

Carrier Address:

City:

State:

Zip Code:

Carrier Phone Number:

Effective Date:

Termination Date:

Has your medical plan been previously underwritten or administered by UnitedHealthcare Insurance Company or any of its affiliates in the last 3 years?
YesNo

Indicate the Plan Sponsor Contribution Amounts: (minimum contribution 50% of plan participant only premium)

What percentage of the costs will you pay for plan participants?

For dependents? (spouse and children)

Indicate the Plan Sponsor Default Plan:

Which default plan did you choose for your business? (Include the letter and number of the plan code)

Additional Plans Elected: (If Applicable)

What class of plan participants do you want to exclude from this plan? (Check all that apply)
None
Union
Non-Union
Hourly
Salary
Non-Management
Management

Medical Benefit Tracking Year (DED/OOP): (Where Available)
Calendar Year
Plan Year

Domestic Partner Coverage:
YesNo

Plan Sponsor/Plan Participant

How many plan participants does your company currently have on the payroll?

Plan participants working a minimum of 30 hours per week (not part time, temporary or substitute) are eligible plan participants:

Number of eligible plan participants:

Number of eligible plan participants waiving coverage:

Number of enrolling plan participants:

Enter the prior calendar year average total number of employees:

Under Health Care Reform law, the number of employees means the average number of employees employed
by the company during the preceding calendar year. An employee is typically any person for which the
company issues a W-2, regardless of full-time, part-time or seasonal status or whether or not they have
medical coverage.
To calculate the annual average, add all the monthly employee totals together, then divide by the number of
months you were in business last year (usually 12 months). When calculating the average, consider all months
of the previous calendar year regardless of whether you had coverage with us, had coverage with a previous
carrier or were in business but did not offer coverage. Use the number of employees at the end of the month
as the “monthly value” to calculate the year average. If you are a newly formed business, calculate your prior
year average using only those months that you were in business. Use whole numbers only (no decimals,
fractions or ranges).

Enter the prior calendar year total number of eligible employees:

For purposes of determining your number of eligible employees, eligible employees are those who are eligible
to enroll in any medical plan you offer, even if they aren’t eligible to enroll in a UnitedHealthcare plan. Here you
may add COBRA and retirees.
Calculate your number of eligible employees from the preceding calendar year: (1) Count the total number of
eligible employees at the end of each month (2) Add all the monthly eligible totals from line (1) and divide
by 12. Use whole numbers only (no decimals, fractions or ranges and round down).

Enter the prior calendar year full-time equivalent total number of employees:

For purposes of determining your number of full-time equivalent employee count, the number of employees
means the average number of employees employed full-time (at least 30 hours/week in any given month), by
the company on business days during the preceding calendar year.
In addition to the number of full-time employees noted above, for any month otherwise determined, include
for such month the number of full-time employees divided by the aggregate number of hours of service of all
employees who are not full-time employees for the month by 120. Employers should exclude employees who
were seasonal workers who worked 120 days or fewer in the preceding calendar year.

Waiting period waived for initial enrollees: YesNo

Plan participant effective date:
Immediate after date of hire
Immediate after 30 days
Immediate after 60 days
Immediate after 90 days
First of month after date of hire
First of month after 30 days
First of month after 60 days

Plan Participant termination date: End of month

Leave of Absence (LOA) Policy

If the plan participant is on a Plan Sponsor approved leave of absence and the Plan Sponsor continues to pay required payments, the coverage will
remain in force for: (1) No longer than 13 consecutive weeks for non-medical leaves (i.e., temporarily laid-off) and (2) No longer than 26 consecutive
weeks for a medical leave. Coverage may be extended for a longer period of time, if required by federal rules such as COBRA.
If the plan participant’s medical coverage terminates under this LOA policy, the plan participant may exercise the rights under any applicable
continuation of coverage under federal law (COBRA) as described in the Summary Plan Description.

Do you continue medical coverage during a leave of absence (not including state continuation or COBRA coverage)?
Yes, we continue medical coverage during an approved leave of absence for plan participants.
No, we do not offer medical coverage during a leave of absence.

Does your current health insurer extend coverage for disabilities after termination date?
(If yes, provide copy of policy and/or plan participant certificate.) YesNo

Consumer Driven Health Plan Options

Health Savings Account (if selected): Which bank will be used:
OptumBank
Other

Eligibility for Medical Coverage

Under federal law, if your group had 20 or more employees during 20 or more calendar weeks in the preceding calendar
year, the Health Plan is primary and Medicare is secondary. This statement does not set forth all rules governing group level
Medicare status. The Group should contact its legal and/or tax advisor(s) for information regarding other rules that may impact
the Group’s Medicare status. Under federal law, it is the Group’s responsibility to accurately determine its Medicare status.

