If you have questions or require assistance when completing this application, please contact one of our offices listed below: Home Office 4510 13th Ave. S. Fargo, ND 58121 Phone: (800) 342-4718 Fargo District Office 4510 13th Ave. S. Fargo, ND 58121 Phone: (701) 277-2232 Grand Forks District Office 3570 South 42nd St., Suite B Grand Forks, ND 58201 Phone: (701) 795-5340 Dickinson Office 1674 15th St. W., Suite D Dickinson, ND 58601 Phone: (701) 225-8092 Bismarck District Office 1415 Mapleton Ave. Bismarck, ND 58503 Phone: (800) 247-3876

BLUE SAVER BENEFIT PLAN I understand the Blue Saver Benefit Plan is a high deductible health plan designed to comply with Section 223 of the U.S. Internal Revenue Code and is intended for use with a Health Savings Account. I also understand BCBSND does not provide tax, investment or legal advice. If I have questions about a Health Savings Account or the tax implications of the Blue Saver Benefit Plan, I should contact a qualified tax, investment or legal professional.

Minot Public School District Group Application

LIMITATIONS AND EXCLUSIONS I understand Members are subject to limitations and exclusions outlined in the relevant Benefit Plan or policy. CONVERSION RIGHTS FOR HEALTH COVERAGE In the event the group through which I am enrolled elects to terminate, BCBSND has the right at its sole discretion to continue my coverage on a non-group basis subject to the premium and Benefit Plan provisions for non-group coverage then in effect. Conversion coverage will not be offered to a Subscriber if the group through which the Subscriber is eligible has terminated coverage with BCBSND and has enrolled as a group with another insurance carrier. METHOD OF PAYMENT In the event my employer adopts the method of payroll deduction, I hereby authorize and direct my employer to deduct the current premium from my wages or salary and remit the same to BCBSND. This authorization is to continue in effect until revoked by me in writing.

Blue Cross Blue Shield of North Dakota (BCBSND) is an independent licensee of the Blue Cross and Blue Shield Association.

Minot District Office 1308 20th Ave. SW Minot, ND 58701 Phone: (701) 858-5000

This health plan is that of your employer. BCBSND is serving only as the Claims Administrator and does not assume any financial risk except for stop-loss coverage.

Devils Lake Office 425 College Dr. S., Suite 13 Devils Lake, ND 58301-3537 Phone: (701) 662-8613 Jamestown Office 300 2nd Ave. NE., Suite 132 Jamestown, ND 58401 Phone: (701) 251-3180 Williston Office 1137 2nd Ave. W., Suite 105 Williston, ND 58801 Phone: (701) 572-4535

Member Services Toll-Free

(800) 247-3876 Visit us on the web www.BCBSND.com 29313344 Noridian Mutual Insurance Company

PPACA Eff. 1/1/2018 11-17

29313344

DCN

4. OTHER COVERAGE INFORMATION

Minot Public School District Group Application

Please type or print in black ink. Press firmly. 1. APPLICANT’S INFORMATION Last Name

First

M.I.

Mailing Address City

State

Zip Code

Rev. 11-17

BPN_________________________ GROUP ROLL__10957________________ Social Security Number – – Home Phone – ( ) Work Phone – ( )



Marital Single Divorced (Give date if changing Marital Status) Sex Birth Date (mm-dd-yy) M F – – – – Status Married Widowed Applicant’s Employer Occupation Average Number of Hours Worked Weekly Minot Public School District Employment Status and Date (mm-dd-yy) Requested Effective Date (mm-dd-yy) Full-time – – – – Part-time 2. SPOUSE/DEPENDENT INFORMATION (Use extra paper if necessary)

• List all family members to be covered, other than yourself. Indicate their relationship to you (i.e. child, stepchild, adopted, legal guardian, grandchild). • Indicate dependent’s address below dependent’s name if the address is different from yours. If Marital Status is Single and you are applying for coverage for your Eligible Dependent(s), you are required to attach a copy of the state birth • certificate for each dependent unless previously submitted. First Name

M.I.

