McLaren Health Plan Application Agreement

Terms, Conditions and Authorizations

By completing and signing this application for individual health insurance coverage, I agree to the following:

1. All information I have provided on this form is true to the best of my knowledge and belief and correctly recorded by me.

2. Any material misstatement in this application may result in denial of a claim and/or rescission of coverage. Once the application is submitted, I may be contacted by phone or e-mail by McLaren Health Plan Community (MHP Community) or its representative to complete the application process.

3. The effective date of coverage will be on the 1st of the month following approval by MHP Community. Evidence of approval will be based upon the issuance of ID cards and policy certificate. Coverage is contingent upon the timely and accurate premiums due and will be terminated if this condition is not met.

4. I certify that I meet all requirements for eligibility stated within this application including but not limited to: a. Michigan residency for nine or more months during the year. b. United States Citizen or have a valid social security number. c. No other health insurance coverage currently in place, except Medicaid.

Authorization to Send Email Messages Periodically MHP Community sends out emails to our members providing them a newsletter, or to send information alerts/notifications or administrative reminders. MHP Community will not sell or give away your email information.

I authorize MHP Community to send periodic emails to me at the email address I have provided. I understand I may open emails on my cell phone and that charges from my cell phone provider may apply. MHP Community is in no way responsible for any fees charged to me by my cellular provider. I understand email is not a secure form of communication. If after receiving such emails, I wish not to receive them in the future, I may opt out of this program.

1. No contract waiver, modification or change of contract shall be binding upon MHP Community unless it is in writing and signed by an authorized officer of MHP Community.

2. I represent that neither I, my spouse, nor any dependent is receiving any form of reimbursement or compensation for this coverage from any employer

3. I understand and agree that no agent, producer or broker has the authority: (i) to bind MHP Community by making promises regarding eligibility, benefits, or the issuance of a policy; (ii) to waive any answer or any portion of any answer to any question on this application or any information MHP Community requests; (iii) approve coverage; (iv) make or alter any contract on behalf of MHP Community; (v) waive or alter any of MHP Community’s other rights or requirements.

4. I understand that, unless required by law, the completion of this application and submission of any estimated initial premium does not provide interim coverage.

5. I understand that, unless required by law, the completion of this application and submission of any estimated initial premium does not provide interim coverage.

6. If you have outstanding premium payments, you still owe the money and must pay it to MHP Community. For unpaid premiums in the past 12 months, any premiums paid under a new Certificate will be applied to what you owed under the prior Coverage. Once that amount is paid and the applicable premiums for the new Certificate are paid, MHP Community will activate Coverage (if you meet all of our eligibility requirements).