C14939-CORE-VI (1/18) Trang 1

n ng K Nhm Chnh (Dnh cho nhm t 101 ngi tr ln)

Blue Shield of California v Blue Shield of California Life & Health Insurance Company (Blue Shield Life)

Lu Hnh Ni B ID Nhm:

Quyn li y t khng c cc ty chn ABHP (chng trnh chm sc sc kho theo

Access+ HMO Access+ HMO SaveNetSM Local Access+ HMO Added Advantage POSSM Trio HMO Active Choice 1 Full PPO Full PPO Savings2 Tandem PPO Tandem PPO Savings Full PPO ASO/Full PPO ASO Savings2

_______________________ Blue Shield 65 PlusSM (HMO)

Quyn li y t c cc tu chn ABHP (chng trnh chm sc sc kho theo ti khon):

Access+ HMO: HRA HIA FSAActive Choice1: HRA HIA FSALocal Access+ HMO: HRA HIA FSAFull PPO: HRA HIA FSAFull PPO Savings2: HRA HIA HSA

LPFSA3 FSA

Full PPO ASO: HRA HIA FSA

Full PPO ASO Savings2: HRA HIA LPFSA3 HSA FSA

Cc quyn li chuyn ngnh

Nhm bo him nhn th c bn c thi hn/AD&D (cht & on chi do tai nn) t nguyn1

Bo him nhn th c bn dnh cho ngi 1

Bo him nhn th b sung1 Bo him AD&D b sung1 Dental PPO Dental HMO Nhn khoa1 Khc

1 c bo him bi Blue Shield of California Life & Health Insurance Company (Blue Shield Life).

2 Cc chng trnh Full PPO Savings l nhng chng trnh sc kho HSA hp l c tnh khu

3 Ch c th kt hp vi mt chng trnh HSA.

Lu : Blue Shield khng cung cp t vn thu cng nh chng ti khng cung cp HSA, HRA, HIA, FSA, hoc LPFSA.

Phn 1 Thng tin Cng ty vui lng in hoc in bng mc en 1 Lm cch no cc c nhn c th ng k tham gia? ng k giy ng k in t Bng tnh ng k in t

2 Tn ng k kinh doanh hp php y ca nhm Ngy yu cu bo him c thi hn (thng/ngy/nm):

Hnh thc kinh doanh (DBA), nu thch hp:

3 a ch gi ha n: s nh, tn ng, thnh ph, tiu bang, m ZIP (nu c th cung cp a ch hp th, vui lng hon tt mc s 4 bn di)

4 a ch thng tr (nu khc trn) Ht ca ni thng tr

5 Lin h i din nhm: A. Ngi i din nhm B. Chc danhC. S T D. S Fax E. a ch email (bt buc)

Ngi i din chnh ca nhm

A. B.

C. D. E.

Qun tr vin trc tuyn A. B.

C. D. E.

Lin h v ho n A. B.

C. D. E.

Lin h v Chng t Bo him/Th Bo him (EOC/COI)

A. B.

C. D. E.

Lin h php l A. B.

C. D. E.

C14939-CORE-VI (1/18) Trang 2

6 Loi php l cng ty: Cng ty ni b Cng ty i chng i tc Doanh nghip t nhn Cng ty trch nhim hu hn Phi li nhun Khc (xin nu r) ________________________________

M s thu doanh nghip Lin Bang (TID) _________________________________ Nhm c nhiu m s thu TID? C Khng Nu "C", hy cung cp M s thu doanh nghip Lin Bang TID cho nh ti tr bo him. _________________________________________________

Hnh thc kinh doanh (cung cp cng nhiu chi tit cng tt):

Lit k cc ngnh cng nghip chnh v sn phm/dch v ca nhm M phn loi (cc) ngnh cng nghip tiu chun (m SIC) trong ngnh kinh doanh c phn loi

Tn hng bo him sc kho gn y nht Ngy bt u/kt thc vi hng trc

Bo him c cn hiu lc? C Khng

Nhm c c cung cp khu tr t hng bo him trc? C Khng

7 Doanh nghip tng mua bao him Blue Shield of California trc y? C KhngNu "c", vui lng cung cp s ID ca nhm bo him Blue Shield v ngy chm dt bo him:

ID Nhm ca Blue Shield _____________________________________________ Ngy dng bo him ________________________________

8 Nhm c d nh s dng bo him Blue Shield cng vi mt hng bo him khc? C Khng Ngy m ng k ca hng bo him khcTn hng bo him S nhn vin T: n:

Ngy bo him c hiu lc ban u ca hng khc (thng/ngy/nm):

Nhm c bt k cng ty con hay cng ty lin kt no khng? C Khng

Tn (cc) cng ty con hoc cng ty lin kt C bao gm trong gi bo him?

C Khng

C Khng

C Khng

C phi tt c nhn vin c bo v bi lut bi thng lao ng trong phm vi yu cu ca php lut?

C Tn hng bo him: ____________________________________________________________________________________________________

Khng Nu "khng", vui lng gii thch: __________________________________________________________________________________________

Phn 2 iu Kin9 Ha Nhp Cng Vic v Thi Gian Ch Doanh nghip c th t ra khong thi gian chnh quy v nh hng (ha nhp) cng vic cho nhn vin

chnh thc, nhng khng c qu 30 ngy. Thi gian ch i cng c th c p dng trc khi bo him c hiu lc, bt u t ngy u tin sau khi thi gian nh hng v khng vt qu 90 ngy.

Xin lu : "Ngy c nhn" ca mt nhn vin s c tnh l ngy u tin lm cho cng ty. Tuy nhin, nu doanh nghip t ra mt nh hng hoc thi gian ch i, th "ngy bo him c hiu lc" l ngy u tin sau khi hon thnh bt k nh hng/thi gian ch i.

9a. Thi Gian Ch ca Doanh Nghip Nhm c th chn mt trong s cc la chn sau. Bo him cho cc nhn vin iu kin s tr nn c hiu sau khi hon tt thi gian ch c ch nh.

Bo him c hiu lc vo ngy u tin ca thng k tip tnh t ngy nhn vin c nhn vo lm hoc ngy hon tt bui nh hng (Nu c tuyn vo ngy u tin ca thng, th bo him s c hiu lc vo ngy u tin ca thng tip theo)

Bo him c hiu lc vo ngy u tin ca thng k tip tnh t ngy nhn vin c nhn vo lm hoc ngy hon tt bui nh hng (Nu c tuyn vo ngy u tin ca thng, th bo him s c hiu lc k t ngy c nhn vic lm)

Bo him c hiu lc vo ngy u tin ca thng k tip sau 30 ngy tnh t ngy c nhn vic lm hoc ngy hon tt thi gian nh hng

Bo him c hiu lc vo ngy u tin ca thng k tip sau 60 ngy tnh t ngy c nhn vic lm hoc ngy hon tt thi gian nh hng

Bo him c hiu lc vo ngy th 91 k t ngy c nhn vo lm hoc ngy hon tt thi gian nh hng

Khng c thi gian ch (c hiu lc t ngy c nhn vic lm)

C14939-CORE-VI (1/18) Trang 3

9tip tc

9b. Nu nh c nhiu la chn cho cc khong thi gian ch khc nhau tu theo loi nhn vin, xin vui lng ghi r:

Bo him c hiu lc vo ngy u tin ca thng tnh t ngy c nhn vo lm hoc ngy hon tt bui nh hng. (Nu c tuyn vo ngy u tin ca thng, th bo him s c hiu lc vo ngy u tin ca thng tip theo.) (V d: Nhn vin c tuyn dng vo ngy 1 thng 12 nm 2017, th ngy bo him c hiu lc l ngy 1 thng 1 nm 2018.) Tt c nhn vin Loi khc (vui lng ghi r): ______________________________________________________________________________________________

Bo him c hiu lc vo ngy u tin ca thng tnh t ngy c nhn vo lm hoc ngy hon tt bui nh hng. (Nu c tuyn vo ngy u tin ca thng, th bo him s c hiu lc k t ngy c nhn vic lm.) (V d: Nhn vin c thu tuyn vo ngy 15 thng 12 nm 2017, th ngy bo him c hiu lc l ngy 1 thng 1 nm 2018.) Tt c nhn vin Loi khc (vui lng ghi r): ______________________________________________________________________________________________

Bo him c hiu lc vo ngy u tin ca thng k tip sau 30 ngy tnh t ngy c nhn vo lm hoc ngy hon tt bui nh hng. (V d: Nhn vin c tuyn dng vo ngy 1 thng 12 nm 2017, th ngy bo him c hiu lc l ngy 1 thng 2 nm 2018.) Tt c nhn vin Loi khc (vui lng ghi r): ______________________________________________________________________________________________

