MBA Health Trust Employee / Subscriber ApplicationPlease complete all sections (front & back) in black ink

MBA-R App 03/20 - page 1

EMPLOYER SECTION: The Employer section must be completed & signed by the Group’s Contact Person as listed on the Employer Participation Agreement. If not fully completed, this form will be returned unprocessed. Group Name: _________________________ Group Number: ______________ Division Number: ___________ Group Phone Number: _________________ Intended Eff ective Date:Intended Eff ective Date: ____/____/_____

Employee Class: Class 1 Class 2 Class 3 Class 4 Date of Hire: ____/___/___ Date of Rehire: ____/___/___ Date Changed from Part-time to Full-time: ____/___/___ Average Hours Per Week:______ Was employee subject to an Orientation Period as selected on the Employer Participation Agreement? Yes No Was employee subject to a Measurement Period as selected on the Employer Participation Agreement? Yes No

If yes, date employee satisfi ed eligibility requirements: ____/____/_____

SIGNATURE OF GROUP’S PRIMARY CONTACT PERSON: _______________________________________________________________ Date : ________________________

Contractual Eff ective Date and Eligibility: Applications for new employees must be received by the MBA Trust within 10 days of the Contractual Eff ective Date. The Contractual Eff ective Date is based on the employee’s date of hire and your company’s established probationary period. Applications received after the Contractual Eff ective Date may delay an employee’s eligibility date to the next MBA Trust Open Enrollment period. New MBA application forms are required to add dependents, including newborns and/or a new spouse (see Plan Booklets for details).

EMPLOYEE RELEASE AND AUTHORIZATION: I hereby verify that all of the information specifi ed above is accurate and complete and acknowledge that I have read and understand all information on the second page of this application. By signing below, I have authorized the release of information, for myself and my dependents listed on this application, to Regence BlueShield, Kaiser Foundation Health Plan of Washington Options, Inc., Kaiser Foundation Health Plan of Washington, Delta Dental of Washington and/or LifeMap Assurance Company. EMPLOYEE’S SIGNATURE : ___________________________________________ DATE : ___________________

A Reason Must be Checked for Application:Add Employee New Group New Employee Open Enrollment Loss of Eligibility on Another Coverage

Add Dependent Birth Marriage Adoption Domestic Partner COBRA coverage exhausted Open enrollment Loss of eligibility on another coverage (must attach proper documentation)

Change of Life Benefi ciary Change of Address Name Change Change Medical Plan

Note: Medical Plan election changes are allowed only during the Open Enrollment Period each year or with a HIPAA qualifying event.

Select Plan

LIFE INSURANCE BENEFICIARY: This section must be completed for all new employee enrollments. If no benefi ciary is designated, benefi ts will be paid under the terms of the group insurance contract. Please contact EPK & Associates for an additional form if you would like to designate a Contingent Benefi ciary. Coverage Underwritten by LifeMap Assurance Company 200 SW Market Street, Portland, OR 97201

Primary Benefi ciary’s Name: ___________________________________ Relationship: ____________________ Benefi ciary’s Birthdate: : ________________ Percentage of Benefi t: _______________ Primary Benefi ciary’s Address: ___________________________________ City/State/Zip: ______________________ PhonePhone Number: : ____________________

EMPLOYEE SECTION: First Name: _______________________ Middle Initial: ____ Last Name: ________________________

Address: _____________________________________________________________________

City: ________________________________________ State: ______ Zip: _________________

Phone #: ____________________ Email: __________________________________________

Marital Status: Married Single D ate of Marriage: _____________

*Washington State Registered Domestic Partners are treated the same as a spouse. Dependent children are eligible for coverage until the age of 26.

Select PlanMedical Dental Vision Relationship* Last Name First Name M.I.

Social Security Number or Individual tax payer ID number (ITIN)

Birth Date(mm/dd/yyyy)

GenderM/F

Employee / /

Spouse/Domestic Partner / /

Child / /

Child / /

Child / /

Note: Only plans being off ered by the employer may be selected for enrollment. Dependents may only enroll in benefi ts in which the employee is also enrolled.

Common Enrollment Plans underwritten by Regence BlueShield, Kaiser Foundation Health Plan of Washington, Kaiser Foundation Health Plan of Washington Options, Inc., and LifeMap Assurance Company: (If an employer off ers common enrollment dental and/or vision benefi ts, employees & dependents will automatically be enrolled in those benefi ts if they enroll in medical benefi ts.) Market/Market “Plus” Plan ____ Foundation/Foundation “Plus” Plan ____ Traditional Plan ____ HSA Plan ____ Kaiser Plan ____ Voluntary Enrollment Plans underwritten by LifeMap Assurance Company: Vol Dental Vol Vision

Application Agreement: I have provided these answers as part of the application procedure required by Regence BlueShield, Kaiser Foundation Health Plan of Washington Options, Inc., Kaiser Foundation Health Plan of Washington, Delta Dental of Washington and/or LifeMap Assurance Company to enroll in coverage and I certify that all information completed on this form is true, correct and complete. I understand that Regence BlueShield, Kaiser Foundation Health Plan of Washington Options, Inc., Kaiser Foundation Health Plan of Washington, Delta Dental of Washington and/or LifeMap Assurance Company will rely on each answer in making coverage and rating determinations. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fi nes, and denial of insurance benefi ts.

HIPAA Special Enrollment Provisions: If I have waived enrollment and completed a “Waiver of Insurance Form” for myself or any of my dependents (including my spouse) because of other health insurance or group health plan coverage, I may in the future be able to enroll the waived individuals in this plan, provided I request enrollment within 30 days after the other coverage of the individual(s) ends due to loss of eligibility or an employer’s ceasing to contribute toward that other coverage. In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my dependents, provided that I request enrollment within 30 days after the marriage, or within 60 days after the birth, adoption, or placement.

Release of Information: I acknowledge and understand my health plan may request or disclose health information about me or my dependents (persons who are eligible for benefi ts coverage and are listed on the enrollment form) for the purpose of facilitating health care treatment, payment or for the purpose of business operations necessary to administer health care benefi ts; or as required by law*. Health information requested or disclosed may be related to treatment or services performed by: a physician, dentist, pharmacist or other physical or behavioral health care practitioner; a clinic, hospital, long term care or other medical facility; any

other institution providing care, treatment, consultation, pharmaceuticals or supplies; or an insurance carrier or group health plan. Health information requested or disclosed may include, but is not limited to: claims records, correspondence, medical records, billing statements, diagnostic imaging reports, laboratory reports, dental records, or hospital records (including nursing records and progress notes). This acknowledgement does not apply to obtaining information regarding psychotherapy notes. A separate authorization will be used for psychotherapy notes.

* For more information about such uses and disclosures, including uses and disclosures required by law, please refer to the Notice of Privacy Practices. A copy is available from our website at www.epkbenefi ts.com or by phone at (800) 545-7011 or (425) 641-7762.Coverage underwritten by: Regence BlueShield 1800 Ninth Avenue -- Seattle, WA 98101 Kaiser Foundation Health Plan of Washington Options, Inc. and Kaiser Foundation Health Plan of Washington 601 Union St, Suite 3100, Seattle, WA 98101 P.O. Box 34750, Seattle, WA 98124-9745 Delta Dental of Washington 400 Fairview Ave N., Suite 800, Seattle, WA 98109 LifeMap Assurance Company 200 SW Market Street, Portland, OR 97201 First Choice Employee Assistance Program 600 University St, Suite 1400, Seattle, WA 98101

MBA-R App 03/20 - page 2

If any dependent child(ren) being added is/are covered under another plan and the natural parents are divorced or separated, Washington State regulations require that we ask the following:Name of parent with custody (if parents have dual custody, indicate): ________________________________________________________________________________________________If divorced, did the court establish fi nancial responsibility for the child(ren)’s health care? Yes No (Please provide a copy of the divorce decree maintenance agreement outlining coverage specifi cations.)If YES, please specify the name and address of the parent with responsibility: __________________________________________________________________________________________ _

Do you or any of your dependents applying for coverage have coverage with any health care plan? Yes No Will coverage remain in eff ect? Yes NoIMPORTANT: If you or any of your dependents applying for coverage have coverage with any health care plan, you MUST complete the information below.

OTHER CURRENT OR PRIOR INSURANCE COVERAGE: Other Insurance Company Name:____________________________________________________ Other Insurance Company Phone #:____________________________________

Other Insurance Company Full Address: ________________________________________________________________________________________________________________ Policyholder’s Name::__________________________________ Policyholder’s Birth Date:____/____/____ (mm/dd/yyyy) Policy Holder’s Member ID# or Social Security #:__________________________

Group Name & Policy #: ______________________ Eff ective Date of Coverage: ____/____/____ Intended Termination Date of Coverage: ____/____/______ Reason for Termination:___________________ Persons covered by prior insurance (list names and date of birth for each): ________________________________________________________________________________________________

Type of CoverageType of Coverage:: Medical Pharmacy Dental Vision Medicare Type of Policy: Group Individual Medicaid Medicare Part A Medicare Part B Other:____________________

If employee or dependents have Medicare, what was the begin date for Part A:_____________ Part B:_____________ Medicare HIC# with Alpha Suffi x:_______________________Name of Person covered by Medicare ____________________________________________ Reason: Disability Over Age 65 End Stage Renal Disease

Mail or Fax to:EPEPEPKK & Associates, Inc. - 15375 SE 30th Place #380 - Bellevue, WA 98007

Phone: 800-545-7011 - Fax 425-641-8114

MBA Health Trust Employee / Subscriber Application

EMPLOYEE SECTION: Employee Social Security Number: _____________________

First Name: _______________________ Middle Initial: ____ Last Name: ________________________

Please use this page, if necessary, to enroll additional dependents.

Addtional Dependents Continued from First Page

MBA-R App 03/20 - page 3

*Washington State Registered Domestic Partners are treated the same as a spouse. Dependent children are eligible for coverage until the age of 26.

Select PlanMedical Dental Vision

Relationship* Last Name First Name M.I. Social Security Number or Individual tax payer ID number (ITIN)

Birth Date(mm/dd/yyyy)

GenderM/F

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Child / /

Note: Only plans being off ered by the employer may be selected for enrollment. Dependents may only enroll in benefi ts in which the employee is also enrolled.

01012017.03PF10LNoticeNDMARegence

DISCRIMINATION IS AGAINST THE LAW Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Regence does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Regence:

Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters

o Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: o Qualified interpreters

o Information written in other languages If you need these services, contact us at 888-344-6347. If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our civil rights coordinator at M/S CS B32B, P.O. Box 1271, Portland, OR 97207-1271, phone: 888-344-6347, TTY: 711, email: CS@regence.com. Please indicate you wish to file a civil rights grievance. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

HELP IN OTHER LANGUAGES

The following translations help people who do not read English understand their rights and responsibilities and who to call for help. Including these translations is a federal requirement for all health plans sold on the state or federal marketplaces.

Spanish: Este aviso tiene información importante. Regence cumple con las leyes de derechos civiles federales aplicables y no discrimina sobre la base de raza, color, nacionalidad, edad, discapacidad o sexo. Este aviso tiene información importante sobre su solicitud o cobertura. Busque las fechas importantes en este aviso. Es posible que tenga que tomar alguna acción en un determinado plazo para mantener su cobertura de salud o ayuda con los costos. Usted tiene derecho a obtener esta información y otra información sobre su solicitud o cobertura, en su propio idioma y sin costo. Llame al 888-344-6347. (TTY: 711)

Chinese Traditional: 本通知含有重要資訊。Regence 遵守適用之聯邦政府民權法，不會因種族、膚色、原始

出生國籍、年齡、身心障礙或性別的不同而予以差別待遇。本通知含有有關您申請或進行承保的重要資訊。請

留意本通知內的重要日期。請在期限之前採取行動，以確保您的醫療保障或協助支付費用。您有權索取使用您

語言撰寫的這類資訊，以及有關您申請或承保的相關資訊。請撥打 888-344-6347 索取。（聽障專線：711）

Vietnamese: Thông báo này có Thông tin Quan trọng. Regence tuân thủ luật pháp Liên bang về quyền công dân hiện hành và không phân biệt đối xử theo chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật hoặc giới tính. Thông báo này có thông tin quan trọng về đơn đăng ký hoặc bảo hiểm của quý vị. Tìm những ngày chính trong thông báo này. Quý vị có thể cần hành động trước một số thời hạn để duy trì bảo hiểm sức khỏe của mình hoặc được giúp đỡ có tính phí. Quý vị có quyền lấy thông tin này và thông tin khác về đơn đăng ký hoặc bảo hiểm, bằng ngôn ngữ của mình miễn phí. Gọi số 888-344-6347. (TTY: 711)

Korean: 이 공지 사항에는 중요 정보가 들어 있습니다. Regence은 해당 연방 민권법을 준수하며 인종, 피부색,

출신 국가, 연령, 장애, 또는 성별에 따라 차별하지 않습니다. 이 공지 사항에는 해당 신청서 또는 적용 범위에

관한 중요한 정보가 있습니다. 이 공지 사항의 주요 날짜를 찾아 보십시오. 해당 건강 보험을 그대로

유지하거나 비용을 지원 받으려면 특정 기한까지 조치를 취하셔야 합니다. 귀하는 모국어로 작성된 본 정보나

해당 신청서 또는 보장 범위에 대한 기타 정보를 무료로 받을 수 있는 권리가 있습니다. 888-344-6347로

연락하십시오. (TTY: 711)

01012017.03PF10LNoticeNDMARegence

Russian: В данном Уведомлении содержится важная информация. Regence несет обязательства

по соблюдению применимых норм федерального законодательства о гражданских правах и не

допускает дискриминации по признаку расы, цвета кожи, национального происхождения, возраста,

статуса инвалидности или пола. В данном уведомлении содержится важная информация о вашем

заявлении или страховом покрытии. Обратите внимание на ключевые даты, указанные в данном

уведомлении. Возможно, вам нужно предпринять некоторые действия к определенному сроку, чтоб

сохранить страховое покрытие или получить помощь с расходами. Вы имеете право получить данную,

а также прочую информацию о вашем заявлении или страховом покрытии на родном языке

бесплатно. Позвоните по номеру 888-344-6347. (TTY: 711)

Tagalog: Ang Abiso na ito ay may Mahalagang Impormasyon. Ang Regence ay sumusunod sa mga naaangkop na Pederal na batas sa mga karapatang sibil at hindi nagdidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan, o kasarian. Ang abiso na ito ay may mahalagang impormasyon tungkol sa iyong aplikasyon o coverage. Hanapin ang mga importanteng petsa sa abiso na ito. Maaaring kailangan mong gumawa ng hakbang hanggang sa mga partikular na takdang araw upang mapanatili mo ang iyong coverage sa kalusugan o tulong sa mga gastusin. May karapatan kang makuha ang impormasyong ito, at iba pang impormasyon tungkol sa iyong aplikasyon o coverage, sa iyong sariling wika nang walang bayad. Tumawag sa 888-344-6347. (TTY: 711)