Last (if different )

Birth Date (mm-dd-yy)

Relationship Sex

SPOUSE Address: Address: Address: Address: Address:

M F M F M F M F M F M F

–

–

–

–

–

–

–

–

–

–

–

–

Active Military Yes No Yes No Yes No Yes No Yes No Yes No

Court Married Ordered Coverage

N/A

N/A

Yes No Yes No Yes No Yes No Yes No

Yes No Yes No Yes No Yes No Yes No

Other Health Benefit Plan including BCBSND coverage/Publicly Sponsored Program (If you have other dental or vision coverage, provide information on a separate piece of paper.) Yes No Are you, your spouse or any of your Eligible Dependents currently or previously covered by another health benefit plan(s)? If yes, please complete this section. Other Coverage Name Other Coverage Phone Number Policy Number Policyholder (first, m.i., last name) Birth Date (mm-dd-yy) – – Policy Coverage Dates (mm-dd-yy) Name(s) of Person(s) Covered – – – – From _____________ to ______________

Social Security Number –

–

–

–

–

–

–

–

–

–

–

–

Yes No Do you intend to keep your current policy in force after the effective date of this application? If not, why?­­­­­­_____________________________________

Medicare Yes No Are you, your spouse or any of your Eligible Dependents currently or previously enrolled in Medicare? If yes, please complete this section. Name(s) of Person(s) enrolled in Medicare Medicare Claim Number (include alpha characters as shown on Medicare card) Hospital Part A Effective Date

-0

1-

Medical Part B Effective Date

-0

1-

Prescription Drug Part D Effective Date

I am applying for: Single Coverage = myself only Single Plus Dependent Coverage = myself and eligible children Family Coverage = myself and spouse OR myself, spouse and eligible children

Plan Selection: SelectChoice 250: Provider Network Name: Trinity/UND Family Practice Prime Care Sanford

5. SIGNATURE(S) (This form must be signed and dated)

I understand that any company(s) with which I am applying for coverage reserves the right to accept or decline this application in whole or in part. I further understand that no contractual right is created by this application or advance premium payment and the same shall not be considered accepted unless or until the Benefit Plan is issued to me. I have read this application in its entirety (including the back page) and understand and acknowledge that the accuracy and sufficiency of the information I provide (or fail to provide) in each and every numbered section of this application serves as the basis in determining my eligibility (and the eligibility of my dependents) for coverage and receiving a Benefit Plan(s), and by signing this application I certify the information is accurate and complete. I understand and agree that inaccurate, incomplete or omitted information represented in this application may constitute a fraudulent act or intentional misrepresentation of material facts voiding or retroactively cancelling any Benefit Plan(s) issued, as well as any claims for medical benefits and services paid, based on the information I submit through this application. I further understand a person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

X______________________________________________________ Applicant’s Signature Date Signed

Blue Saver® 100 2700

*Refusal of Coverage The group Benefit Plan provided by my employer has been explained to me thoroughly, and I understand it fully. I elect not to participate and understand that I will not be entitled to any benefits provided by the group Benefit Plan. I make this election voluntarily and under no compulsion or duress.

1-

Workers’ Compensation/No-Fault Yes No Are you, your spouse or any of your Eligible Dependents currently receiving or have received workers’ compensation benefits? Yes No Are you, your spouse or any of your Eligible Dependents currently receiving or have received no-fault benefits? Person’s Name Injury Date (mm-dd-yy) Type of Injury Company Providing Benefits Company Phone Number – –

3. COVERAGE INFORMATION HEALTH (BCBSND) coverage: New Coverage (I do not have BCBSND coverage now) Change in Existing BCBSND Coverage I Refuse Coverage*

-0

Agent Number

46

Agent Name

WHITE ORIGINAL - BCBSND

Katie Veidel YELLOW COPY - Employer

WHITE COPY - Applicant

29313344

DCN

4. OTHER COVERAGE INFORMATION

Minot Public School District Group Application

Please type or print in black ink. Press firmly. 1. APPLICANT’S INFORMATION Last Name

First

M.I.

Mailing Address City

State

Zip Code

Rev. 11-17

BPN_________________________ GROUP ROLL__10957________________ Social Security Number – – Home Phone – ( ) Work Phone – ( )



Marital Single Divorced (Give date if changing Marital Status) Sex Birth Date (mm-dd-yy) M F – – – – Status Married Widowed Applicant’s Employer Occupation Average Number of Hours Worked Weekly Minot Public School District Employment Status and Date (mm-dd-yy) Requested Effective Date (mm-dd-yy) Full-time – – – – Part-time 2. SPOUSE/DEPENDENT INFORMATION (Use extra paper if necessary)

• List all family members to be covered, other than yourself. Indicate their relationship to you (i.e. child, stepchild, adopted, legal guardian, grandchild). • Indicate dependent’s address below dependent’s name if the address is different from yours. If Marital Status is Single and you are applying for coverage for your Eligible Dependent(s), you are required to attach a copy of the state birth • certificate for each dependent unless previously submitted. First Name

M.I.

