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Social Security no.* (required)Section F: Prior and other group coverageAre you or anyone applying for coverage currently eligible for Medicare?YesNoIf yes, give name:Medicare ID no.Part A effective dateMedicare Part D ID no.Medicare Part D carrierPart B effective dateMedicare eligibility reason (check all that apply)Age DisabilityESRD: Onset date:Part D effective dateAre you or a family member previously or currently covered by a Medicare, health and/or dental plan?YesNoIf yes, please provide the following:Name of person covered(Last name, first, M.I.)Type(check one)IndividualGroupMedicareCoverage(check allthat apply)Carrier nameHealthDentalOrthodontiaCarrier phone no.Policy ID no.PolicyholdernameDates(if roupMedicareHealthDentalOrthodontiaStart:End:* Anthem is required by the Internal Revenue Service to collect this information.6 of 9

Social Security no.* (required)Section G: Terms, Conditions and AuthorizationsPlease read this section carefully before signing the application.Eligible employee:} An active employee of the Employer who works the number of hours per week to be eligible for benefits as defined by the Employer and approved byAnthem Blue Cross and Blue Shield (Anthem) as of the effective date. Employment must be verifiable from state or federal wage tax reports.} An employee, as defined above, who enters into employment after the coverage effective date and who completes the group imposed waiting period for eligibility (ifany) and applies for coverage within 30 days.} Any other class of persons identified by the Employer, provided that written approval of their eligibility is obtained from the Company(ies); or} Employees eligible for continuous coverage under state or federal laws.Eligible employee does not include independent contractors (whose compensation is reported on IRS Form 1099) and directors and officers of the GroupPolicyholder if they do not work the required number of hours per week described above.Eligible dependent:} Employee’s spouse, or children age 26 or younger, which includes a newborn, natural child, or a child placed with the employee for adoption, a stepchild or any otherchild for whom the employee has legal guardianship or court ordered custody. The age limit for enrolling a child is age 26. Coverage for children will end on the lastday of the month in which the children reach age 26.} The age limit of 26 does not apply for the initial enrollment or maintaining enrollment of an unmarried child who cannot support himself or herself because of mentalretardation, mental illness, or physical incapacity that began prior to the child reaching the age limit. Coverage may be obtained for the child who is beyond theage limit at the initial enrollment if the employee provides proof of handicap and dependence at the time of enrollment. (The employee may be asked to provide aphysician’s certification of the dependent’s condition.)} Dependents eligible for continuous coverage under state or federal laws.As an eligible employee, I am requesting coverage for myself and all eligible dependents listed and authorize my employer to deduct any requiredcontributions for this insurance from my earnings. All statements and answers I have given are true and complete. I understand it is a crime to knowinglyprovide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment,fines or a denial of insurance benefits. I understand all benefits are subject to conditions stated in the Group Contract and coverage document.In signing this application I represent that: I have read or have had read to me the completed application, and I realize any false statement ormisrepresentation in the application may result in loss of coverage. I certify each Social Security number listed on this application is correct.For Health Savings Account enrollees: Except as otherwise provided in any agreement between me and the financial custodian, the custodian of my HealthSavings Account (HSA), I understand that my authorization is required before the financial custodian may provide Anthem with information regarding my HSA.I hereby authorize the financial custodian to provide Anthem with information about my HSA, including account number, account balance and informationregarding account activity. I also understand that I may provide Anthem with a written request to revoke my authorization at any time.Coverage option: If your employer/group offers HMO coverage which does not permit you to receive the full range of covered services from the provider ofyour choice, you will also have the option at the time of your initial enrollment and at each renewal to choose a health care plan allowing you to access carefrom the provider of your choice (“point-of-service” plan). This point-of-service plan may be offered by the HMO, Anthem or by another carrier.Abbreviated Notice of Insurance Information Practices Privacy Act. Georgia state law establishes standards for the collection, use and disclosure ofinformation gathered in connection with insurance transactions. The application attached to this notice contains specific personal questions about you andyour dependents. We are required to advise you that personal information may be collected from persons other than you or other individuals proposed forcoverage. An investigative consumer report may be made to help us obtain additional medical data from physicians or hospitals.All data confidential. O.C.G.A. section 33-39-5, subsection (c) (1 through 4) requires that: 1. Personal information may be collected from persons other thanthe individual or individuals proposed for coverage; 2. Such information as well as other personal or privileged information subsequently collected by theinsurance institution or agent may in certain circumstances be disclosed to third parties without authorization; 3. A right of access and correction existswith respect to all personal information collected; 4. The notice prescribed in subsection (b) of the above referenced Code section will be furnished to theapplicant or policyholder upon request.Access to your data. You have the right to see or obtain a photocopy of your personal information which we have. You also have the right to send us a writtenrequest if you want any of your personal information to be amended, corrected or deleted. If you wish to have a more detailed explanation of our informationpractices, please contact Anthem Blue Cross and Blue Shield Customer Service Department, Post Office Box 7368, Columbus, Georgia 31908-7368.I’m signing here because I WANT TO GET INFORMATION ABOUT MY BENEFITS BY EMAIL OR ELECTRONICALLY. SUCH ELECTRONIC MAILINGS OR COMMUNICATIONSMAY EVEN INCLUDE CANCELLATION OR NONRENEWAL NOTICES. This may include my certificate or evidence of coverage, explanation of benefits statements,required notices and helpful or personalized information to get the most out of my plan, so I will make sure Anthem has my most up to date email. Theseelectronic communications may include specific details about me and my plan. I know I can change my mind at any time or request a free copy of specificmaterials by mail. I’ll just contact Anthem to do either.Date (MM/DD/YYYY)Sign Applicant signaturehereX* Anthem is required by the Internal Revenue Service to collect this information.7 of 9

Social Security no.* (required)Section H: Waiver/Declining coverageMedical coverageMedical coverage declined for — check all that apply:Reason for declining coverage — check all that apply:MyselfSpouse/domestic partnerDependent(s)Covered by spouse’s/domestic partner’s group coverageEnrolled in other insurance — Please provide company name and plan:Enrolled in individual coverageSpouse covered by employer’s group medical coverageMedicare/Medicaid/VAOther — please explain:No coverageDental coverageDental coverage declined for — check all that apply:Reason for declining coverage — check all that apply:MyselfSpouse/domestic partnerDependent(s)Covered by spouse’s/domestic partner’s group coverageEnrolled in other insurance — Please provide company name and plan:Enrolled in individual coverageSpouse covered by employer’s group medical coverageMedicare/Medicaid/VAOther — please explain:No coverageVision coverageVision coverage declined for — check all that apply:Reason for declining coverage — check all that apply:MyselfSpouse/domestic partnerDependent(s)Covered by spouse’s/domestic partner’s group coverageEnrolled in other insurance — Please provide company name and plan:Enrolled in individual coverageSpouse covered by employer’s group medical coverageMedicare/Medicaid/VAOther — please explain:No coverageLife coverage†Life/AD&D coverage declined for:MyselfSpouse, Domestic Partner and dependent coverage not available if life coverage is waived/declined.Dependent Life coverage declined for:Spouse/domestic partner and dependentsShort Term Disability coverage declined for:MyselfLong Term Disability coverage declined for:MyselfOptional Supplemental/Voluntary coverage declined for:MyselfOptional Supplemental/Voluntary Dependent Life coverage declined for:Spouse/domestic partner and dependentsVoluntary Short Term Disability coverage declined for:MyselfVoluntary Long Term Disability coverage declined for:MyselfReason for declining coverage — check all that apply:Covered by spouse’s/domestic partner’s group coverageEnrolled in other insurance — Please provide company name and plan:Enrolled in individual coverageSpouse covered by employer’s group medical coverageMedicare/Medicaid/VAOther — please explain:No coverage† I hereby certify that I have been given the opportunity to apply for the available group life benefits offered by my employer, the benefits have been explainedto me, and I and/or my dependent(s) decline to participate. Neither I nor my dependent(s) were induced or pressured by my employer, agent, or life carrier,into declining this coverage, but elected of my (our) own accord to decline coverage. I understand that if I wish to apply for such coverage in the future,I may be required to provide evidence of insurability at my expense.Sign here only if you are declining coverage.Signature of applicantPrinted nameSocial Security no.Date (MM/DD/YYYY)X* Anthem is required by the Internal Revenue Service to collect this information.8 of 9

Social Security no.* (required)Special enrollment rightsIf you declined enrollment for yourself or your dependent(s) (including a spouse) because of other health insurance or group health plan coverage, you may beable to enroll yourself and your dependent(s) in this plan if you or your dependent(s) lose eligibility for the other health insurance or group health plan coverage(or if the employer stops contribution towards your coverage or your dependent’s other coverage). However, you must request enrollment within 31 days aftercoverage ends (or after the employer stops contribution toward the other coverage). In addition, if you have a dependent as a result of marriage, birth, adoptionor placement for adoption, you may be able to enroll yourself and your dependent(s) provided that you request enrollment within 31 days after the marriage,birth, adoption or placement for adoption. I also understand that my dependents and I may enroll under two additional circumstances:Either your or your dependent’s Medicaid or Children’s Health Insurance Program (CHIP) coverage is terminated as a result of loss of eligibility; or} You or your dependent becomes eligible for a subsidy (state premium assistance program).In these cases, you may be able to enroll yourself and your dependents provided that you request enrollment within 60 days of the loss of Medicaid/CHIP or ofthe eligibility determination.} * Anthem is required by the Internal Revenue Service to collect this information.9 of 9

The BI-WEEKLY rates effective 5/1/2019 to 4/30/2020 with Blue Cross Blue Shield are as follows:BCBS‐MEDICALMONTHEmployeeEmployee SpouseEmployee ChildrenEmployee FamilyANNUAL 596.97 7,163.64 1,253.64 15,043.68 1,164.09 13,969.08 1,820.76 21,849.12MEDICALEMPLOYEE COMPANYPER PAY PERIODEmployeeEmployee SpouseEmployee ChildrenEmployee Family DENTALEMPLOYEE COMPANYPER PAY PERIODEmployeeEmployee SpouseEmployee ChildrenEmployee Family VISIONEMPLOYEE COMPANYPER PAY PERIODEmployeeEmployee SpouseEmployee ChildrenEmployee Family 55.10358.18316.85619.93 BS‐DENTALANNUALMONTHEmployeeEmployee SpouseEmployee ChildrenEmployee Family 36.0975.8375.06119.97 433.08909.96900.721,439.643.3321.6721.3142.04 IONANNUALMONTHEmployeeEmployee SpouseEmployee ChildrenEmployee Family 6.7513.5013.8420.59 81.00162.00166.08247.080.633.743.907.01 Employees are responsible for the bi‐weekly premiums shown in red.2.492.492.492.493.126.236.399.50

High Bridge Associates, Inc.Anthem BlueCross and BlueShieldYour Plan: Anthem Blue Open Access POS OAP5 1500/0%/6000 AEYour Network: Blue Open Access POSThis summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each andevery benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please reviewthe formal Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of Insurance or Evidence ofCoverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail.Cost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderOverall DeductibleSee notes section to understand how your deductible works. Your plan mayalso have a separate Prescription Drug Deductible. See Prescription DrugCoverage section. 1,500 person / 3,000family 3,000 person / 6,000 familyOut-of-Pocket LimitWhen you meet your out-of-pocket limit, you will no longer have to pay costshares during the remainder of your benefit period. See notes section foradditional information regarding your out of pocket maximum. 6,000 person / 12,000family 12,000 person / 24,000 familyPreventive care/screening/immunizationIn-network preventive care is not subject to deductible, if your plan has adeductible.Non-Network preventive care services for children prior to their 6th birthdayhave no deductible.No charge30% coinsuranceafter deductible ismetPrimary Care Office Visit to treat an injury or illness 30 copay per visitdeductible does notapply30% coinsuranceafter deductible ismetSurgery Performed by a Primary CarePhysician/Specialist0% coinsurance afterdeductible is met40% coinsuranceafter deductible ismetCovered Medical BenefitsDoctor Home and Office ServicesPage 1 of 10

Cost if you use an InNetwork ProviderCost if you use aNon-NetworkProvider 60 copay per visitdeductible does notapply30% coinsuranceafter deductible ismet0% coinsurancedeductible does notapply30% coinsuranceafter deductible ismetRetail Health Clinic Visit 30 copay per visitdeductible does notapply40% coinsuranceafter deductible ismetOn-line Medical VisitNo charge for the first12 visits and then 30per visit deductible doesnot apply40% coinsuranceafter deductible ismetChiropractic/Manipulation TherapyLimit is combined across professional visits and outpatient facilities.Coverage is limited to 20 visit(s) per year. Limit is combined InNetwork and Non-Network. 60 copay per visitdeductible does notapply30% coinsuranceafter deductible ismetAcupunctureNot coveredNot coveredAllergy Testing 30 copay per visit or 60 copay if performedin a specialist officedeductible does notapply40% coinsuranceafter deductible ismetChemo/Radiation Therapy0% coinsurance afterdeductible is met40% coinsuranceafter deductible ismetDialysis/Hemodialysis0% coinsurance afterdeductible is met40% coinsuranceafter deductible ismetCovered Medical BenefitsSpecialist Care VisitAll services performed in the office are included in the office copay.Maternity Physician ServicesGlobal obstetrical care (prenatal, delivery and postpartum services.Other Practitioner Visits:Other Services in an Office:Page 2 of 10

Covered Medical BenefitsPrescription DrugsFor the drugs itself dispensed in the office through infusion/injection.Cost if you use an InNetwork ProviderCost if you use aNon-NetworkProvider0% coinsurance afterdeductible is met40% coinsuranceafter deductible ismetOfficeAll services performed in the office are included in the office copay. 30 copay per visit or 60 copay if performedin a specialist officedeductible does notapply40% coinsuranceafter deductible ismetFreestanding Lab/Reference Lab0% coinsurancedeductible does notapply40% coinsuranceafter deductible ismetOutpatient Hospital0% coinsurance afterdeductible is met40% coinsuranceafter deductible ismetOfficeAll services performed in the office are included in the office copay. 30 copay per visit or 60 copay if performedin a specialist officedeductible does notapply40% coinsuranceafter deductible ismetFreestanding Radiology Center0% coinsurancedeductible does notapply40% coinsuranceafter deductible ismetOutpatient Hospital0% coinsurance afterdeductible is met40% coinsuranceafter deductible ismetDiagnostic ServicesLab:X-Ray:Page 3 of 10

Covered Medical BenefitsCost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderAdvanced Diagnostic Imaging (for example,MRI/PET/CAT scans):Office0% coinsurance afterdeductible is met40% coinsuranceafter deductible ismetFreestanding Radiology Center0% coinsurancedeductible does notapply40% coinsuranceafter deductible ismetOutpatient Hospital0% coinsurance afterdeductible is met40% coinsuranceafter deductible ismetUrgent Care (Office Setting) 75 copay per visitdeductible does notapply30% coinsuranceafter deductible ismetEmergency Room Facility ServicesCost share waived if admitted. Non-emergency use of Emergency RoomServices is Not Covered. 200 copay per visit and0% coinsurancedeductible does notapplyCovered as InNetworkAmbulance (Air, Ground, and Water)0% coinsurance afterdeductible is metCovered as InNetwork 30 copay per visitdeductible does notapply30% coinsuranceafter deductible ismetFacility Fees0% coinsurance afterdeductible is met40% coinsuranceafter deductible ismetDoctor Services0% coinsurance afterdeductible is met40% coinsuranceafter deductible ismetEmergency and Urgen

Georgia F0301.EE - 01012019 Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Life and Disability products are underwritten by Greater Georgia Life Insurance Company using the trade name Anthem Life. Independent licensees of the Blue Cross and Blue Shield Association.