ServiceBridge VEBA Enrollment Form

ServiceBridge VEBA Trust Enrollment Form

1Part I

2Part II

3Part III

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Tell Us About the Retiree (Eligible Member)

Please tell us about the retiree that is being enrolled to get started.

Please Choose(Required)

Retiree Full Name(Required)

First Middle Last

Retiree Gender(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Daytime telephone number(Required)

Retiree Social Security Number(Required)

Enter a valid SSN. Your Social Security Number is secured with AES-256, encryption used by banks and the military, ensuring utmost safety. Additionally, all data in transit is protected with robust TLS/SSL encryption.

Retiree Email Address

Enter Email Confirm Email

This is to keep in communication after submission.

Referral Code

Does the Retiree Have Dependents Enrolling?(Required)

Yes Dependents

No Dependents

Section II: List Spouse and/or All Dependents That Are Enrolling

You indicated the retiree has dependents. Please list each spouse and child who will be included in this application. To add a dependent, click the plus (+) icon at the right side of any row.

Dependents List

First Name

Last Name

Relationship to Retiree

Sex

DOB

Full-Time Student?

Dependent SSN

Please list your Spouse (if applicable) or any applicable dependents.

Choose Your Plan

Effective Date for Coverage(Required)

When do you want your coverage to start?

Choose only one plan and network that best suits you and your needs.

Basic PPO BCBS Network Plan

Retiree Only

Retiree + Spouse

Retiree + Children

Family

Basic PHCS Network Plan

Retiree Only

Retiree + Spouse

Retiree + Children

Family

Plus PPO BCBS Network Plan

Retiree Only

Retiree + Spouse

Retiree + Children

Family

Plus PHCS Network Plan

Retiree Only

Retiree + Spouse

Retiree + Children

Family

Ultra PPO BCBS Network Plan

Retiree Only

Retiree + Spouse

Retiree + Children

Family

Ultra PHCS Network Plan

Retiree Only

Retiree + Spouse

Retiree + Children

Family

Bronze PPO BCBS Network Plan

Retiree Only

Retiree + Spouse

Retiree + Children

Family

Basic PHCS Network Plan

Retiree Only

Retiree + Spouse

Retiree + Children

Family

Silver PPO BCBS Network Plan

Retiree Only

Retiree + Spouse

Retiree + Children

Family

Silver PHCS Network Plan

Retiree Only

Retiree + Spouse

Retiree + Children

Family

Retiree Confirmation

To ensure that we are meeting all regulatory and VEBA Trust requirements, and using program and member support resources efficiently, please confirm the following:

Are you currently retired from your career as an active First Responder?(Required)

Yes

Are you currently unable to work?(Required)

Yes

Are you currently confined in a hospital, skilled nursing facility, or similar institution?(Required)

Yes

Are you currently covered by a qualified health plan (e.g., group health plan, ACA Marketplace Exchange plan, etc.)(Required)

Yes

Are you in active treatment for an ongoing medical condition that requires specialty prescription medication?(Required)

Yes

Payment Information

Please provide your bank account details below for payment.

Account Type

Bank Name(Required)

Account Number(Required)

Your data is secured with AES-256, encryption used by banks and the military, ensuring utmost safety. Additionally, all data in transit is protected with robust TLS/SSL encryption.

Confirm Account Number(Required)

Bank Routing Number(Required)

Enter a valid Bank Routing Number shown at the bottom of your bank checks. Your data is secured with AES-256, encryption used by banks and the military, ensuring utmost safety. Additionally, all data in transit is protected with robust TLS/SSL encryption.

Consent(Required)

I authorize Solidarity Health Network to debit my bank account for the the amount indicated on the policy.

Final Section

AUTHORIZATION AND ACKNOWLEDGMENT(Required)

I have read the above and acknowledge my understanding of, and authorization to, the requirements for Plan participation.

Please read carefully before submitting this form.

I HEREBY:

Request enrollment in the self-funded Group Health Plan (the “Plan”) established and maintained by the ServiceBridge VEBA Benefit Trust (the “Trust”) for its eligible Members and their eligible dependents;

Represent that I am an eligible Member as defined by the Plan and that none of the persons for whom coverage is being requested are currently confined to a hospital, skilled nursing facility, or similar institution;

Represent that my statements and answers to the questions in this enrollment form are true and complete to the best of my knowledge and belief;

Authorize the Plan to collect any required contribution in accordance with the Plan’s administrative practices; and

Consent to receive informational communications, including electronic mail and SMS text messages, from affiliated service providers supporting the Plan’s administration.

I FURTHER ACKNOWLEDGE AND UNDERSTAND:

This is not an insured benefit plan;

All Plan benefits are self-funded (self-insured) by the Trust;

The Trust is solely responsible for all benefit payments;

Coverage is not effective until the Plan approves this enrollment form;

Plan benefits are available only if a person is covered under, and all required contributions for such coverage have been received by, the Plan;

If I have waived coverage for a dependent, I also waive all claims under the Plan for benefits for that dependent, and if I decide to enroll that person at a later date, the effective date for my dependent will be subject to the Annual Open Enrollment and/or Qualifying Event provisions as defined by the Plan;

A full description of the medical expense benefits under the Plan appears in the Summary Plan Description, which summarizes the official Plan Document;

The agent submitting this enrollment lacks authority to change the enrollment form, approve Plan coverage, alter Plan terms, or adjust claims;

The Reinsurer, The Program Manager, The Broker, The GA, The MGA or the TPA is not responsible for funding benefit payments;

My statements and answers in this enrollment form will be the basis for approving Plan coverage and any material misrepresentation or omission may result in an increase in Plan contribution rates or termination of my coverage;

Fraud Warning: Any person who, knowingly and with intent to defraud, submits an enrollment form, or files a claim, containing a materially false statement, or omitting materially false information, may be found guilty of fraud in a court of law.