Last (if different )

Birth Date (mm-dd-yy)

Relationship Sex

SPOUSE Address: Address: Address: Address: Address:

M F M F M F M F M F M F

–

–

–

–

–

–

–

–

–

–

–

–

Active Military Yes No Yes No Yes No Yes No Yes No Yes No

Court Married Ordered Coverage

N/A

N/A

Yes No Yes No Yes No Yes No Yes No

Yes No Yes No Yes No Yes No Yes No

Other Health Benefit Plan including BCBSND coverage/Publicly Sponsored Program (If you have other dental or vision coverage, provide information on a separate piece of paper.) Yes No Are you, your spouse or any of your Eligible Dependents currently or previously covered by another health benefit plan(s)? If yes, please complete this section. Other Coverage Name Other Coverage Phone Number Policy Number Policyholder (first, m.i., last name) Birth Date (mm-dd-yy) – – Policy Coverage Dates (mm-dd-yy) Name(s) of Person(s) Covered – – – – From _____________ to ______________

Social Security Number –

–

–

–

–

–

–

–

–

–

–

–

Yes No Do you intend to keep your current policy in force after the effective date of this application? If not, why?­­­­­­_____________________________________

Medicare Yes No Are you, your spouse or any of your Eligible Dependents currently or previously enrolled in Medicare? If yes, please complete this section. Name(s) of Person(s) enrolled in Medicare Medicare Claim Number (include alpha characters as shown on Medicare card) Hospital Part A Effective Date

-0

1-

Medical Part B Effective Date

-0

1-

Prescription Drug Part D Effective Date

I am applying for: Single Coverage = myself only Single Plus Dependent Coverage = myself and eligible children Family Coverage = myself and spouse OR myself, spouse and eligible children

Plan Selection: SelectChoice 250: Provider Network Name: Trinity/UND Family Practice Prime Care Sanford

5. SIGNATURE(S) (This form must be signed and dated)

I understand that any company(s) with which I am applying for coverage reserves the right to accept or decline this application in whole or in part. I further understand that no contractual right is created by this application or advance premium payment and the same shall not be considered accepted unless or until the Benefit Plan is issued to me. I have read this application in its entirety (including the back page) and understand and acknowledge that the accuracy and sufficiency of the information I provide (or fail to provide) in each and every numbered section of this application serves as the basis in determining my eligibility (and the eligibility of my dependents) for coverage and receiving a Benefit Plan(s), and by signing this application I certify the information is accurate and complete. I understand and agree that inaccurate, incomplete or omitted information represented in this application may constitute a fraudulent act or intentional misrepresentation of material facts voiding or retroactively cancelling any Benefit Plan(s) issued, as well as any claims for medical benefits and services paid, based on the information I submit through this application. I further understand a person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

X______________________________________________________ Applicant’s Signature Date Signed

Blue Saver® 100 2700

*Refusal of Coverage The group Benefit Plan provided by my employer has been explained to me thoroughly, and I understand it fully. I elect not to participate and understand that I will not be entitled to any benefits provided by the group Benefit Plan. I make this election voluntarily and under no compulsion or duress.

1-

Workers’ Compensation/No-Fault Yes No Are you, your spouse or any of your Eligible Dependents currently receiving or have received workers’ compensation benefits? Yes No Are you, your spouse or any of your Eligible Dependents currently receiving or have received no-fault benefits? Person’s Name Injury Date (mm-dd-yy) Type of Injury Company Providing Benefits Company Phone Number – –

3. COVERAGE INFORMATION HEALTH (BCBSND) coverage: New Coverage (I do not have BCBSND coverage now) Change in Existing BCBSND Coverage I Refuse Coverage*

-0

Agent Number

46

Agent Name

WHITE ORIGINAL - BCBSND

Katie Veidel YELLOW COPY - Employer

WHITE COPY - Applicant

If you have questions or require assistance when completing this application, please contact one of our offices listed below: Home Office 4510 13th Ave. S. Fargo, ND 58121 Phone: (800) 342-4718 Fargo District Office 4510 13th Ave. S. Fargo, ND 58121 Phone: (701) 277-2232 Grand Forks District Office 3570 South 42nd St., Suite B Grand Forks, ND 58201 Phone: (701) 795-5340 Dickinson Office 1674 15th St. W., Suite D Dickinson, ND 58601 Phone: (701) 225-8092 Bismarck District Office 1415 Mapleton Ave. Bismarck, ND 58503 Phone: (800) 247-3876

BLUE SAVER BENEFIT PLAN I understand the Blue Saver Benefit Plan is a high deductible health plan designed to comply with Section 223 of the U.S. Internal Revenue Code and is intended for use with a Health Savings Account. I also understand BCBSND does not provide tax, investment or legal advice. If I have questions about a Health Savings Account or the tax implications of the Blue Saver Benefit Plan, I should contact a qualified tax, investment or legal professional.