Bo him c hiu lc vo ngy u tin ca thng k tip sau 60 ngy tnh t ngy c nhn vo lm hoc ngy hon tt bui nh hng. (V d: Nhn vin c tuyn dng vo ngy 15 thng 12 nm 2017, cng thm 60 ngy th ngy bo him c hiu lc l ngy 1 thng 3 nm 2018.) Tt c nhn vin Loi khc (vui lng ghi r): ______________________________________________________________________________________________

Bo him c hiu lc vo ngy th 91 k t ngy c nhn vo lm hoc ngy hon tt thi gian nh hng. (V d: Nhn vin c tuyn dng vo ngy 15 thng 12 nm 2017, cng thm 90 ngy th ngy bo him c hiu lc l ngy 16 thng 3 nm 2018.) Tt c nhn vin Loi khc (vui lng ghi r): ______________________________________________________________________________________________

9c. Xin vui lng gii thch nhng trng hp ngoi l v thi gian ch. (V d: Thi gian ch c min i vi cc gim c iu hnh.)

9d. Thi gian ch c c min i vi: B sung/thay i iu l cho php:

C Khng i vi nhn vin ang lm vic ti s Trong vng 30 ngy cng thm thng ny

C Khng Dnh cho nhn vin bn thi gian sp chuyn qua thnh nhn vin ton thi gian Trong vng 60 ngy cng thm thng ny

C Khng Cho nhn vin c tuyn dng li trong vng: 1 thng 90 ngy 3 thng 6 thng 12 thng

Trong vng 90 ngy cng thm thng ny

9e. Cch thc chm dt bo him dnh cho ngi ng k: Bo him s kt thc vo ngy hp ng lao ng kt thc Bo him s kt thc vo cui thng ca ngy hp ng lao ng kt thc

10 S nhn vinBlue Shield yu cu nhm hy c cc nh ngha v "nhn vin" v cung cp thng tin yu cu da vo nhng nh ngha th hin bn di. Chng ti da vo thng tin c cung cp t pha nhm xc nh iu kin cho nhm v nhn vin tham gia bo him. 1. Tt c nhn vin Mi c nhn c tuyn dng bi nhm, bao gm c nhn vin ton thi gian v bn thi gian, (29 USC 1002 (6)).2. Nhn vin Ton Thi Gian (FTE) v Tng ng FTE FTE v Tng ng FTE c nh ngha Phn 4980H(c)(2) ca M Thu nhp Ni b. Mt FTE l mt nhn vin c trung bnh t nht 30 gi lm vic mi tun, hay t nht 130 gi lm vic trong mt thng, theo lch. S ca Tng ng FTE c quyt nh bng cch kt hp s gi lm vic ca tt c cc nhn vin khng phi FTE trong thng, nhng khng nhiu

hn 120 gi lm vic i vi mi nhn vin, sau chia tng s cho 120.3. Nhn Vin iu Kin nh ngha ny dng xc nh cc nhn vin iu kin tham gia, v tip tc tham gia bo him. Mt Nhn Vin

iu Kin l c nhn: L c nhn tham gia trn c s ton thi gian trong qu trnh thc hin cng vic vi Ch lao ng, c t nht 30 gi lm vic mi tun, v nhim v

trong ngh nghip c thc hin ti cc a im lm vic chnh quy ca Ch lao ng; hoc L ch s hu hoc i tc duy nht ca mt s hp tc c thc hin trn c s ton thi gian, t nht 30 gi mi tun, trong cng vic ca Ch

lao ng v ngi c bao gm vi t cch Nhn vin trong Hp ng ca chng trnh chm sc sc kho ca Ch lao ng. Mt nhn vin iu kin khng bao gm cc c nhn lm vic trn c s bn thi gian, tm thi hoc thay th.

10 a. Tng s nhn vin:

10 b. Tng s Nhn Vin Ton Thi Gian iu kin:

10 c. Tng s Nhn Vin iu Kin tham gia bo him: 10 d. Tng s Nhn Vin iu Kin t chi tham gia bo him:

Bo him y khoa: Bo him y khoa:

Bo him nha khoa: Bo him nha khoa:

Bo him nhn khoa: Bo him nhn khoa:

Bo him nhn th: Bo him nhn th: