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Application for group insurance See reverse side for additional information. New York, NY 1. Applicant’s legal name 2. Doing business as 3. 10. Dependent Participation: Employer contributes % of

Employer may pay 100% of premiums.) Eligible Dependent/Aged Dependent. Covered by Employer Not Covered by Employer Covered by Employer Not Covered by Employer Covered by Employer Not Covered by Employer Covered by Employer New York, NY 2A. Application for group insurance See reverse side for additional information. New York, NY 3. Applicant's legal name 4. Being a resident of New York 5. Applicant resides outside of New York (Applicant's spouse is not a resident of New York) 6. Applicant is not physically present in New York 7. Applicant has the ability to act from location, and will be willing to pay for medical care 8. Applicant is not required to pay premiums for group insurance 9. Applicant is not older than 21 years of age 10. Applicant is eligible for a non-contributory policy; the policy must meet the same deductibles, co-payments and maximum benefits as a contributory policy 11. Applicant has an approved medical card for current medical needs 12. Applicant is not currently receiving medical treatment for any medical condition that may be eligible for coverage 13. Applicant will not be subject to any medical examination or treatment in compliance with New York State law’s minimum benefit standards 14. Applicant is not required to be in active military. 15. Employer contributes to a deductible, co-payment and maximum benefits amount. If there is a premium increase due to higher premium level or cost’s, Employer will be responsible for the increased premium, additional co-payments and maximum benefits. If there is a premium increase due to actuarial factors affecting premiums or costs, Employer will be responsible for the increase(s) in excess of the applicable excess premiums, co-payments and maximum benefit amounts for a year’s premium increases. 16. Employer will not be responsible for a medical examination or treatment required by the Employee’s doctor or in compliance with New York State law as outlined in item 17. 17. Applicants age 21 to age 26 without coverage by employer who are currently receiving medical care from a licensed health care provider will be required to purchase group health insurance coverage from the New York State Health Resources and Services Administration as of April 1 and meet the same deductibles, co-payments and maximum benefits requirements as New York State law as of July 1, 2013, which is subject to a state premium increase of 50 percent.

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