ConnectiCare Application Agreement

TERMS, CONDITIONS AND CONSENT

Important: [The applicant, spouse/partner and all dependents aged 18 and over must sign this form]. By [selecting I (we) agree] signing here I acknowledge and agree that I have read and understand the information on all pages of this Application. I also agree that the Member Consent below is valid as long as I am enrolled in a ConnectiCare health plan. I certify that I have personally completed this application on behalf of myself and on behalf of my dependents listed on the application who are under the age of 18. I represent that the answers and statements made herein are true, complete and correctly recorded to the best of my knowledge and belief. I acknowledge that I have received a copy of the Outline of Coverage for the Plan I have selected above. I acknowledge and agree that with respect to any dependents under age 18 that I am authorized to make these statements on their behalf. I further understand and agree that: (1) this application does not give me immediate coverage; (2) the broker is only authorized to submit this application; (3) if I have knowingly provided incorrect or incomplete information on this application that ConnectiCare may rescind any policy within 2 years of issuance. This means that ConnectiCare will cancel coverage as if the policy never existed; and (4) I have personally read and completed this application and that application will become part of the contract between ConnectiCare and me and I agree to abide by the terms of that contract. I understand that the phone number(s) I provided on this application may be used by ConnectiCare or any of its contracted parties to contact me about my account, the provision of services to me or my health benefit plan or related programs. THIS PLAN IS ISSUED ON AN INDIVIDUAL BASIS AND IS REGULATED AS AN INDIVIDUAL HEALTH INSURANCE PLAN.