GROUP APPLICATION

GENERAL INFORMATION:

Name of Group: # of Eligible Employees Address: Group Tax ID# City/State/Zip: Phone: County: Fax:

CONTACTS: (Please include titles)

Administration: Title: Email: Enrollment: Title: Email: Billing: (name & location)

Electronic Enrollment: Yes No Automatic Deduction of Premiums: Yes (Please print, complete and mail the Authorization for Direct Payment) No Electronic Billing: Yes - Email: No

ELIGIBILITY INFORMATION:

Dependents will be covered through the end of the birth month. Please complete the following age limits: -Primary dependents covered to age: (max age limit is 19) AND -Full-time students covered to age: (max age limit is 25) OR -IRS dependents covered to age: (max age limit is 25) PLAN DESIGN AND RATES: Plan #: Effective Date: Renewal Date: The Preferred Plan The Choice Plan The Direct Plan ASO   Core   In Network Out of Network Admin Fee Admin Fee Preventive Preventive Reimbursement Schedule   Basic Basic Level 1   Major Major Level 2   Deductible Deductible Level 3   Contract Maximum Contract Maximum Level 4   Orthodontic Orthodontic Orthodontic Maximum   Orthodontic Maximum Orthodontic Maximum Contract Maximum   Max Advantage Contract Maximum               Year 2               Year 3               Rates Rates Funding Rates Funding Rates Employee Employee Employee Employee EE + Spouse EE + Spouse EE + Spouse EE + Spouse EE + Child(ren) EE + Child(ren) EE + Child(ren) EE + Child(ren) EE + Family EE + Family EE + Family EE + Family If choosing the 3-tier or 4-tier rates above, groups must have at least one employee enrolled in each of the tiers to be eligible for the rates. ADDITIONAL OPTIONS: Superior Vision: Option #1 Option #2 Other EyeMed Vision Care Access Plan D is offered with all SDC plans at no additional charge. COBRA Offered by Ceridian: Yes No Contribution Levels: Employer pays: Employee pays: Association Plan: Chamber Plan: Yes - Name of chamber: No Note: All chamber information will be verified with designated chamber before group is installed. BROKER INFORMATION: *Firm: Address: Phone: City/State/Zip: Fax: Selling Agent Name: Selling Agent Email: Servicing Agent Name: Servicing Agent Email: Tax ID#: Is the firm incorporated? Yes No *Commission will be paid to the firm unless otherwise agreed upon.

Corporate 6683 Centerville Business Parkway Centerville, OH 45459 937-438-0283 / 800-762-3159 Claims/Member Services / Fax: 937-291-8695 / Sales/Service Fax: 937-438-0288