BLUE CROSS BLUE SHIELD OF IDAHO APPLICATION AGREEMENT

By signing this application, I represent that all my answers are complete and accurate to the best of my knowledge and belief and that I understand and agree to the following conditions:

No independent producer, agent or employee of the insurance carrier can change any part of this application or waive the requirement that I answer all questions completely and accurately.

The insurance carrier may terminate or rescind an insured's coverage for any misrepresentation, omission of fact by, concerning, or on behalf of any insured that was or would have been material to the insurance carrier's acceptance of a risk, extension of coverage, provision of benefits or payment of any claim.

If this application is approved, coverage for me and any eligible persons named on this application will begin on the effective date assigned by the insurance carrier.

I understand that this application will become part of the contract between the insurance carrier and me. I affirm that I have reviewed all answers given on this application and, regardless of whether an independent producer or other person has filled out the answers for me, I verify that the answers are true and complete. Healthy Smiles Plus and Healthy Smiles Preferred include waiting periods. Preventive and diagnostic dental services do not have a waiting period. Basic dental services have a six month waiting period. Major dental services have a 12 month waiting period.

I acknowledge and understand my health plan may request or disclose health information about me or my dependents (persons who are listed for benefits coverage on the enrollment form) from time to time for the purpose of facilitating health care treatment, payment or for the purpose of business operations necessary to administer health care benefits; or as required by law. For more information about such uses and disclosures, including uses and disclosures required by law, please refer to the Blue Cross of Idaho Notice of Privacy Practices that is available here Blue Cross of Idaho Notice of Privacy Practices.

I affirm the answers given in this universal application are complete and correct. I am providing these answers as part of the application procedure required by this insurance carrier to enroll in its insurance coverage. I understand that the insurance carrier will rely on each answer in making its determination to extend coverage and to determine the type of coverage offered. I understand if this application contains any material misstatements or omissions, the insurance carrier may, within the first 24 months of coverage, deny coverage retroactively and/or take any other legal action available by law. I will promptly inform the insurance carrier in writing if anything happens before my coverage takes effect that makes any answer in this application incomplete or incorrect. I understand and agree no coverage shall be in force until approved by the insurance carrier. If approved, coverage will be in force as of the effective date determined by the insurance carrier.

By typing your name below, you are hereby signing this document.

• I hereby accept full responsibility for the payment of - premiums and the answers and information provided in this application.

• I verify that this application for health and/or dental medical coverage is the result of a qualifying life event. I understand that I may be required to provide proof of the qualifying life event.