Today's Date (MM/DD/YYYY)
Your Legal Acknowledgement and
Mandatory Binding Arbitration Agreement
(Read, sign and date where indicated)
(3 of 5)
Print Employee Name
I declare under the penalty of perjury under the laws of the state of California that the following statements are true, correct and pertain to the
employer named on this application, myself and my dependents named on this application.
California law prohibits an HIV test from being required or used by health care service plans as a condition of obtaining coverage.
• I am either actively, permanently working for the employer and considered eligible by my employer because I work either 20+ or 30+ hours per week, or I
am an eligible COBRA/Cal-COBRA participant.
• I am not a temporary, seasonal, per diem, 1099 or substitute employee or insured by or eligible to be insured by the employer’s union policy.
• My children’s dates of birth are accurate. My children are born to me or my spouse/domestic partner, or legally adopted, or a nontemporary legal ward,
and/or have an established parent-child relationship with me or my spouse/domestic partner. I understand that I am required to notify CaliforniaChoice
when an established parent-child relationship ceases to exist.
I understand that the preceding statements are subject to audit at any time and agree to provide CaliforniaChoice with any and all information necessary to
prove the above statements.
I understand that any persons, business or health plan that suffers a loss because of false-declarations contained in this statement may take legal action
against me to recover their losses.
• The representations made are the basis upon which coverage may be issued.
• The coverage may be cancelled or the employer’s contract rescinded because of the performance of an act or practice constituting fraud or making of an
intentional misrepresentation of a material fact to an insurance company for the purposes of defrauding the company.
• I have READ, UNDERSTAND and ATTEST that I myself and my dependents have met all of the eligibility requirements.
MANDATORY BINDING ARBITRATION
I understand that, if I select a Health Plan that uses mandatory binding arbitration to resolve disputes, I am agreeing to
arbitrate claims that relate to my or a dependent's membership in the Health Plan (except for Small Claims Court cases
and claims that cannot be subject to binding arbitration under governing law). I understand
that any dispute between
myself, my heirs, relatives, or other associated parties on the one hand and the Health Plan, any contracted health
care providers, administrators, or other associated parties on the other hand for alleged violation of any duty arising
out of or related to membership in the Health Plan, 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 under California law and not by lawsuit or resort to court process, except as applicable
law provides for judicial review of arbitration proceedings. I agree
to give up our right to a jury trial and accept the use
of binding arbitration. I understand
that the full arbitration provision is in the Health Plan's coverage document, which
is available for my review.
Employee SIGN HERE FOR MEDICAL, DENTAL, LIFE OR VISION COVERAGE
My signature acknowledges that I have read Section E, the applicable mandatory binding arbitration of the plan I selected in Section C and my
decision to enroll in the medical, dental, life or vision coverage that I selected in Sections C and D.
By submitting this signed application, I agree and understand that the health plan I have chosen through the CaliforniaChoice program shall
automatically have a lien on any payment of monies from any source, for services rendered in conjunction with an injury caused by the acts or omissions of a
for myself and my dependents to be bound by the benefits, copays, deductibles, exclusions, limitations and other terms of the health plan’s small
I authorize my physician, healthcare provider, hospital, clinic or other medically related facility to furnish my, and my dependent’s, protected health
information, including medical records, to the health plan I have chosen through the CaliforniaChoice program or its authorized agents for the purpose of
review, investigation, or evaluation of an application or claim, and for quality assurance and utilization review. I authorize CaliforniaChoice and the health plan
I have chosen, and their agents, designees or representatives, to disclose to a hospital, health plan, insurer or healthcare provider any protected health
information if such disclosure is necessary to allow the performance of any of those activities. This authorization shall become effective immediately and shall
remain in effect for up to 30 months from the date the authorization was signed. I understand that I, or a person authorized to act on my behalf, is entitled to
receive a copy of this authorization form.
I have read and understand the information provided to me pertaining to the Premium Only Plans and the tax consequences.
ll statements and answers I have given are true and complete. I understand it is a crime to knowingly perform an act or practice constituting fraud or make
an intentional misrepresentation of material fact 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 documents. If my plan is
rescinded or canceled, I will receive from my insurer a notice at least 30 days prior to the effective date of the rescission explaining the reasons for the
intended rescission and my right to appeal that decision to the Commissioner of Insurance pursuant to subdivision (b) of Section 10273.4 of the California
Insurance Code. Notwithstanding subdivision (a) of Section 10273.4 or any other provision of the law, I understand that after 24 months following the issuance
of my health plan or insurance policy, my insurer may not rescind my health plan or insurance policy for any reason, and shall not cancel my health plan or
insurance policy, limit any provisions of the health plan or policy, or raise premiums due to any omissions, misrepresentations, or inaccuracies in the
application for, whether willful or not.
CC 0310B 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.