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Section lll: All questions must be answered1.Is there any Group Health Plan now in force and to be continued? YesNo If yes, identify:a. Name of the Group Health Plan(s):b. Description of the plan(s):c. Name of insurance carrier(s):Is there any Group Health Plan currently being applied for through another carrier? YesNo If yes, identify:a. Name of the Group Health Plan(s):b. Description of the plan(s):c. Name of insurance carrier(s):2.Name of present or prior group carrier:a. Effective date of prior coverage://b. Cancellation/Termination date://c. Is the coverage applied for in this application replacing other group insurance?d. If yes, explain reason:YesNo3.Are extended benefits provided in case of termination of health benefits?4.To the best of your knowledge, are there any current or former employees or their eligible dependents whose health insurance is being continued?a. If yes, please provide the following information for each current/former employee or dependent on health continuationsName of Employee/DependentDate of BirthYesNoType of Continuation State/Federal Extended BenefitsReason for TerminationDisability/OtherYesNoContinuation DatesStartEndIf additional space is needed, please attach a separate sheet, signed and dated.5.6.To the best of your knowledge are any employees or dependents presently incapacitated? YesNoTo the best of your knowledge are any dependent children incapable of self-support due to a physical or mental disability?YesNoNoDoes the employer participate in an arrangement with a Professional Employer Organization? YesRefer to Advisory Bulletin 00-SEH-02 if you need information concerning what constitutes a Professional Employer Organization.Section lV: Agent / Producer InformationAgent/Broker Name:Section V: SignatureIt is understood that, except as provided under applicable regulations, no individual shall become insured while not actively at work on a full-time basis, and only full-timeemployees are eligible. A full-time employee is one who regularly works at least 25 hours per week at his employer’s place of business. It is further understood that no agenthas power on behalf of AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey to make or modify any request or application for insurance or to bindAmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey by making any promise or representation or by giving or receiving any information.It is further understood that no insurance will be effective unless and until the application is accepted in writing by AmeriHealth HMO, Inc. and/or AmeriHealth InsuranceCompany of New Jersey. Final rates will be based on enrollment data as of the policy effective date. No contract of insurance is to be implied in any way on the basis of thecompletion and/or submission of this application.Please read this statement and check to confirm. I confirm that I have received the Summary of Benefits and Coverage (SBC) documents associated with the plan or plans Iselected on this application. I confirm I will provide SBCs to plan participants and beneficiaries as required by federal regulations and guidance related to the distribution of theSBC, including the requiring for timing and delivery.Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.Dated at:Dated on:Print name of Officer, Partner, or Proprietor:Signature of Officer, Partner, or Proprietor:Witness to Signature:Note: If there are any modifications to the statement and answers given in this application (i.e. crossed out, whited-out, erased, etc.), the applicant must attest to the modificationsby giving a complete signature in the margin near the modification. 2013 AmeriHealth HMO, Inc. AmeriHealth Insurance Company of New JerseyNovember 2013 — SEH Group Application 17491

Please Mail To:AmeriHealth Insurance Company of New JerseyAmeriHealth HMO, Inc.259 Prospect Plains Road, Building MCranbury, NJ 08512Tel 215-640-7573 Fax 215-238-7940Email: NJSEH-Cert@amerihealth.comwww.amerihealth.comNew Jersey Small Employer CertificationCustomer NameCustomer ID or Group NumberAddress of Company(if a current customer)CityStateZip(For Existing Small Employer Groups in the State of New Jersey OR New Applicants)The following will be used to determine Small Employer eligibility. Please refer to the definition of “eligibleemployee” on the next page.*Total # Eligible Employees*Total # Eligible Employees applying/enrolling for health benefits coverage*Total # Eligible Employees waiving health benefits coverage under the policy with coverage undertheir spouse’s coverage, other than individual coverage, Medicare, Medicaid, or NJ FamilyCare or Tricare or any othergroup Health Benefits Plan through a different employer*Total # Eligible Employees waiving health benefits coverage under the policy with coverage under a Health BenefitsPlan issued by another carrier and offered by the small employerPlease separately list the name(s) of the other carrier(s) and the number of employees covered under each:Carrier Name(s):# of Employee(s):*Total # Eligible employees waiving health benefits coverage under the policy without coverage undera spouse’s coverage, other than individual coverage; Medicare, Medicaid, or NJ FamilyCare or Tricare or any otherHealth Benefits Plan*Total # Employees in an ineligible class or classes*Is your firm subject to Working Aged Provisions of federal law (TEFRA/DEFRA)?(You may be subject to the law if you employed 20 or more employees for 20 weeks in the current or prior calendaryear)*Is your firm subject to the requirements of the federal COBRA law?(You may be subject to the law if you employed 20 or more employees during 50% or more of the working daysduring the previous calendar year.)*What is the average number of employees you employed during the entire previous calendar year regardlessof whether they were eligible for enrolled for group coverage?(When answering this question please count any employee for whom your company issues a W-2 and include fulltime, part-time and seasonal workers.)YesNoYesNo

