NLA Cigna Group Contract_210312.2
coverage. All reinstatements are subject to review, potential rerate and/or declination.
At the Plan’s discretion, any Employer/Group that is terminated from the Plan for non-payment of Maximum Funding
Rates may resume participation in the Plan once all outstanding Maximum Funding Rates is paid in full, if reinstatement
has been approved.
Employee and dependent terminations must be sent to the Master General Agent (“MGA”) or TPA using the
appropriate form(s) at least fifteen (15) days (“Minimum Notice”) prior to the requested date of termination.
Employer/Group understands that any failure to provide this Minimum Notice will result in a termination delay, which
will be no less than thirty (30) days. Employer/Group understands and agrees to remain liable for payment of Maximum
Funding Rates for those experiencing a termination delay.
By signing this Request/Contract in Section Twelve (12), the Employer/Group agrees to the “Billing and Collection
Guidelines,” as described herein, and understands that failure to do so shall result in the termination of this Request/Contract.
Furthermore, the Employer/Group understands and agrees they shall remain liable for Maximum Funding Rates due to the
Plan, even if this Request/Contract is terminated by the Plan for non-payment of Maximum Funding Rates.
Section 4 Requested Effective Date
Requested Effective Date: _______________,20___
Employer/Group: In the space above, please indicate the month in which you would like for coverage from the Plan to
begin. This date is a non-binding request that is contingent upon receipt of all quoting/enrollment materials and subject
to the Plan’s acceptance of this Request/Contract. Once accepted, the Employer/Group will provide notification of your
actual Effective Date, which shall only be on the first day of any given month.
Section 5 Plan Type & Employee Coverage
Employer/Group hereby requests participation for _____ Employees as indicated on the Employer/Group’s Plan Selection,
as shown in Section Eleven (11), which is incorporated herein by reference.
Employer/Group: Please enter the number of Employees, including (1) Owners; (2) Sole Proprietors; and or (3) Partners
that are enrolling for coverage.
Section 6 Maximum Funding Rates and Contract Terms
Employers/Groups seeking first-time coverage from the Plan (“New Groups”) agree that Maximum Funding Rates
assessed pursuant to Initial Contracts shall remain in force from the Effective Date through April 30
of the then-current
plan year unless otherwise modified by the Plan. New Groups shall be construed to include any Employer/Group that
had previously lost coverage from the Plan as the result of any failure to remit payment of Maximum Funding Rates
before the end of the Grace Period.
Upon conclusion of an Initial Contract, Employers/Groups may continue their coverage with the Plan for subsequent periods
that are no less than twelve (12) months. Unless otherwise modified by the Plan, Maximum Funding Rates amounts
assessed pursuant to Renewal Contracts remain valid from May 1
(“Renewal Date”) until April 30
of the then-current plan
year. Employers/Groups that remit payment for Maximum Funding Rates as due on the Renewal Date will be deemed to
have accepted the Renewal Contract. Unless otherwise notified by the Plan, Employers/Groups understand and agree that
the terms and conditions of Renewal Contracts are the same as those in effect for the Initial Contract. Employers/Groups
agree the Plan reserves the right to adjust Maximum Funding Rates during Initial and or Renewal Contracts if the claims
expense and or Plan utilization exceeds projections.
By signing this Request/Contract in Section Twelve (12), the Employer/Group, as stated in Section One (1) and incorporated
herein by reference, agrees to all the terms and conditions contained herein.
Section 7 Termination of Contract
Employer/Group may terminate this Request/Contract upon renewal.
Employer/Group agrees that the Plan reserves the right to modify, terminate, or rescind this Request/Contract back
to the original Effective Date if any employee intentionally provides the Plan with inaccurate information about their
health or the health of their dependents during the underwriting process. Rescind means that the coverage was
never in effect. Should this Request/Contract be rescinded, the Employer/Group agrees to accept liability for all
claims that have been incurred by their employees or dependents of their employees but not paid.