Medicare Primary
Plan Primary

Do you currently utilize the services of a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), Staff
Leasing Company, HR Outsourcing Organization (HRO) or Administrative Services Organization (ASO)?

YesNo

Is your group a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), or other such entity that is a
co-employer with your client(s) or client-site employee(s)?

YesNo

If you answered Yes, then by signing this application you agree with the certification in this section. I hereby certify that my
company is a PEO, ELC or other such entity and that only those employees who are the corporate employees of my company,
and not my co-employees, are permitted to enroll in this group policy. If my group at any point after I sign this application
determines that the group will provide coverage to the co-employees under the group’s plan, I understand that UnitedHealthcare
will not cover the co-employees under this group policy.

Does your group sponsor a plan that covers employees of more than one Plan Sponsor?

YesNo

Do you have common ownership with any other businesses? If you own multiple companies, or a parent-subsidiary relationship
exists between your company and another, this may indicate common ownership of businesses.

YesNo

Plan Sponsor Agreement
The agent has explained the details of the coverage and I, the undersigned, acknowledge reading the entire application. The answers I have provided are
true and complete. I understand that the terms and conditions herein bind the Applicant and United HealthCare Services, Inc. only when the Application
receives written approval from United HealthCare Services, Inc.
All enrollees requesting or changing coverage must submit complete medical history. Approval of such changes is subject to United HealthCare Services,
Inc. underwriting guidelines. All late enrollees will be declined or excluded for a period of time. Late enrollees are those whose enrollment form is received
more than 31 days following their initial eligibility date.

Important Information
Important Information
UnitedHealthcare reserves the right to review the applicant’s payroll/wage and tax records at any time to confirm eligibility. UnitedHealthcare may request
the applicant’s most recent wage and tax payroll records. The applicant agrees to furnish UnitedHealthcare with all information and documentation which
may be reasonably required with regard to eligibility for coverage.
I understand that the information provided on this application and on the Plan Participant Enrollment Application Form is used to make decisions regarding
eligibility and pricing. I also understand that misrepresentation, concealment or omission of fact, or a mistake of fact (whether or not a mutual mistake) by
the Plan Sponsor, agent of the Plan Sponsor, Plan Participant covered under the Plan, could materially affect the underwriting, premium, rating or terms and
conditions of the Plan Sponsor’s Excess Loss Coverage. In addition, such misrepresentation, concealment, omission of fact or a mistake of fact (whether or
not a mutual mistake) could result in increased premium rates, attachment points and/or otherwise change the terms and conditions of the Plan Sponsor’s
Excess Loss Insurance Policy retroactive to the effective date or as of any premium due date thereafter or termination of that Policy as of the next premium
due date. I also understand that the Excess Loss Insurance Policy may be declared null and void in its inception if the Plan Sponsor, any agent of the Plan
Sponsor, or Plan Participant covered under the Plan has willfully or intentionally misrepresented, concealed, omitted any material fact affecting terms,
conditions, or underwriting of the Excess Loss Insurance Policy.
I further certify that Plan Sponsor is a Plan Sponsor eligible to sponsor a group health plan under federal law known as ERISA. I also certify that the
individuals covered under the Plan Sponsor’s group health plan are common law plan participants. United HealthCare Services, Inc. or its affiliates reserves
the right to terminate the parties’ agreement in the event that information shows that the Plan Sponsor is not eligible to sponsor a group health plan.

Coverage is not in effect until the undersigned receives written approval from United HealthCare Services, Inc.
Final approval or disapproval is not
taken on the Application until all required information in the Application and all required information for enrolling plan participants and their dependents is
submitted and reviewed. No person other than an officer of United HealthCare Services, Inc. has the authority to bind or alter coverage, and the undersigned
agrees that any such attempt by the agent is void and is not effective. The deposit amount will be returned to the Plan Sponsor if coverage is declined.
United HealthCare Services, Inc. reserves the right to contact any plan participant at the place of business to complete the enrollment process. Any person
who, knowingly and with intent to defraud any insurance company, submits an application or files a claim containing any materially false information may be
guilty of insurance fraud, which is a crime, and may be subject to fines and confinement in prison.

Important Notice for Government Contractors:
The UnitedHealthcare Level Funded product is not available to any government contractor which is
prohibited by contract, regulation or otherwise from receiving a refund or credit of any surplus or money (including the refund or credit of surplus under
the Level Funded product) that was allocated under their government contract to pay for plan participant benefits. If you have any questions about whether
you are subject to such a prohibition, please consult with your legal counsel, as United HealthCare Services, Inc. is not able to provide you with legal
advice on such matters. By completing and signing this application, you are representing to United HealthCare Services, Inc. that you are not prohibited by
government contract, regulation or otherwise from receiving a refund or credit of any surplus or money under the Level Funded product.
Unless all pages are attached and completed, this will not be considered as a complete Application.

