Section D: General agreement
Please read this section carefully before signing the application:
We apply to obtain the coverage designated herein. To the best of our knowledge and belief, all information on this application is true and
complete, and Cigna + Oscar Health Plan of California (“Cigna + Oscar”) may rely on this application in deciding whether to provide coverage. If
the application is not complete, Cigna + Oscar reserves the right to reject it and notify us in writing. We understand and agree that no coverage
will be effective before the date determined by Cigna + Oscar, and that such coverage will be effective only if we have paid our first month’s
premium and this application is accepted. We further understand and agree that we should keep prior coverage in force until notified of
acceptance in writing by Cigna + Oscar and that no agent has the right to accept this application or bind coverage. In addition, the Brokers
named on this application are hereby authorized to process any enrollment transactions for the company’s Cigna + Oscar coverage upon
direction from the authorized group representative (including, but not limited to, member enrollment, member terminations, member address
changes, group contact changes, group address changes, plan renewal changes, and group contract terminations). This authorization shall be
effective immediately and we agree that the company will be bound by the actions performed by the herein-named Broker pursuant to the
signature below. Additionally, we acknowledge that we must notify Cigna + Oscar in writing to void this agreement in the event of a change in
the company’s Broker of Record. We understand that if we have committed fraud or made any intentional misrepresentation of material fact in
conjunction with this application, within the first 24 months of issuance of coverage, Cigna + Oscar may cancel coverage; adjust premium
amounts; or, following notice, rescind the contract.
Binding Arbitration
All disputes including but not limited to disputes relating to the delivery of services under the agreement or any other issues related to the
agreement and claims of medical malpractice must be resolved by binding arbitration (with the sole exception of Adverse Benefit
Determinations, as defined in Section 147.136 of Title 45 of the Code of Federal Regulation), if the amount in dispute exceeds the jurisdictional
limit of small claims court and the dispute can be submitted to binding arbitration under applicable federal and state law, including but not
limited to, the patient protection and affordable care act. It is understood that any dispute including disputes relating to the delivery of services
under the agreement or any other issues related to the agreement, including any dispute as to medical malpractice, that is as to whether any
medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered will
be determined by submission to arbitration as permitted and provided by federal and California law, and not by a lawsuit or resort to court
process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving
up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. You
and Cigna agree to be bound by this arbitration provision and acknowledge that the right to a jury trial or to participate in a class action is waived
for both disputes relating to the delivery of service under the agreement or any other issues related to the agreement and medical malpractice
claims.
The Federal Arbitration Act shall govern the interpretation and enforcement of all proceedings under this BINDING ARBITRATION section. To
the extent that the Federal Arbitration Act is inapplicable, or is held not to require arbitration of a particular claim, State law governing
agreements to arbitrate shall apply. The arbitration findings will be final and binding except to the extent that State or federal law provides for
the judicial review of arbitration proceedings.
The arbitration is initiated by the Member making a written demand on Us. The arbitration will be conducted by a single neutral arbitrator from
Judicial Arbitration and Mediation Services (“JAMS”), according to JAMS’ applicable Rules and Procedures. If for any reason JAMS is unavailable
to conduct the arbitration, the arbitration will be conducted by a single neutral arbitrator from another neutral arbitration entity, by agreement of
the Member and Oscar, or by order of the court, if the Member and Cigna cannot agree. If the parties cannot agree on the individual neutral
arbitrator, the arbitrator will be selected in accordance with JAMS Rule 15 (or any successor rule).
However, in the case of a medical malpractice dispute in which the total amount of damages claimed is fifty thousand dollars ($50,000) or less,
the parties may select a single neutral arbitrator who shall have no jurisdiction to award more than fifty thousand dollars ($50,000). If the parties
are unable to agree on the selection of a neutral arbitrator, the method provided in Section 1281.6 of the CA Code of Civil Procedure should be
utilized.
In signing, you agree (1) That to the best of my knowledge, the information on the application is complete and accurate; (2) I explained to the
applicant, in easy-to-understand language, the risk to the applicant of providing inaccurate information and that the applicant understood the
explanation.
Business administrator signature
Agent signature
Printed name and title
Printed name and title
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
Sign here
Sign here
of
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Cigna + Oscar: Business Enrollment Form - California 2021 (effective dates on and after 1/1/2021)