Ukrainian: Це повідомлення містить важливу інформацію. Regence дотримується застосовного федерального законодавства про громадянські права та не проводить політику дискримінації за расовою приналежністю, кольором шкіри, походженням, віком, інвалідністю та статевою ознакою. Це повідомлення містить важливу інформацію про пов’язану з вами програму або страхове покриття. Зверніть увагу на ключові дати в цьому повідомленні. Щоб зберегти за собою план медичного страхування або право отримувати грошову допомогу, можливо, вам потрібно буде вжити відповідні заходи, для яких установлено певні часові обмеження. Ви маєте право на безкоштовне отримання рідною мовою як цієї інформації, так і будь-якої іншої, пов’язаної з програмою чи страховим покриттям. Телефонуйте за таким номером: 888-344-6347 (телетайп: 711).

Mon-Khmer, Cambodian: សេចក្ត ីជូនដំណឹងសនេះមានព័ត៌មានេំខាន់ ។ Regence អនុលោមលៅតាមច្បាប់របស់សហព័នធសត ីពីសិទ្ធ ិពលរដ្ឋ លហើយមិនមានការលរ ើសលអើងច្បំល ោះពូជសាសន៍ ពណ៌សមបុ រ សញ្ជា តិលដ្ើម អាយុ ពិការភាព ឬលេទ្ល ើយ ។ លសច្បក្ត ីជូនដ្ំណឹងលនោះមានព័ត៌មានសំខាន់សត ីអំពី ក្យសំុ ឬការធានារ៉ា ប់រងសុខភាពរបស់អនក្ ។ សូមរក្លមើលកាលបរលិច្បេទ្សំខាន់ៗក្ន ុងលសច្បក្ត ី ជូនដ្ំណឹងលនោះ ។ អនក្អាច្បត្តវូចាត់វធិានការឲ្យបានត្តឹមកាលបរលិច្បេទ្ក្ំណត់ លដ្ើមបីរក្ាបាននូវការធានារ៉ា ប់រងសុខភាព ឬបានទ្ទួ្លការជួយលច្បញការច្បំណាយថ្លៃថលទសំុខភាពរបស់អនក្ ។ អនក្មានសិទ្ធ ិទ្ទួ្លបានព័ត៌មានលនោះ និងព័ត៌មានដ្ថ្ទ្ អំពី ក្យសុំ ឬការធានារ៉ា ប់រងសុខភាពរបស់អនក្ ជាភាសាថដ្លអនក្លត្បើ លោយមិនបាច្ប់បង់ត្បាក្់ល ើយ ។ លៅមក្លលខ 888-344-6347 ។ (អនក្ពិបាក្សាត ប់ ឬពិបាក្និយាយថដ្លលត្បើ TTY សូមលៅមក្លលខ ៖ 711)

Japanese: このお知らせには大変重要な情報が含まれています。Regence は、適用される連邦公民権法を遵守し、人

種、肌の色、出身国、年齢、身体障害、性別による差別をしません。このお知らせには保険の申請と適用に関する重要な情

報が含まれています。このお知らせに記載されている重要な日付にご注意ください。健康保険適用や医療費支援を引き続き

受けるためには締切日までに手続きを行う必要があります。あなたにはこのお知らせおよび申請と保険適用に関するその他の

情報について、無料かつ母国語で知る権利があります。こちらまでお電話ください： 888-344-6347。(TTY: 711)

Amharic: ይህ ማሳሰቢያ ጠቃሚ መረጃ ይዟል፡፡ Regence በሚተገበረው የፌደራል ሲቪል መብቶች ህግጋት በዘር፣ በቀለም፣ በመጡበት ብሄር፣ እድሜ፣ የአካል ጉዳት ወይም ፆታ መድሎ አይደረግም፡፡ ማሳሰቢያው ስለ ማመልከቻዎትና ሽፋን ጠቃሚ መረጃ አለው፡፡ በዚህ ማሳሳቢያ ላይ ቁልፍ ቀናትን ይፈልጉ፡፡ በተወሰኑ የመጨረሻ ቀናት የጤና ሽፋኑ ላይ ወይም የወጪን ድጋፍ እንዲቀጥል እረምጃ መውሰድ ያስፈልጋል፡፡ ይህንን መረጃ እንዲሁም በማመልከቻዎት ወይም ሽፋኑ ላይ ሌሎችንም መረጃዎች በራስዎን ቋንቋ ያለምንም ክፍያ የማግኘት መብት አሎት፡፡ 888-344-6347

