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1. Fill in this section.2. Verify form is Completed and signed.3. BlueCross BlueShield of South Carolina Foundation must receive the form and proper documentation by March 31 of the following year.

Our address:BlueCross BlueShield of SouthCarolina FoundationI-20 @ Alpine RoadMail Code AX-G22Columbia, SC 29219

Phone 803-264-4669Email Address:info.foundation@bcbssc.com

Website Address:www.bcbsscfoundation.org

GIVING BACK GRANT PROGRAMAPPLICATION – VOLUNTEER’S SECTION

TO BE COMPLETED BY PARTICIPANT

EMP ID/Agent Code E-mail Address Agent Employee Retiree Daytime phone number

Last Name First Name MI

Home Address City State ZIP Code

Name of qualified charitable organization receiving your volunteer efforts

How many volunteer hours have you completed since Jan. 1, (enter year) through the date of this application? (# hours)

Description of service

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1. Verify application section.2. Complete this section.3. Supply supporting documentation as required.4. Requests submitted without proper documentation or received after March 31, after year of volunteer service, will not be accepted,5. If the organization does not meet the requirement in Step 3, it is not eligible.

The BlueCross BlueShield ofSouth Carolina Foundation in itsdiscretion reserves the right todecide whether a grant will bemade. The Foundation alsoreserves the right to discontinueor change its programs at anytime without notice.

VERIFICATION – ORGANIZATION’S SECTION

TO BE COMPLETED BY AUTHORIZED OFFICER

Name of Authorized Officer Title Phone Number

Organization (As it appears on required documentation. Grants will be made payable to official organizations.)

Taxpayer ID Number E-mail address Website address

Name of program where hours were accumulated

Organization’s address City State ZIP Code

Please complete steps 1 and 2.

Step 1: How many hours has the volunteer completed since Jan. 1, (enter year) through the date of this application? (#hours)Step 2: Please attach proper documentation for grant processing.

The BlueCross BlueShield of South Carolina Foundation is an independent licensee of the Blue Cross Blue Shield Association.

I certify to the best of my knowledge that the information provided is accurate and this organization is an eligible organization.Organizations that participate in the Giving Back Grant Program are subject to all Program rules and guidelines, as well as theInternal Revenue Service’s regulations. Furthermore, this organization does not discriminate against any person or group onthe basis of age, political affiliation, race, national origin, ethnicity, gender, disability, sexual orientation or religious belief.

Signature Date

Participants in the Giving Back Grant Program (“the Program”) are subject to all program rules and guidelines, as well as theexpectations of honest and ethical behavior outlined in the BlueCross BlueShield of South Carolina Code of Conduct.

The agent, employee or retiree signature authorizes the recipient organization to report your volunteer efforts to the BlueCrossBlueShield of South Carolina Foundation to apply for a grant.

I certify that my application for the Giving Back Grant made by the BlueCross BlueShield of South Carolina Foundation (the“Foundation”) to the recipient organization is true and meets all the qualifications of the Program; will not be used for politicalor religious purposes; and will not entitle me or my family to goods, services, or benefits with monetary value from any source. Ifurther certify that my grant will not fulfill a financial pledge I have made to the recipient organization and that servicesperformed for eligible nonprofit organizations under the Program (“Volunteer Services”) are purely voluntary by me.

If I am an active employee of BlueCross BlueShield ofSouth Carolina or any of its subsidiaries or affiliates (“BlueCross”), Iagree that I will not be compensated for the Volunteer Services by BlueCross or the Foundation. I further agree that theVolunteer Services and my participation in the Giving Back Program are not work-related and are not deemed to be within thescope of any employment for BlueCross or the Foundation, are not the result of any promise, requirement, or coercion byBlueCross, do not constitute services performed for BlueCross or the Foundation, will not positively or negatively impact anyemployment at BlueCross, and that any injuries received in connection with such services will not be covered by BlueCross orthe Foundation, including any Worker's Compensation insurance.

Signature Date