EMPLOYER INFORMATION ( must be completed )

Company Name/DBA : *

Company Address : *

You must complete this form in its entirety in order for you or your dependents to be covered under the health insurance plan. If you are waiving coverage for yourself or your dependents, it musts be clearly indicated on this form. If you do not complete this form in its entirety for yourself or your dependents at least 5 business days prior to the effective date , you or your dependents maybe not be eligible for coverage until the next open enrollment period.

TO BE COMPLETED BY EMPLOYEE( if applying or waiving coverage )

Benefit Plan :

Group Number :

A- EMPLOYEE ( Primary Applicant )

Full Name : *

First

Last

DOB : *

SSN : *

Gender *

Male
Female

Address : *

Address Line 1

City

State

Zip Code

Cell Phone : *

Work Phone :

Home Phone :

Email : *

Best Time to Call : *

Date

Time

Job Title *

Status : *

Single
Married

Employee Status : *

W2
1099
Owner / Partner

Earning Basis *

Salaried
Hourly
Commission

National General Benefits Solutions markets products underwritten and issued by National Health Insurance Company, Time Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation.

Complete and sign if waiving any or all coverages for self. All eligible employees must be listed as either enrolling or waiving coverage when first eligible.

Neither I nor dependents have been induced or pressured to decline coverage by my employer, the agent , or National Health Insurance Company. I and my dependents have waived such coverage of our own accord.

Printed Name

Date / Time

National General Benefits Solutions markets products underwritten and issued by National Health Insurance Company, Time Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation.

Requested effective date :

Groups with multiple medical plans, indicate which plan you are requesting. Medical Plan #

If dental coverage offered, are you electing ?

Yes
No

If multiple dental plans are offered, which plan are you requesting ? Dental Plan

If vision coverage offered, are you electing ?

Yes
No

Please contact your employer for the plan options/descriptions which are identified on your employer's billing statement and/or quote.

If enrolling outside of your employer's open enrollment period, indicate the special enrollment reason ( documentation may be required )

Marriage
Birth
Adoption
Court Ordered ( copy of court order required )

For any event in a, list date of event :

If enrolling outside of your employer's open enrollment period, indicate the special enrollment reason ( documentation may be required ) (copy)

Divorce/Separation
Involuntary loss of coverage
COBRA/ Continuation
Other

For any event in b, list coverage termination date :

* Certificate of Creditable Coverage is required for all loss of coverage special enrollment events.

National General Benefits Solutions markets products underwritten and issued by National Health Insurance Company, Time Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation.

Include yourself and all family members to be insured. If more space is needed, attach and additional sheet :

Employee Only
Employee Spouse
Employee Child ( ren )
Family : Employee, Spouse, & Child( ren )

National General Benefits Solutions markets products underwritten and issued by National Health Insurance Company, Time Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation.

Will any current medical plan remain active if coverage is approved ?

Yes
No

Are you, your spouse or any dependent children currently covered under Medicare Part A , B or D?

Yes
No

Will coverage remain active if the coverage for which you are applying is approved

Yes
No

National General Benefits Solutions markets products underwritten and issued by National Health Insurance Company, Time Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation.

Complete all questions below and check all that apply in Question 1. Complete Section G on the next page by providing complete details for each Yes answer and for all conditions Checked in Question 1.

Have you or any of your dependents included on this enrollment form within the past 5 years received treatment, tetsing, consulted with or received a diagnosis form a physician or provider for any of the following ?

Yes
No

Arthritis or other Skeletal Disorder

Diabetes Mellitus

Diabetic Related Disorders

Digestive Disorders

Heart Disorders

Angioplasty
Heart attack
Bypass
Other

Liver Disorder/Hepatitis

Mental, Nervous or Behavioral Disorder

Respiratory/Lung Disorders

Thyroid Disorder

Transplant

National General Benefits Solutions markets products underwritten and issued by National Health Insurance Company, Time Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation.

In the last 5 years, have you or any of your dependents included on this enrollment form :

Been diagnosed with or treated for any condition(s) not identified above ?

Yes
No

Been advised of the necessityor possibility of any future hopitalization , treatment , testing or surgery ?

Yes
No

Are you or any of your dependents included on this enrollment form currently pregnant ?

Yes
No

Is a Cesarean Section anticipated ?

Yes
No

Are multiple births expected ?

Yes
No

Are you/your dependent experiencing or anticipating any other complications ?

Yes
No

Have medications been prescribed in the past 18 months for you and/or any dependents included on this enrollment form. ( Include pills, creams, injections, liquids, inhalers, pumps, etc. )

Yes
No

National General Benefits Solutions markets products underwritten and issued by National Health Insurance Company, Time Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation.

APPLICATION Authorization & Signature

I hereby represent that I am an employee of the participating employer and that the statements and answers to the questions on this enrollment form are true and complete to the best of my knowledge and belief. I understand that the statements and answers contained herein will be used by National General Benefits Solutions (“NGBS”) to determine eligibility for coverage under the Self-Funded Program (“Program”) for myself and persons listed on this enrollment form as my spouse and/or dependent children.

I understand and acknowledge that I have elected to participate in the Section 125 plan offered by my employer, and I agree that my qualified insurance premiums may be paid by my employer through pre-tax salary/earnings reduction. I further acknowledge that my Social Security contribution and subsequent Social Security benefit will be slightly reduced.

I understand that (1) the answers given will be the basis of any coverage provided; (2) any material misrepresentation or failure to provide complete information to questions on this enrollment form may be used as a basis for changing rates or terminating coverage; (3) if coverage is not approved, I, my spouse, and/or dependent children are not entitled to benefits; (4) if I, my spouse, and/or dependent children waive coverage and decide to apply for coverage at a later date, evidence of eligibility may be required and benefits may be deferred for a specified period of time;and (5) coverage will not be effective until my employer receives notice that this enrollment for has been approved by NGBS.

I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, pharmacy or pharmacy related entity, pharmacy benefits manager (PBM) or PBM-related entity, insurance or reinsurance company or employer, having information about me or my minor children to provide all such information as may be requested to NGBS, its legal representative or any medical records retrieval service NGBS may engage.

This authorization includes any and all information any of the foregoing may have about me, including, but not limited to, information regarding diagnosis, testing, treatment and prognosis of my physical or mental condition as well as alcohol abuse treatment, drug abuse treatment, psychiatric treatment, pharmacy prescriptions, HIV testing and treatment, STD testing and treatment, sickle cell testing and treatment, lab data and EKGs. This information may also be disclosed to any medical records company engaged by NGBS. Although federal regulation requires that we inform you of the potential that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by such regulation, all information received by NGBS pursuant to this authorization will be protected by federal and state privacy laws and regulations.

I understand and agree that in connection with my application for coverage under the Program: (1) NGBS may obtain consumer reports which may include credit information, a driver history report, and/or personal or privileged information from third parties; (2) such information may be disclosed to affiliated or unaffiliated third parties without my prior permission but only as permitted or required by law; (3) upon my written request, NGBS will inform me if a consumer report was requested and the name and address of the consumer reporting agency that furnished the report; (4) I may also request access to and correction of information NGBS has collected on me; (5) NGBS may request and use subsequent consumer reports in updating and renewing any insurance afforded in connection with this Application; and (6) NGBS will furnish a more detailed explanation of its information practices upon my request.

In connection with this application for insurance, NGBS will review my credit report or obtain or use an insurance credit score based on the information contained in that credit report. NGBS may use a third party in connection with the development of my insurance credit score. I may request that my credit information be updated and if I question the accuracy of the credit information, NGBS will, upon my request reevaluate me based on corrected credit information from a consumer reporting agency.

I hereby authorize NGBS to obtain consumer reports on me.

I understand that this authorization is required in order to enable NGBS to make eligibility or enrollment determination relating to me, my spouse, and/or my dependents or for NGBS to make underwriting or risk rating determinations. If I refuse to sign or revoke this authorization, or refuse to authorize NGBS to obtain a consumer report on me, NGBS may refuse to consider my application for enrollment.

I understand that I may revoke this authorization at any time by notifying NGBS in writing of my desire to revoke. Such revocation must be sent by certified mail to the following address: Privacy Office, National Health Insurance Company, 4455 LBJ Freeway, Ste 375, Dallas TX, 75244. Such revocation will not be valid to the extent NGBS has taken action in reliance on the authorization prior to its revocation. This authorization expires upon the earliest of the following: denial of my application, declination of enrollment, or when I am no longer covered under the Program, but in no event will this authorization be in effect for longer than 24 months from the date signed.

I acknowledge that knowing and willful misstatements in this enrollment form may constitute health care fraud, a criminal violation of 18 US Code Section 1347 (punishable by up to 10 years in prison).

Employee/Primary Applicant Signature : *

Date *

National General Benefits Solutions markets products underwritten and issued by National Health Insurance Company, Time Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation.

Employee Enrollment Health App

EMPLOYER INFORMATION ( must be completed )

TO BE COMPLETED BY EMPLOYEE( if applying or waiving coverage )

A- EMPLOYEE ( Primary Applicant )

Complete all questions below and check all that apply in Question 1. Complete Section G on the next page by providing complete details for each Yes answer and for all conditions Checked in Question 1.

In the last 5 years, have you or any of your dependents included on this enrollment form :

APPLICATION Authorization & Signature