SPECIAL ENROLLMENT RIGHTS

You may be able to enroll dependents without delay or penalty in the following situations:

New Dependent (31 days): If you acquire a new dependent by marriage, birth, adoption or placement for adoption, he/she may be able to enroll if you request enrollment within 31 days;

Loss of Other Coverage (31 days): If you decline enrollment for any dependent (including your spouse) because of other health plan or group insurance coverage, and that dependent subsequently becomes ineligible for the other coverage (or the employer stops contributing towards that coverage), he/she may be able to enroll if you request enrollment within 31 days;

Loss of Medicaid/CHIP (60 days): If you decline enrollment for any dependent (including your spouse) because of coverage under Medicaid or a State child health plan, and that dependent’s coverage is subsequently terminated due to ineligibility, he/she may be able to enroll if you request enrollment within 60 days;

Premium Assistance Eligibility (60 days): If you decline enrollment for any dependent (including your spouse) and that dependent subsequently becomes eligible for a premium assistance subsidy from Medicaid or a State child health plan, he/she may be able to enroll if you request enrollment within 60 days of eligibility.

To request special enrollment, contact the Plan Administrator.

PERSONAL INFORMATION NOTICE

As required by law, this notice informs you that:

Personal information may be collected from third parties;

Such information as well as other personal or privileged information collected by the health plan or its legal representative may be, in certain instances as prescribed by law, disclosed to other third parties without your prior authorization;

You have the right to access and correct the collected information;

Your right to access does not include any information which relates to and is collected in connection with, or in reasonable anticipation of, a claim or civil or criminal proceeding;

We will provide a more detailed notice of information practices upon request.

AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize the disclosure of all nonpublic personal information and individually identifiable protected health information for me (and my dependent(s), if applicable), including but not limited to employment status, other health plan coverage, diagnosis, prognosis, medical treatment or care, and physical or mental conditions (including alcohol or drug dependency), by any physician, medical practitioner, hospital, other medical related facility, insurance company, employer or benefit plan having such information, to the health plan or its legal representative, agent or vendor, for the purpose of processing enrollment and claims.

I acknowledge and agree that:

This authorization shall be valid for two (2) years;

I may revoke it in writing at any time;

I may request a copy of this authorization;

Enrollment, but not the processing of claims, is conditioned on my signing this authorization;

This authorization will be used as its own document, separate from the enrollment form;

A photocopy of this authorization shall be as valid as the original;

Any documentation or information disclosed pursuant to this authorization may be redisclosed and may no longer be covered by federal or state privacy laws;

I have authority to act as the personal representative of my dependent(s) (if requesting dependent coverage).

I also hereby authorize any physician, medical practitioner, hospital, clinic, Veterans Administration facility, other medical or medically related facility, insurance or reinsurance company, pharmacy, pharmacy benefit manager, health plan, or Consumer Reporting Agency, having information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition, including drug or alcohol abuse, as well as diagnosis, treatment, and testing results related to HIV, AIDS, and sexually transmitted diseases, and/or treatment of me or my minor children and other nonmedical information of me and my minor children, to release to the claims or third party administrator, any other excess loss insurance carrier designated by the Plan, or its legal representative, any and all such information as required for determination of eligibility for benefits.

I understand that my dependents of legal age, in order to be eligible for benefits, may be required to sign a similar release of medical records for the purpose of determining the accuracy of statements made by me on this form and for the ultimate determination of eligibility for benefits under the Plan.

IMPORTANT LEGAL PROVISIONS

I understand that I may request a copy of this authorization at any time;

I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information;

I agree that a photographic copy of this authorization shall be as valid as the original, and that this authorization shall be valid for two and one-half (2.5) years from the date shown below;

I understand the information obtained by use of this authorization may be used by the Plan Sponsor, claims or third party administrator, and any excess loss insurance carrier designated by the Plan to determine eligibility for coverage;

Any information obtained will not be released to any person or organization, except to reinsuring companies or other persons or organizations performing business or legal services in connection with my enrollment for the coverage, for any claim, for medical management purposes, or as may be otherwise lawfully required or as I may further authorize;

I understand that I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization;

Important: Failure to sign this Authorization, or subsequent revocation of this Authorization, may impair the ability of the underwriter to process your application/enrollment or evaluate claims, and may be a basis for denying an application or claim for benefits; however, your ability to receive health care services will not be changed if you do not sign this Authorization;

All pages must be attached and complete, including this authorization for the statement to be considered complete. Incomplete statements may be rejected.

By submitting this form, you acknowledge that you have read, understood, and agree to all terms and conditions stated above.