Business/AlieraHC SB001 March 2014 V.2. 12.20.16 www.alierahealthcare.com www.healthpassusa.com Copyright © 2016

COMPANY INFORMATION Company Name: Years in

Business: Language preferred:

○ English ○ Spanish

Send Welcome Kits to

Employer: ○ Yes ○ No

Doing Business As (DBA): Web Address:

Contact Name: Contact Phone: Contact Email:

Street Address (No P.O. Box): EIN#:

City: State: Zip:

Phone: Fax: Authorized to email? ○ Yes ○ No

BILLING CONTACT INFORMATION Check if the same as above

Billing Contact Person: Email:

Address: City: State: Zip:

ENROLLMENT INFORMATION Total # Employees: Eligible Employees: Enrollment Goal %: Coverage: Benefits offered to employees working (check one)

○ 20 hours or more per week ○ 30 hours or more per week

Waiting Period: Benefits are effective the first of the month following (check one)

○ Date of hire ○ 30 days ○ 60 days ○ 90 days ○ 180 days

Requested Effective Date for plan year __________________to ____________________ (1st of the month start date) Please reference Enroll/Deduct/Bill Formula PDF Form available on Agent’s Back Office. Coverage cannot be back-dated.

Enrollment Start Date: ____________ End Date:____________ Enrollment Method: ○ Electronic ○ Paper ○ Census

Enrollment is: ○ Ongoing (Monthly) ○ Yearly (Open Enrollment only) Grant broker/agent ‘User’ access to company back office: ○ Yes ○ No

Group portal can be suspended to avoid unintended enrollments: ○ Yes, suspend after open enrollment ○ No, do not suspend

PLANS

Please select your company’s requested Plan: (See your enrollment materials, contact your broker for plan choices and complete plan descriptions.

○ HealthPass Value PPO ○ HealthPass PLUS PPO ○ HealthPass Premium PPO ○ HealthPass PLUS Closed ○ HealthPass Premium Closed ○ Med-Select

○ AlieraCare 5000 – ○ Value ○ PLUS ○ Premium | ○ AlieraCare 7500 – ○ Value ○ PLUS ○ Premium | ○ AlieraCare 10000 – ○ Value ○ PLUS ○ Premium

Add On: ○ HP Wholesale Pharmacy Plan – powered by Rx Valet ○ Aliera VB ○ Aliera VB +

Type of Plan: ○ New ○ Modified ○ Reinstatement (HPID#): _________________

Section 125: ○ No ○ Yes* * Checking Yes confirms the Company has an existing Cafeteria Plan. Please add these Plans to Company's existing Cafeteria Plan.

COMPANY FEE CONTRIBUTION

The contribution can be a percentage or a fixed dollar amount. No minimum required.

Company contribution for employee:

$ or % of the membership

Company contribution for dependents:

$ or % of membership

BILLING

Billing Frequency: ○ Monthly ○ Quarterly ○ Semi-Annually ○ Annually (Payments are due in advance)

Payroll Cycle: ○ Bi-Weekly (26) ○ Weekly (52) ○ Bi-Monthly (24) ○ Monthly (12)

PAYMENT OPTIONS

List Bill Invoice: ○ Yes ○ No Invoice Delivery: ○ Post Office ○ Email Invoice Payment: ○ Check ○ ACH ○ Credit Card

CREDIT CARD (2.9% fee will be assess – Monthly limit applies)

Name on card:

Card type: ○ Visa ○ MasterCard ○ Discover

Card Number: Exp: /

Card billing address: CVC:

ACH Please attach a voided company check to this form Monthly limit applies

Bank Name: Account type: ○ Checking ○ Savings

Name on account: Routing Number:

Business Account Email to: application@alierahealthcare.com

NEW GROUP APPLICATION

Business/AlieraHC SB001 March 2014Rev. 1116 www.alierahealthcare.com www.healthpassusa.com Copyright © 2016

AUTHORIZATION This is an application for membership only. No contract for membership services will exist until Aliera Healthcare, Inc./HealthPass USA LLC (“AHI/HP USA”) completes its review and communicates to the business applicant or the applicant’s broker that the application has been accepted. A group membership plan contract/ group service plan will be issued at that time. As a company principal/corporate officer, having authority to contract with AHI/HP USA, I agree that: • Prepaid monthly premiums will be posted to HealthPass USA account by the due date on HealthPass USA’s billing statement.• My company will use employee enrollment application forms provided or approved by AHI/HP USA for new employees.• My company will abide by the contract provisions.I certify, to the best of my knowledge, that all of the responses given are true, correct, and complete. I understand that if I have misrepresented or omitted any material fact, any membership services approved by AHI/HP USA may be canceled or the applicable membership fees may be adjusted.Aliera Healthcare, Inc. Arbitration Agreement Notice is given that, and as more fully set forth in the arbitration provision in the applicable Explanationof Coverage (EOC), disputes between Members, their heirs, relatives, or associated parties on the one hand and AHI/HP USA and contracted healthcare providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membershipin AHI/HP USA or coverage by AHI/HP USA, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of,services or items, irrespective of legal theory, must be decided by binding arbitration and not by lawsuit or resort to court process, except asapplicable law provides for judicial review of arbitration proceedings. Members give up their right to a court or jury trial and accept the use of bindingarbitration as specified in the applicable EOC except that the following types of claims are not subject to binding arbitration: Claims within the jurisdiction of the Small Claims CourtThe Company acknowledges and understands the following;1. It is voluntarily becoming an AHI/HP USA (“AHI/HP USA”) group member and that this agreement is non-transferable and carries a term of 12months.2. The Company has reviewed the AHI/HP USA Explanation of Coverage Guide and it has had the opportunity to ask questions and receive answersregarding its content.3. This agreement does not provide comprehensive health insurance coverage or insurance of any kind nor is it a contract of insurance and that itprovides only the health care services specifically described in the AHI/HP USA Explanation of Coverage Guide.4. The employee is responsible for any charges incurred for health care services performed outside of AHI/HP USA including but not limited toemergency room, hospital and specialty services and that AHI/HP USA will not bill insurance carriers for any services provided by AHI/HP USA. TheCompany acknowledges and understands that AHI/HP USA network providers must maintain a record of each employee’s health information andmust protect the privacy of the employee’s health information in accordance with HIPPA and as per the terms of the Notice of Privacy Practices. It is understood and acknowledged that this policy is available for review at any time upon request.5. Membership monthly fees will be paid on or before each due date. In the event that it is unable to pay its fee(s) on time, it understands that it willbe charged a $25 late fee and that its service agreement may be terminated. In addition, a $25 fee will be charged for declined credit/debit card/ACH/orcheck transactions that are not honored.6. This Member Agreement may be terminated at any time and for any or for no reason by providing (60) sixty written notice to AHI/HP USA. Monthly fees will continue to accrue until written termination notice is received. Any pre-paid monthly membership fees will be prorated to the date AHI/HPUSA has received the Company’s written termination and refunded to it within ten (10) business days.7. AHI/HP USA may terminate this Member Agreement by providing it written notice and any pre-paid monthly membership fees will be prorated tothe date of termination and refunded to the Company within ten (10) business days. AHI/HP USA will not terminate this Member Agreement solely onthe basis of any employee’s health status.8. AHI/HP USA may add or discontinue services or may increase the Company’s fee schedule at any time (but no more than once per year), and thatit will be given, in writing, at least sixty (60) days’ notice of such fee schedule changes.9. If employees are enrolled in Medicare they will receive a copy of the Medicare Opt-out Agreement for review and signature before their firstappointment. (The Opt-out Agreement does not prevent the Company’s employees from receiving current or future Medicare benefits from non-AHI/HP USA providers; neither employee nor employee’s AHI/HP USA health care provider(s) will seek reimbursement from Medicare for the medicalservices the employee receives from AHI/HP USA’s network.)10. Monthly membership fee covers the services described in the AHI/HP USA Explanation of Coverage Guide. At times, however, your employees’care may require durable medical supplies or third-party services that are not covered by the Company’s monthly membership fee. To streamlinean appointment check-out, please note that by providing the above billing information the Company authorizes AHI/HP USA to automatically chargeits card or draw on its bank account for any incidental items at the time of service. In all cases, incidental items are charged at or near our cost andwill be discussed with the member in advance. If Company is not responsible for employee’s incidental items, including consult and/or film/analogfees, employee/member will be required to make payment to provider at time of service.11. By signing below, the Company hereby authorizes AHI/HP USA to make contact using the information provided above. By signing below, the Company hereby authorizes AHI/HP USA to initiate charges to its credit card, debit card or bank account for its periodic or recurring membershipfee and any incidental fees (if elected) that employee members incur or have incurred on its account since its last billing date. The Company understands that the transaction amount is the total of the employee members’ membership fees plus the membership fees of any dependents, ifapproved by the Company, on its account.12. This authorization to perform periodic charges to the Company’s credit card, debit card or bank account will remain in full force and effect untilAHI/HP USA has received written notification from the Company of its termination in such time and in such manner as to afford AHI/HP USA and theCompany’s financial institution a reasonable opportunity to act on it.13. The Company understands that the participation in AHI/HP USA is continuous and that, by signing below, it authorizes recurring credit/debit cardcharges or monthly list billing with invoice payments accepted directly via ACH from Company’s bank account.14. THIS IS NOT INSURANCE15. Employer acknowledges this is an Employer sponsored level self-funded program and as such is responsible for any ACA fees or TransitionRelief program (TRP) fees for each employee. 2016/2017 fees are approximately as follows: $27 TRP fee and $8 ACA fee per employee.

ACCEPTED BY:

Signature of Officer: X

Date:

Please print name full name: Title:

Aliera Healthcare/HealthPass Representative

Servicing Agent: Agent ID: Email:

Assisting Agent: Agent ID: Email: