A Summary of Benefits and Coverage (SBC) is available for medical plans only to assist you in understanding the details of the plan. A Uniform Glossary of insurance-related terms is also available. The SBC and/or the Uniform Glossary are accessible on the web at www. bluecrossmn.com or available free of charge when requested by contacting your employer or your employer’s Agent or Broker, or by calling Customer Service at 1-800-382-2000 toll-free.

I hereby acknowledge that I have been given the opportunity to participate in the group medical, dental, and/or vision plans provided by my employer. If I and/or any of my eligible dependents desire to apply for this coverage at a later date, I may be required to wait until my group’s renewal or until a special enrollment event occurs before coverage will be offered.

Special Enrollment Rights: If you are declining enrollment for yourself or your dependents (including your spouse), you may in the future be able to enroll yourself and your dependents in this plan, provided that you request enrollment within 31 days after you and your dependent’s other coverage ends, or not later than 60 days if the other plan coverage was through Medicaid or a state Children’s Health Insurance Program (CHIP). In addition, if you have a new eligible dependent as a result of birth, adoption or placement for adoption, or foster care or court order, you may be able to enroll yourself and your eligible dependents. (For dental and/or vision coverage only, you may also enroll an eligible dependent under age 3 anytime up to 30 days following the child’s third birthday.) In order to avoid claim delays, you should request enrollment within 30 days after the birth, adoption or placement for adoption, or foster care or court order. Special enrollment may also be available as a result of a marriage, provided that you request enrollment within 30 days after the marriage.

Read this section, sign and date the Application. Blue Cross and Blue Shield of Minnesota and/or Blue Plus hereinafter referred to as Blue Cross, will act in reliance on the information you provide on this Application. For the purposes of the Application, I understand and agree that ‘employee’ is defined as only those individuals subject to FICA and other tax withholding, and performing services for compensation for the employer listed in Section I of this Application. In order to process this Application, Blue Cross may collect personal information regarding me or my family members listed on this Application. The information collected by Blue Cross or Blue Cross’s authorized agents may in certain circumstances be disclosed to third parties without authorization. I have the right to see my personal records that are maintained by Blue Cross and to correct personal information Blue Cross has collected about me or my family members listed on this Application. Upon my request, Blue Cross will furnish a more detailed notice of Blue Cross information practices. Blue Cross keeps this information confidential, but may release it if I authorize release, or if state or federal law permits or requires release without authorization. For purposes of obtaining information in connection with this Application, reinstatement, or change in policy benefits, this release is valid as long as I am continually insured with the insurer. I am entitled to receive a copy of any release I sign. I agree if I am enrolling in a product that features certain designated providers, Blue Cross may share my name, address and telephone numbers, as well as my past, current and future health and account records with such designated providers about services I’ve received from such designated providers and other care providers unrelated to such designated providers. These records may be used by the designated providers as needed to manage or coordinate my care and to improve the quality of that care. Blue Cross primarily relies upon the information provided and full disclosure of the information listed on this Application in the decision whether to accept me and my family members listed on this Application for coverage. I acknowledge the importance of providing accurate and complete information. I acknowledge I must answer all required questions in the Application, even if I and/or my family members listed on this Application currently have coverage or had prior coverage with Blue Cross. I understand and agree that payment of a claim does not preclude the right of Blue Cross to deny future claims or take any action it determines appropriate, including rescission of the contract and seeking repayment of claims already paid. I understand that neither the medical plan nor the dental plan includes coverage for the pediatric dental essential health benefit and that Blue Cross has made me aware of pediatric dental coverage available for purchase. For additional information on available pediatric dental plans, please visit www.mnsure.org. I agree to notify Blue Cross immediately of any change in my or my family member’s enrollment information between the date of this Application and the effective date of coverage. Failure to notify Blue Cross of any change in the information contained on this Application may result in the denial of a claim(s), rescission of the contract and/or a premium adjustment. Upon request, I agree to furnish any additional information needed concerning the eligibility of any family member applying for coverage. Blue Cross may, in its sole discretion and in accordance with applicable law and regulatory guidance, decline to accept premium and cost-sharing payments made directly or indirectly by ineligible third parties. “Ineligible third parties” include any person or entity from which Blue Cross is not required by law to accept such third-party payments. This may include, for example, commercial entities, healthcare providers and suppliers, and other persons or entities with direct or indirect pecuniary interests. “Payments” include those made by any means, for example: cash, check, money order, credit card payment, electronic fund transfer, etc. If you have questions about this third party payment policy or whether Blue Cross will accept premium and/or cost-sharing payments made by a specific person or entity, please contact Blue Cross. I acknowledge that I am not applying for this coverage in connection with any offer from any ineligible third-party to pay any premium or cost-sharing related to this plan. I understand that the health plan I have selected may contain a limited number of providers in the network listed on my application, the providers in the network may change from time to time, and not every provider is in-network for my plan. I also understand and acknowledge that with limited exceptions if I visit a provider or a location that is not in-network, I will pay more for my care, and these costs will count towards any applicable Out-of-Network cost sharing (e.g., the Out-of-Network deductible and Out-of-Pocket [Limitation / Maximum]). I understand and agree that Blue Cross may share my past, current and future health and account records with my network providers about services I’ve received from my network providers and non-network providers. These records may be used by my network providers as needed to manage or coordinate my care and to improve the quality of that care. By providing your email address, you agree to receive communications and/or marketing materials related to the Plan you selected and products offered by or made available from Blue Cross and its affiliates. You may unsubscribe or change your email address at any time by following the instructions included in each email communication. By providing your phone number, you expressly consent to accept and receive communications and /or marketing materials related to the Plan you selected and products offered by or made available from Blue Cross and its affiliates, via text message or voice call to your mobile device and to the cellular/mobile telephone number(s) that you provided to us. WARNING: E-mail and text messaging transmission cannot be guaranteed to be secure or error-free as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. As the recipient of an email or text message from an unsecured email or device, Blue Cross, does not accept liability for any errors or omissions in the contents of this message, which arise as a result of e-mail or text message transmission. I have read the preceding instructions, statements and answers and represent them to be true and complete to the best of my knowledge and belief. I understand and agree Blue Cross will act in reliance upon the information I have provided on this Application and that any false information, omissions or misstatements on this Application which materially affect enrollment eligibility may result in the denial of a claim(s), rescission of the contract and/or a premium adjustment. If this Application is completed as an electronic or online Application form, both parties agree to conduct this transaction electronically.

• Please contact your employer or your employer’s Producer for assistance. • This information is available in other ways for people with disabilities who need it translated into another language by calling 1- 800-382-2000 (toll free). For TTY, call 711. Hours: 8 a.m. to 6 p.m., Central Time, Monday through Friday. Submission Instructions - Employees: Please return your completed form to your employer. Employers: Completed employee forms should be returned to Blue Cross via the following - • New Group Business: Please refer to your agent or benefits administrator. • Open Enrollment: Employees and dependents who want the effective date of their coverage to be on the annual renewal date of the employer’s plan (during the 30 day period before the annual renewal date) and • Ongoing Enrollment: Adding new employees/contractholders/or dependents to an existing group. Please submit on the employer portal; or fax, email or mail to Blue Cross: Fax (651) 662-7258 / Enrollment.Forms@bluecrossmn.com Blue Cross and Blue Shield of Minnesota / P.O. Box 64024 / St. Paul, MN 55164-0024 4