New Jersey Small Employer CertificationFor purposes of certification as a New Jersey Small Employer, an Employer is considered to be a Small Employer if the Employer satisfieseither of the definitions set forth below. Check which definition applies to the Employer named above.(A) Small Employer pursuant to N.J.S.A. 17B:27A-17 modified as required by 26 U.S.C. 4980HThis definition counts eligible employees. Eligible employee means a full-time employee who works a normal work week of 25 or more hours.Eligible employee excludes sole proprietors, a partner in a partnership, independent contractors, spouses and employees working fewer than25 hours per week, employees working on a temporary or substitute basis and employees participating in an employee welfare arrangementpursuant to a collective bargaining agreement.In connection with a Group Health Plan with respect to a Calendar Year and a Plan Year, any person, firm, corporation, partnership, or politicalsubdivision that is actively engaged in business that: employed an average of at least one, but not more than 50, eligible employees on business days during the preceding Calendar Year, and employs at least one eligible employee on the first day of the Plan Year.Eligible employees and any dependents to be covered must live, work or reside in the service area of the Group Health Plan.All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 shall betreated as one employer. In the case of an employer that was not in existence during the preceding Calendar Year, the determination ofwhether the employer is a small or large employer shall be based on the average number of Employees that it is expected that the employerwill employ on business days in the current Calendar Year.(B) Small Employer pursuant to 45 C.F.R. 155.20This definition counts employees. Employee means an individual who is an employee under the common law standard. Employee excludes asole proprietor, a partner in a partnership and a 2 percent S corporation shareholder as well as immediate family members of such individuals.Employee also excludes a leased employee.In connection with a Group Health Plan with respect to a Calendar Year and a Plan Year, an employer with a business location in the stateof New Jersey who: employed an average of at least one but not more than 50 employees on business days during the preceding calendar year; and who employs at least one employee on the first day of the Plan Year.Employees and any dependents to be covered must live, work or reside in the service area of the Group Health Plan.All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 shall betreated as one employer. In the case of an Employer which was not in existence throughout the preceding Calendar Year, the determination ofwhether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected suchEmployer will employ on business days in the current Calendar Year.The following calculation must be used to determine if an employer employs at least 1 but not more than 50 employees. For purposes of thiscalculation:a) Employees working 30 or more hours per week are full-time employees and each full-time Employee counts as 1;b) Employees working fewer than 30 hours per week are part-time and counted as the sum of the hours each part-time Employee works perweek multiplied by 4 and the product divided by 120 and rounded down to the nearest whole number.Add the number of full-time Employees to the number that results from the part-time employee calculation. If the sum is at least 1 but notmore than 50 the employer employs at least 1 but not more than 50 Employees.Complete the following sections if the Employer is a Small Employer as defined in (A) or (B) above.

New Jersey Small Employer CertificationCERTIFICATION AS A SMALL EMPLOYER IN THE STATE OF NEW JERSEY IN ACCORDANCE WITH NEW JERSEY STATUTE,CHAPTER 27A OF TITLE 17BFor a Group Health Benefits PlanPlease sign and date appropriate section indicating whether or not you meet the definition of a small employer which is an“either or” definition.I certify that I qualify as a Small Employer in the State of New Jersey.(A)(B)ANDI certify that the information provided to AmeriHealth is true and complete. I understand that if the above informationis not complete or is not provided to AmeriHealth in a timely manner, then health benefits coverage does not have to be offered orcontinued. I further understand that incomplete or untrue information may void health benefits coverage.I certify that I have obtained and maintain a stand-alone pediatric dental plan for all employees and dependents enrolling forhealth benefits coverage (If applicable).Signature of Officer, Partner or OwnerTitleDatePrint Name of Officer, Partner or ProprietorSignature of WitnessDateI certify that I am NOT a Small Employer in the State of New Jersey as defined above.Signature of Officer, Partner or ProprietorTitleDatePrint Name of Officer, Partner or ProprietorSignature of WitnessDate

New Jersey Small Employer CertificationAny person who includes any false or misleading information on an application or enrollment form orcertification for a health benefits plan is subject to criminal and civil penalties.Group Health Benefits Policy ParticipationCOMPLETE THIS SECTION ONLY IF YOU HAVE CERTIFIED THAT YOU ARE A SMALL EMPLOYER IN THE STATE OF NEW JERSEY.*Employee Census InformationPlease include the following persons in the following list:a employees, owners, partners, officers, and independent contractors who are actively working for theemployer on a regular basis, and are paid by the employer on a regular basis, whether or not they areeligible to be covered under the policy.b employees, owners, partners, officers, and independent contractors who are not working, but who arecurrently covered under the employer’s health benefits plan for reasons such as continuation of coverageor total disability.Please use the following letters to indicate Status:O: Owner, Partner or officerS: Seasonal EmployeeF: Full-time employee who works 25 or more hours per weekD: Totally Disabled employeeP: Part-time employee who works less than 25 hours per weekT: Temporary employeeC: Continuee under state or federal lawI: Independent ContractorU. Employee participating in an employee welfare arrangementestablished pursuant to a collective bargaining agreement.If you have listed less than 5 (five) eligible employees, please include tax documents that show proof of ownership and/oremployment for all eligible employees. Acceptable documents include: New Jersey WR-30 – Employer Report of Wages PaidW-2 (if recent)W-4 (if needed to verify recent new hire)Payroll documents showing taxes taken outSchedule C, Schedule K-1 or Schedule F (for owners only)

New Jersey Small Employer CertificationNameJob TitleDate of HireHoursworkedper te)GenderDate of Birth123456789101112131415*If additional space is needed, attach a separate sheet.Please indicate below the number of employees by work location/State. All employees must be included, regardlessof whether or not they currently have medical coverage and through whom that coverage is provided.Number of EmployeesWork Location (List by State)Full-timePart-time 2014 AmeriHealth 17921AmeriHealth Insurance Company of New Jersey AmeriHealth HMO, Inc.AHNJ SEH Cert Rev. 1/7/2014RetiredCOBRA or State ContinueesOther

AmeriHealth New JerseyApplication for Small Group Member CoverageAPPLYAmeriHealth New Jersey259 Prospect Plains Rd, Building MCranbury, NJ 08512Group Information – to be completed by Employer:AmeriHealth New JerseyGroup Name:Group Number:Class Code:A. Type of Activity – To be completed by Applicant. Refer to instructions before completing this form. Print clearly.Activity – Check all that applyDate of EventDate of Hire/Reason for n:REMOVEEmployee Withdrawal/TerminationRemove SpouseCivil Union PartnerRemove Domestic PartnerRemove Dependent ChildRemove Over-Age Child as a Dependent Under HERCHANGESName ChangeChange PlanOtherAdd/Change Office ID Numbers: Primary/OB/Gyn/Dentist*See list of Triggering Events in Instructions////////ADDEnrollment of a new SubscriberAdd SpouseAdd Civil Union PartnerAdd Domestic PartnerAdd Dependent ChildAdd Over-Age Child as a Dependent Under 31(and complete Coverage Continuation section)Total Disability*COBRA/NJSGCFor EmployeeBilling:COVERAGECONTINUATIONGroupLength of Continuation (in months):18 29GroupDate of Loss of Coverage: Qualifying Event #:Date of Qualifying Event://**//Home (Section B)For Spouse/Civil Length of ContinuationUnion Partner* (in months): 18 36Billing:/Home (what address?)For Dependent/Over-age ChildCOBRA/NJSGC*Attach proof of disabilityDate of Loss of Coverage://Section B ORSection E**Date of Qualifying Event://*Civil union partners are eligible to make an election pursuant to NJSGC, if applicable.Length of Continuation(in months): 18 36Dependent Under 31 Qualifying Event #:Qualifying Event #:Date of Loss of Coverage: Qualifying Event #:Date of Qualifying Event://**//** Billing:GroupHome (what address?)Section B ORSection E**Qualifying event #s: see list in Instructions. ***Billing through the group for a Dependent Under 31 Continuation Election requires agreement by the employer at Section J.B. Employee Information – To be completed by the EmployeeName (Last, First, MI):HOMEWORKSSN:Birthdate (mm/dd/yyyy)Street/Apt:Street/Apt:City, State, Zip Code:Phone:Email:[Employer] Name:Address:City, State, Zip Code:Phone:Employment Date:Email:Hours worked per week:Sex:MF

