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Section 1 Employer Information

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NLA Group Contract_210312.1
1
Health Plan Participation
Request/Contract
Section 1 Employer Information
Employer/Group Name
Federal Tax ID Number
Address Phone #
City, State, Zip Code
Fax #
Email Address
Participating Association Broker Name
Section 2 Billing Information (If Different from Above)
Billing Address Phone #
City, State, Zip Code Fax #
Billing Contact Name
Section 3 Billing & Collections Guidelines
Initial Contract for the Employer/Group, as stated in Section One (1) and incorporated herein by reference, shall remain in
force from the Effective Date of Coverage (“Effective Date”) through April 30
th
of the then-current plan year, unless terminated
pursuant to the terms and conditions contained herein. Unless otherwise agreed to in writing by the NLA Health Plan (“Plan”),
the Effective Date shall always be the first day of the month. Any subsequent Contracts for Renewal of Coverage (“Renewal
Contracts”) shall remain in force for subsequent periods of twelve (12) months unless terminated by the Employer/Group or
the Plan. Payment of money to cover the cost of Health Benefits (“Maximum Funding Rates”) shall be remitted to the Plan
monthly, subject to the following guidelines for Billing and Collections:
1
Billing shall be based on the current census of employees and dependents that are on record with the Plan, as
of the date on which invoices are generated. Employer/Group understands that any changes to their census
may result in changes to their Maximum Funding Rates.
2
On approximately the 5th of each month, you will receive your invoice via email. We bill about 30 days in advance
of each month. The invoice is due the first of each month, considered late if not paid by the 10
th
of the month and
subject to termination if not paid by the 25
th
of the month due.
3
Unless notified otherwise by the Plan, Maximum Funding Rates shall be drafted via Automated Clearing House
(“ACH”) on the first business day of each month from a Maximum Funding Rates Pull Account, which is a bank
account designated by the Employer/Group for purposes of pulling Maximum Funding Rates. If insufficient monies
are available in the Maximum Funding Rates Pull Account, the Employer/Group shall experience a suspension in
the payment of claims. Said suspension shall continue until the Employer/Group’s Maximum Funding Rates Pull
Account has enough monies to correct the delinquency, at which point the Employer/Group’s account can be
considered current.
4
Employer/Group agrees to reimburse the Plan for any claims incurred and or paid during any period of
delinquency, including, but not limited to, additional expenses that may be assessed due to late and or non-
payment.
5
Any Employer/Group that fails to remit Maximum Funding Rates by the 25
th
day of the then-current month shall be
terminated from the Plan. If payment of Maximum Funding Rates is received within 30 days of the original due date
(“Grace Period”), then the Employer/Group’s participation in the Plan may be reinstated, without a break in coverage.
All reinstatements are subject to review, potential rerate and/or declination.
NLA Group Contract_210312.1
2
6
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.
7
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
th
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
st
(“Renewal Date”) until April 30
th
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.
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.
NLA Group Contract_210312.1
3
Section 8 Summary of Benefits and Coverage (SBC)
The Patient Protection and Affordable Care Act has established many new requirements and standards for group
health plans, including the requirement to create and distribute a uniform Summary of Benefits and Coverage (SBC).
The purpose of the SBC is to provide standard information and uniform language across the health benefits business
to allow consumers to compare options and select health plans easily. For more information regarding this health care
reform provision, please visit www.healthcare.gov.
Section 9 Underwriting Guidelines
Underwriting Guidelines, as established by the Plan, shall be enforced while all Initial and Renewal Contracts are in
force and shall continue to do so unless the Employer/Group is notified otherwise by the Plan.
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 be bound by the Plan’s Underwriting Guidelines.
Section 10 Conditions of Participation
E
mployer/Group further agrees that:
1
For coverage to go into effect, the Employer/Group’s Request/Contract must be accepted by the Plan.
2
For coverage by the Plan to remain in force, the Employer/Group must: (1) be a member in good standing of the
National Limousine Association or eligible to become a member of the National Limousine Association when applying
for participation in this Plan; (2) meet membership requirements established by the governing documents of the
National Limousine Association; (3) have at least one common-law employee other than the owner or sole proprietor
and (4) become and or remain a member in good standing of the National Limousine Association.
3
The Employer/Group has seen a copy of the benefits proposed and agrees to remit all applicable Maximum Funding
Rates to the Plan as outlined in Section Three (3). Employer/Group further agrees to allow all eligible employees
an opportunity to enroll for coverage.
4
At all times, the coverage is subject to the benefit plan applied for by the Employer/Group, which alone constitutes
the Contract under which benefits become payable.
5
Employer/Group agrees that the Plan shall not be liable for any health care claims incurred by any Employee(s) and or
Dependent(s) after the date on which coverage was terminated. Employer/Group agrees to reimburse the Plan for
covered charges which were incurred by any Employee(s) and or Dependents(s) after the date on which coverage
was terminated.
Acceptance of this Request/Contract by the Plan is subject to the Employer/Group’s willingness to be bound by the
Plan’s requirements. For purposes of this Section, these requirements include the provisions of any Administrative
Services Agreement between the Plan and its TPA, but only to the extent, such provisions apply to rights and or
obligations of Employers/Groups that participate in the Plan.
By signing this Request/Contract in Section Twelve (12), the Employer/Group, as stated in Section One (1) and
incorporated herein by reference, hereby requests participation in the Plan and agrees to be bound by all the terms and
conditions contained herein.
Section 11 Employer Plan Selection
INSTRUCTIONS:
STEP 1: Select your Medical Plan Option - You can select one plan, or any combination of the multiple medical plan
options offered.
STEP 2: Employee Selection - Send a signed identifying census which plans and what tier (e.g., family, EE, etc.) currently
covered employees are choosing. Otherwise, plan implementation cannot move forward, and you will experience a
delay.
Note: Please ensure you fully understand the Plan Benefits you are enrolling in, as you can only change your selections during the
Plans Open Enrollment.
NLA Group Contract_210312.1
4
Medical Plan Options Check your selected plan(s)
Pharmacy Plan
Section 12 Employer Attestation and Signature
Employer/Group hereby acknowledges and understands that (1) all enrolled Employees must meet all of the Plan’s terms
and conditions, outlined herein; (2) waivers must be provided for all employees waiving coverage; and (3) absent a
Qualifying Life Event, as defined in 26 CFR 1.125-4, employees and any of their respective dependents are not permitted
to make changes until the next open enrollment period, as established by the Plan.
Employer/Group takes full responsibility that the information provided to the Plan by its employees and any of their respective
dependents is accurate. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefits
or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
Authorized Representative of Employer/Group (Name)_______________________________________________
Authorized Representative’s Signature__________________________________________ Date ____/____/____
Plan #1 1000 RBP
$1,000 Individual Deductible $2,000 Family Deductible
Integrated with the medical
Plan #2 1500 RBP $1,500 Individual Deductible $3,000 Family Deductible
Integrated with the medical
Plan #3 2500 RBP $2,500 Individual Deductible
$5,000 Family Deductible
Integrated with the medical
Plan #4 3500 RBP $3,500 Individual Deductible
$7,000 Family Deductible Integrated with the medical
Plan #5 5000 RBP $5,000 Individual Deductible
$10,000 Family Deductible Integrated with the medical
Plan #6 7350 RBP $7,350 Individual Deductible
$14,700 Family Deductible Discount Card
Plan #7 5000 HSA
$5,000 Individual Deductible $10,000 Family Deductible
Discount Card
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Section 1 Employer Information

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Completed 15 June 2021

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