Minot Public School District Group Application

LIMITATIONS AND EXCLUSIONS I understand Members are subject to limitations and exclusions outlined in the relevant Benefit Plan or policy. CONVERSION RIGHTS FOR HEALTH COVERAGE In the event the group through which I am enrolled elects to terminate, BCBSND has the right at its sole discretion to continue my coverage on a non-group basis subject to the premium and Benefit Plan provisions for non-group coverage then in effect. Conversion coverage will not be offered to a Subscriber if the group through which the Subscriber is eligible has terminated coverage with BCBSND and has enrolled as a group with another insurance carrier. METHOD OF PAYMENT In the event my employer adopts the method of payroll deduction, I hereby authorize and direct my employer to deduct the current premium from my wages or salary and remit the same to BCBSND. This authorization is to continue in effect until revoked by me in writing.

Blue Cross Blue Shield of North Dakota (BCBSND) is an independent licensee of the Blue Cross and Blue Shield Association.

Minot District Office 1308 20th Ave. SW Minot, ND 58701 Phone: (701) 858-5000

This health plan is that of your employer. BCBSND is serving only as the Claims Administrator and does not assume any financial risk except for stop-loss coverage.

Devils Lake Office 425 College Dr. S., Suite 13 Devils Lake, ND 58301-3537 Phone: (701) 662-8613 Jamestown Office 300 2nd Ave. NE., Suite 132 Jamestown, ND 58401 Phone: (701) 251-3180 Williston Office 1137 2nd Ave. W., Suite 105 Williston, ND 58801 Phone: (701) 572-4535

Member Services Toll-Free

(800) 247-3876 Visit us on the web www.BCBSND.com 29313344 Noridian Mutual Insurance Company

PPACA Eff. 1/1/2018 11-17

In accordance with federal regulations, Blue Cross Blue Shield of North Dakota is required to provide you the following disclosure: Blue Cross Blue Shield of North Dakota complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of North Dakota does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of North Dakota: 

Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Written information in other formats (large print, audio, accessible electronic formats, other formats)



Provides free language services to people whose primary language is not English, such as: - Qualified interpreters - Information written in other languages

If you need these services, please call Member Services at 1-800-342-4718 (toll-free) or through the North Dakota Relay at 1-800-366-6888 or 711. If you believe that Blue Cross Blue Shield of North Dakota has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator 4510 13th Ave S Fargo, ND 58121 701-297-1638 or North Dakota Relay at 800-366-6888 or 711 701-282-1804 (fax) [email protected] (email) You can file a grievance in person or by mail, fax, or email within 180 days of the date of the alleged discrimination. Grievance forms are available at http://www.bcbsnd.com/report or by calling 800-342-4718. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC 20201 800-368-1019 or 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-342-4718 (TTY: 1-800-366-6888 o 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-342-4718 (TTY: 1-800-366-6888 oder 711). 4510 13th Avenue South, Fargo, North Dakota 58121 Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association 29376608

11-16 Noridian Mutual Insurance Company

繁體中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-342-4718（TTY：1-800-366-6888 或 711）。 Oroomiffa (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-342-4718 (TTY: 1-800-366-6888 ykn 711). Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-342-4718 (TTY: 1-800-366-6888 hoặc 711). Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 1-800-342-4718 (TTY: 1-800-366-6888 canke 711). ‫( العربية‬Arabic) :‫ (رقم هاتف الصم والبكم‬800-342-4718-1 ‫ اتصل برقم‬.‫ فإن خدمات المساعدة اللغوية تتوافر لك بالمجان‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ملحوظة‬ .) 711‫ أو‬1-800-366-6888 Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 1-800-342-4718 (TTY: 1-800-366-6888 au 711). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-342-4718 (телетайп: 1-800-366-6888 или 711). 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-342-4718 （TTY: 1-800-366-6888 または 711）まで、お電話にてご連絡ください。 नेपाली (Nepali)

ध्यान दिनुहोस ्: तपार्इंले नेपाली बोल्नुहुन्छ भने तपार्इंको ननम्तत भाषा सहायता सेवाहरू ननिःशुल्क रूपमा उपलब्ध छ । फोन गनुहोस ् 1-800-342-4718 (दिदिवार्इ: 1-800-366-6888 वा 711) ।

Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-342-4718 (ATS : 1-800-366-6888 ou 711). 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-342-4718 (TTY: 1-800-366-6888 또는 711)번으로 전화해 주십시오. Tagalog (Tagalog – Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-342-4718 (TTY: 1-800-366-6888 o 711). Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 1-800-342-4718 (TTY: 1-800-366-6888 eller 711). Diné Bizaad (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę́ę́’, t’áá jiik’eh, éí ná hólǫ́, kojį’ hódíílnih 1-800-342-4718 (TTY: 1-800-366-6888 éí doodagó 711.)