AddRemoveContinuationOther Change – If a name change, indicate prior name:Primary Loc #:NPI or PCP ID #:Current Patient:YesNoNPI or PCP ID #:Current Patient:YesNoNPI or PCP ID #:Current Patient:YesNoAddress:ACTIVITYOb/Gyn Loc #:Address:Dentist Loc #:Address:Other Health Coverage?Payer Name:Policy #:Medicare ID#, if any:YesNo If yes:Other Rx Coverage? YesPayer Name:Policy #:Medicare ID#, if any:C. Plan Option – to be completed by the EmployeeNo If yes:Plan Name:D. Other Individuals Covered – to be completed by the Employee Identify individuals other than yourself for whom you are adding/changing removing coverage.Attach additional pages if necessary, dated and signed by you. Attach proof of disability if necessary.1.Spouse/Domestic Partner/Civil Union Partner2. ChildAdd Remove OtherContinue SpouseContinue CU Partner (NJSGC)AddRemove3. ChildOtherContinueAddRemove4. ChildOtherContinueAddRemoveOtherName (last, first, MI)Name (last, first, MI)Name (last, first, MI)Name (last, first, MI)L:L:L:L:F:F:F:F:MI:MI:MI:MI:Birthdate (mm/dd/yyyy):Male//FemaleBirthdate (mm/dd/yyyy):Male//FemaleBirthdate (mm/dd/yyyy):Male//FemaleBirthdate (mm/dd/yyyy):MaleSocial Security Number:Social Security Number:Social Security Number:Other health coverageNo Yes – If Yes:Payer Name:Policy #:Medicare ID #:Other health coverageNo Yes – If Yes:Payer Name:Policy #:Medicare ID #:Other health coverageNo Yes – If Yes:Payer Name:Policy #:Medicare ID #:Other health coverageNo Yes – If Yes:Payer Name:Policy #:Medicare ID #:Other Rx Coverage:No Yes – If Yes:Payer Name:Policy #:Medicare ID #:Other Rx Coverage:No Yes – If Yes:Payer Name:Policy #:Medicare ID #:Other Rx Coverage:No Yes – If Yes:Payer Name:Policy #:Medicare ID #:Other Rx Coverage:No Yes – If Yes:Payer Name:Policy #:Medicare ID #:Primary Care Provider:NPI or PCP ID #:Address:Primary Care Provider:NPI or PCP ID #:Address:Primary Care Provider:NPI or PCP ID #:Address:Primary Care Provider:NPI or PCP ID #:Address:YesNoNAOb/Gyn OfficeNPI or PCP ID #:Address:Current Patient?Current Patient?YesNoNAOb/Gyn OfficeNPI or PCP ID #:Address:YesNoNACurrent Patient?Current Patient?YesNoNAOb/Gyn OfficeNPI or PCP ID #:Address:YesNoNACurrent Patient?//FemaleSocial Security Number:Current Patient?ContinueCurrent Patient?YesNoNAYesNoNAOb/Gyn OfficeNPI or PCP ID #:Address:YesNoNACurrent Patient?

Dentist OfficeNPI or PCP ID #:Address:Current Patient?Dentist OfficeNPI or PCP ID #:Address:YesNoNACurrent Patient?Dentist OfficeNPI or PCP ID #:Address:YesNoNACurrent Patient?Dentist OfficeNPI or PCP ID #:Address:YesNoNACurrent Patient?YesNoIf last name is different fromEmployee’s, please explain:If last name is different fromEmployee’s, please explain:If last name is different fromEmployee’s, please explain:Home or billing address same asEmployee? Yes NoLiving with Employee?Yes NoLiving with Employee?Yes NoLiving with Employee?Yes NoIf NO, complete Section E2If NO, complete Section FIf NO, complete Section FIf NO, complete Section FEmployed?YesNoNAIf yes, complete Section E1E. Additional Spouse/Civil Union Partner/Domestic Partner Information – to be completed by Employee If not applicable, please m

Portal, IBXpress, effective _ (“Date”) and ending _ (“Date” – Do not enter date if one does not apply at this time ) or until transfer of the Broker/Agent of Record Le tter as described in the Primary Agent Agreement, whichever