ይደውሉ፡፡ (ቲቲዋይ፡- 711)

Cushite/Oromo: Beeksisni kun odeeffannoo barbaachisaa qabatee jira. Regence Ulaagaa seera mirga Siivilii Federaalaa kan guutuu fi sanyii, bifa, lammummaa, umrii, miidhama qaamaa ykn saala irratti hundaa’ee addaan hinqoodne dha. Beeksisni kun iyyannoo ykn haguuggii kara keessan irratti odeeffannoo barbaachisaa qabatee jira. Guyyoota furtuu beeksisa kana keessa jiran ilaalaa. Haguuggii fayyaa ykn gargaarsa keessan eeggachuuf hanga dhuma yeroo ta’eetti tarkanfii ta’e gatii bastanii fudhachuu qabdu. Odeeffannoo kana fi waa’ee iyyannoo ykn haguuggii keessanii kaffaltii tokko malee afaan keessaniin argachuuf mirga qabdu. Bilbilaa 888-344-6347. (TTY: 711)

01012017.03PF10LNoticeNDMARegence

Arabic:

إلى قوانين الحقوق المدنية الفيدرالية المعمول بها وال تمارس التمييز على أساس العرق أو Regenceتمتثل يحتوي هذا اإلخطار على معلومات مهمة. التواريخ اللون أو األصل القومي أو السن أو اإلعاقة أو الجنس. يحتوي هذا اإلخطار على معلومات مهمة عن الطلب أو التغطية الخاصة بك. ابحث عن

لى اتخاذ إجراء ما قبل بعض المواعيد النهائية للحفاظ على التغطية الصحية الخاصة بك أو تلقي مساعدة بخصوص الرئيسية في هذا اإلخطار. فقد تحتاج إ رقمالتكاليف. لديك الحق في الحصول على هذه المعلومات والمعلومات األخرى المتعلقة بالطلب أو التغطية الخاصة بك بلغتك مجاًنا. اتصل بال

(711. )الكتابة عن ُبعد للصم: 888-344-6347

Punjabi: ਇਸ ਨੋਟਿਸ ਟ ਿੱ ਚ ਮਹਿੱ ਤ ਪੂਰਨ ਜਾਣਕਾਰੀ ਹੈ। Regence ਲਾਗ ੂਫੈਡਰਲ ਨਾਗਰਰਕ ਅਰਿਕਾਰਾਂ ਦ ੇਕਨੂੂੰ ਨ ਦ ੇਅਨੁਰੂਪ ਹੈ ਅਤੇ ਜਾਰਤ, ਰੂੰਗ, ਰਾਸ਼ਟਰੀ ਮੂਲ, ਉਮਰ, ਅਪਾਰਹਜਤਾ, ਜਾਂ ਰਲੂੰ ਗ ਦ ੇਅਿਾਰ ‘ਤ ੇਭੇਦਭਾਵ ਨਹੀਂ ਕਰਦਾ। ਇਸ ਨੋਰਟਸ ਰਵਿੱ ਚ ਤੁਹਾਡੇ ਬੇਨਤੀ-ਪਿੱਤਰ ਅਤ ੇਸੁਰਿੱ ਰਿਆ ਬਾਰੇ ਮਹਿੱਤਵਪੂਰਨ ਜਾਣਕਾਰੀ ਹੈ। ਇਸ ਨੋਰਟਸ ਰਵਿੱ ਚ ਮੁਿੱ ਿ ਰਮਤੀਆਂ ਵੇਿੋ। ਤੁਹਾਨੂੂੰ ਤੁਹਾਡੀ ਰਸਹਤ ਸੁਰਿੱ ਰਿਆ ਰਿੱਿਣ ਜਾਂ ਲਾਗਤਾਂ ਨਾਲ ਮਦਦ ਕਰਨ ਲਈ ਰਨਯਤ ਰਮਆਦ ਸੀਮਾਵਾਂ ਦੁਆਰਾ ਕਾਰਵਾਈ ਕਰਨ ਦੀ ਲੋੜ ਹੋ ਸਕਦੀ ਹੈ। ਤੁਹਾਨੂੂੰ ਇਹ ਜਾਣਕਾਰੀ, ਅਤੇ ਆਪਣੇ ਬੇਨਤੀ ਪਿੱਤਰ ਜਾਂ ਸੁਰਿੱ ਰਿਆ ਬਾਰੇ ਹੋਰ ਜਾਣਕਾਰੀ ਆਪਣੀ ਭਾਸ਼ਾ ਰਵਿੱ ਚ ਰਬਨਾ ਰਕਸੇ ਲਾਗਤ ਤੋਂ ਪਰਾਪਤ ਕਰਨ ਦਾ ਅਰਿਕਾਰ ਹੈ। 888-344-6347 ‘ਤ ੇਕਾਲ ਕਰੋ। (TTY: 711)

German: Diese Mitteilung enthält wichtige Informationen. Regence hält die Grundrechte der USA ein

und es finden keine Diskriminierungen aufgrund von Rasse, Hautfarbe, nationaler Herkunft, Alter,

Behinderung oder Geschlecht statt. Diese Mitteilung enthält wichtige Informationen über Ihren Antrag oder

die entsprechende Versicherungsdeckung. Beachten Sie wichtige Fristen in dieser Mitteilung. Sie müssen

unter Umständen Maßnahmen innerhalb bestimmter Fristen ergreifen, um Ihren

Krankenversicherungsschutz zu erhalten oder eine Kostenerstattung zu erhalten. Sie haben das Recht,

diese Informationen und andere Informationen über Ihren Antrag oder Ihren Versicherungsschutz kostenlos

in Ihrer Sprache zu erhalten. Rufen Sie folgende Nummer an 888-344-6347. (Fernschreiber: 711)

Laotian: ແຈ້ງການສະບັບນ ້ ມ ຂ ້ ມູນທ ີ່ ສ າຄັນ. Regence ສອດຄີ່ ອງກັບກົດໝາຍ ວີ່ າດ້ວຍ ສິ ດທິ ພົນລະເມື ອງຂອງຣັຖບານກາງ ທ ີ່ ກີ່ ຽວຂ້ອງ ແລະ ບ ີ່ ມ ການຈ າແນກ ເຊື ້ ອຊາດ, ສ ຜິວ, ຊາດກ າເນ ດ, ອາຍຸ, ຄວາມເປັນຄົນພິການ ຫ ື ເພດ. ແຈ້ງການສະບັບນ ້ ມ ຂ ້ ມູນທ ີ່ ສ າຄັນກີ່ ຽວກັບການນ າໃຊ້ຂອງທີ່ ານ ຫ ື ການຄຸ້ມຄອງ. ຊອກຫາວັນທ ທ ີ່ ສ າຄັນໃນແຈ້ງການສະບັບນ ້ . ທີ່ ານອາດຈະຕ້ອງການດ າເນ ນການໃນຂອບເຂດເວລາໃດໜ ີ່ ງ ເພືີ່ ອ ໃຫ້ສື ບຕ ີ່ ໄດ້ຮັບການຄຸ້ມຄອງສຸຂະພາບຂອງທີ່ ານ ຫ ື ການຊີ່ ວຍເຫ ື ອທາງດ້ານງົ ບປະມານ. ທີ່ ານມ ສິ ດເອົ າຂ ້ ມູນນ ້ ແລະ ຂ ້ ມູນອືີ່ ນ ກີ່ ຽວກັບການສະໝັກ ຫ ື ການຄຸ້ມຄອງຂອງທີ່ ານ ທ ີ່ ເປັນພາສາຂອງທີ່ ານໂດຍບ ີ່ ເສຍຄີ່ າໃຊ້ຈີ່ າຍ. ຕິດຕ ີ່ 888-344-6347. (TTY: 711)