Dated at (City and State):

Dated on (Month, Day and Year):

Legal Business Name:

Signature (Must be signed by a person authorized to purchase coverage for the Plan Sponsor.):

Print Name and Title:

General Agent Information

General Agent:

Telephone Number:

NPN#

Street Address:

City:

State:

Zip Code:

Producer Information

I hereby certify that all information contained in this form has been explained to the Plan Sponsor and that the answers are correct to the best of
my knowledge. I am not aware of anything unfavorable about the Plan Sponsor or any person proposed for coverage except as noted herein. I
have complied with the underwriting rules and regulations of the third-party administrator and have explained to the Plan Sponsor the coverages,
limitations and exclusions, and other details of the coverage applied for.

I have notified the Plan Sponsor not to terminate present coverage until notified in writing by United HealthCare Services, Inc. of acceptance of
this application.

Producer Name:

Address:

Telephone Number:

Fax Number:

Social Security/Identification Number:

Producer Signature:

Date:

Case Submission

Please submit the following forms for application of coverage:

Plan sponsor application form
Plan participant enrollment forms
Payment authorization form
First month's payment
A copy of the quoted rates
Excess loss insurance application
Most recent copy of wage and tax report

UnitedHealthcare Level Funded Payment Authorization Form

A. Applicant Information

Plan Sponsor Name:

B. Initial Method of Payment

Electronic funds transfer (EFT) (Complete EFT Authorization below.)
Check enclosed

The group’s first month payment plus all applicable fees must be submitted by check with this form or by EFT (Electronic funds transfer). All future
payments must be paid with a Plan Sponsor’s check or automatically withdrawn through the Plan Sponsors bank account. Checks must be made out
to United HealthCare Services, Inc. UnitedHealthcare will provide customer with an online invoice in advance of the first of each month.

A $25 fee will apply for each future payment made by direct bill (does not apply to the first month’s payment submitted with the application). The
billing fee covers the cost of monthly processing of each account. Nonpayment of this fee will result in termination of the administrative services
agreement and excess loss insurance coverage. Payments made by electronic funds transfer do not have a billing fee.

Total payment deposit:
$ A service fee will be applied to non-sufficient funds.

C. Ongoing Method of Payment

Electronic funds transfer (EFT) (Complete EFT Authorization below.)
Direct bill - monthly (Fees may apply)

D. Statement of Understanding

As a participant of Scheduled Direct Deposit, I agree to and/or understand all of the following on behalf of my business:

It may take up to 1 month to establish this process.

I authorize United HealthCare Services, Inc. to debit my business checking or savings account for the monthly payment for Administrative
Services, Excess Loss Insurance, and claim funding. I will ensure sufficient funds are in my business checking or savings account to cover
my monthly payment. If the necessary funds are not on deposit in the account at the beginning of the month, my Administrative Services
Agreement with United HealthCare Services, Inc. and Excess Loss Insurance policy with UnitedHealthcare Insurance Company may be subject
to termination under the terms stated in the contracts. Also, I understand my business may be subject to additional service fees incurred by
United HealthCare Services, Inc. subsequent to the termination date as a result of insufficient funds.

I will promptly notify United HealthCare Services, Inc. of any change to my business checking or savings account. If a change occurs, it is my
responsibility to provide United HealthCare Services, Inc. with the current information.

E. EFT Authorization

Type of Account:
Checking
Savings

Account Holder's Name:

Financial Institution:

Routing/Transit Number (9 Digits Required):

Account Number:

I (we) hereby authorize United HealthCare Services, Inc. to initiate debit entries to the account and the financial institution
named above.

In submitting this payment authorization with the application, I understand that the initial payment may be adjusted based on the
applicant’s medical history (or that of any dependent to be covered) and agree that the additional amount(s) required may be charged
to this account. United HealthCare Services, Inc. will not be held responsible for a contract lapse or termination due to nonpayment if
the withdrawal is presented and not honored for any reason and the amount due is not paid. United HealthCare Services, Inc. is not
responsible for charges I may incur from my bank due to late notification of the termination or change. This authorization is to remain
in full force and effect until United HealthCare Services, Inc. has received written notice of my intention to terminate this authorization.
I understand that I must give at least 30 days’ advance notice to terminate or change this authorization. If the automatic bank draft or
direct payment by check transaction is returned for any reason, a $25 nonrefundable service fee will be applied.

Authorized or Account Holder Signature:

Date:

Plan Sponsor's Email Address: