Anthem Virginia Application Agreement

Important Legal Information:

I understand that:

• I must send my first (initial) premium with this application, but it does not mean coverage has been approved. I’m applying for the coverage I chose on this form. To the extent permitted by law, Anthem and HealthKeepers, Inc. has the right to accept or decline this application, and that there are no guarantees of any kind just because I filled out this form. If my application is denied, my bank account or credit card will not be charged, and if I paid with a money order, it will be returned to me.

• I’m responsible to let Anthem and HealthKeepers, Inc. know, in a timely manner, of any change that would make me or any dependent ineligible for coverage.

• Anthem and HealthKeepers, Inc. may change check payments to electronic Automated Clearinghouse (ACH) debit transactions. If this happens, my original check will be destroyed. This charge will appear on my bank statement but my check won’t be given to my financial institution or sent back to me. This charge will not enroll me in any Anthem Blue Cross and Blue Shield and HealthKeepers, Inc. automatic debit process and will only occur each time I send a check to Anthem and HealthKeepers, Inc. Any resubmissions due to insufficient funds may also occur electronically. All checking transactions will remain secure, and my payment by check means I agree to these terms.

• I agree and consent to the recording and/or monitoring of any telephone conversation between Anthem and HealthKeepers, Inc. and myself.

• I’m applying for individual health and/or dental and/or vision coverage which is not part of any employer sponsored plan and I’m responsible for all of the premium payments and making sure that all premiums are paid.

• I certify that each Social Security number listed on this application is correct.

• My domestic partner, if applicable, is only eligible for coverage if: he or she has been my sole domestic partner for 12 months or more; he or she is at least 18 years of age; he or she is mentally competent; he or she is not related to me in any way (including by blood or adoption) that would prohibit us from being married under state law; he or she is not married to or separated from anyone else; and he or she is financially interdependent with me.

• I certify to the best of my knowledge and belief, the responses herein are accurate. I certify that I have read, or had read to me, the completed application and that I realize that any act, practice, or omission that constitutes fraud or intentional misrepresentation of material fact in theapplication may result in the denial of benefits, rescission or cancellation of coverage(s).

I sign this application for and on behalf of any eligible dependents and myself if covered by Anthem and HealthKeepers, Inc. I am acting as their agent and representative.

This application cannot be altered by the applicant after submission to Anthem and HealthKeepers, Inc absent the acknowledgement and consent of Anthem and HealthKeepers, Inc.

By signing this application, I certify that the premium for my coverage will not be paid by a provider of health care services, hospital, non-profit organizations (including religious organizations) that have or whose primary donors have a financial interest in the benefits of the Evidence of Coverage, commercial entity with a direct or indirect financial interest in the benefits of the Evidence of Coverage or an employer that offers coverage under an employer health plan. I understand that if a third party is paying my premium, Anthem may decline to accept such premium payment if it is made by a person or entity from which it is not required by law to accept. The undersigned applicant and the agent certify that the applicant has read, or had read to him, the completed application and that the applicant realizes that any false statement or misrepresentation in the application may result in the loss of coverage under the policy. Dental plans may contain waiting periods for certain types of services as disclosed in marketing materials and your policy. A waiting period is the length of time you must be covered under your dental policy and pay premiums before we will pay for covered services. You are eligible for payment of covered services once your waiting period has been met.