MarketMarket Plus Plan: OffVoluntary Enrollment Plans underwritten by LifeMap Assurance Company: FoundationFoundation Plus Plan: Offandor vision benefits employees dependents will automatically be enrolled in those benefits if they enroll in medical benefits: Traditional Plan: Offundefined_2: HSA Plan: OffFoundation Health Plan of Washington Options Inc and LifeMap Assurance Company If an employer offers common enrollment dental: Kaiser Plan: Offundefined: Vol Dental: OffVol Vision: OffFirst Name: Middle Initial: Last Name: Address: City: State: Zip: Phone: Email: Married: OffSingle: OffDate of Marriage: New Group: OffNew Employee: OffOpen Enrollment: OffLoss of Eligibility on Another Coverage: OffChange of Life Beneficiary: OffChange of Address: OffName Change: OffChange Medical Plan: OffBirth: OffMarriage: OffAdoption: OffDomestic Partner: OffCOBRA coverage exhausted: OffOpen enrollment: OffLoss of eligibility on another coverage: OffCheck Box1: OffCheck Box2: OffCheck Box3: OffLast 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dependents applying for coverage have coverage with any health care plan: OffOther Insurance Company Name: Other Insurance Company Phone: Other Insurance Company Full Address: Policyholders Name: Policyholders Birth Date: undefined_7: undefined_8: s Member ID or Social Security: Group Name Policy: Effective Date of Coverage: undefined_9: undefined_10: Intended Termination Date of Coverage: undefined_11: undefined_12: Reason for Termination: Persons covered by prior insurance list names and date of birth for each: Medical: OffPharmacy: OffDental: OffVision: OffMedicare: OffGroup: OffIndividual: OffMedicaid: OffMedicare Part A: OffMedicare Part B: OffOther: Offundefined_13: If employee or dependents have Medicare what was the begin date for Part A: Part B: Medicare HIC with Alpha Suffi x: Name of Person covered by Medicare: Disability: OffOver Age 65: OffEnd Stage Renal Disease: OffGroup2: OffEmployee Social Security Number: First Name_2: Middle Initial_2: Last Name_2: Check Box16: 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ITINChild_13: Text44: Text45: Text46: Gender MF_15: Check Box46: OffCheck Box47: OffCheck Box48: OffLast NameChild_14: First NameChild_14: MIChild_14: Social Security Number or Individual tax payer ID number ITINChild_14: Text47: Text48: Text49: Gender MF_16: Check Box49: OffCheck Box50: OffCheck Box51: OffLast NameChild_15: First NameChild_15: MIChild_15: Social Security Number or Individual tax payer ID number ITINChild_15: Text50: Text51: Text52: Gender MF_17: Check Box52: OffCheck Box53: OffCheck Box54: OffLast NameChild_16: First NameChild_16: MIChild_16: Social Security Number or Individual tax payer ID number ITINChild_16: Text53: Text54: Text55: Gender MF_18: Check Box55: OffCheck Box56: OffCheck Box57: OffLast NameChild_17: First NameChild_17: MIChild_17: Social Security Number or Individual tax payer ID number ITINChild_17: Text56: Text57: Text58: Gender MF_19: Check Box58: OffCheck Box59: OffCheck Box60: OffLast NameChild_18: First NameChild_18: MIChild_18: Social Security 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