Please complete all sections (front & back) in black ink

BIIT-R Combo App 03/20

EMPLOYER SECTION: The Employer section must be completed & signed by the Group’s Contact Person as listed on the Employer Participation Agreement. If not fully completed, this form will be returned unprocessed. Group Name: _________________________ Group Number: ______________ Division Number: ___________ Group Phone Number: _________________ Intended Effective Date: ____/____/_____

Employee Class: q Class 1 q Class 2 q Class 3 q Class 4 Date of Hire: ____/___/___ Date of Rehire: ____/___/___ Date Changed from Part-time to Full-time: ____/___/___ Average Hours Per Week:______ Was employee subject to an Orientation Period as selected on the Employer Participation Agreement? q Yes q No Was employee subject to a Measurement Period as selected on the Employer Participation Agreement? q Yes q No

If yes, date employee satisfied eligibility requirements: ____/____/_____

SIGNATURE OF GROUP’S PRIMARY CONTACT PERSON: _______________________________________________________________ Date : ________________________

Contractual Effective Date and Eligibility: Applications for new employees must be received by the BIIT Trust within 10 days of the Contractual Effective Date. The Contractual Effective Date is based on the employee’s date of hire and the company’s established probationaryperiod. Applications received after the Contractual Effective Date may delay an employee’s eligibility date to the next BIIT Trust Open Enrollment period. New BIIT application forms are required to add dependents, including newborns and/or a new spouse/domestic partner (see Plan Booklets for details).

EMPLOYEE RELEASE AND AUTHORIZATION: I hereby verify that all of the information specified above is accurate and complete and acknowledge that I have read and understand all information on the second page of this application. By signing below, I have authorized the release of information, for myself and my dependents listed on this application, to the issuer. EMPLOYEE’S SIGNATURE : ___________________________________________ DATE : ___________________

A Reason Must be Checked for Application:Add Employee q New Group q New Employee q Open Enrollment q Loss of Eligibility on Another Coverage

Add Dependent q Birth q Marriage q Adoption q Domestic Partner q COBRA coverage exhausted q Open enrollment q Loss of eligibility on another coverage (must attach proper documentation)

q Change of Life Beneficiaryq Change of Addressq Name Changeq Change Medical Plan*

* Medical Plan election changes are allowed only during the Open Enrollment Period each year or due to a HIPAA qualifying event.

SelectEmployee

Plan

LIFE INSURANCE BENEFIT (Coverage underwritten by LifeMap Assurance Company 200 SW Market Street, Portland, OR 97201) LIFE INSURANCE BENEFICIARY DESIGNATION: This section must be completed for all new employee enrollments. If no beneficiary is designated, benefits will be paid under the terms of the group insurance contract. Please contact EPK

& Associates for an additional form if you would like to designate a Contingent Beneficiary.

Primary Beneficiary’s Name: ___________________________________ Relationship: ____________________ Beneficiary’s Birthdate: : ________________ Percentage of Benefit: _______________ Primary Beneficiary’s Address: ___________________________________ City/State/Zip: ______________________ Phone Number: : ____________________

EMPLOYEE SECTION: First Name: _______________________ Middle Initial: ____ Last Name: ________________________

Address: _____________________________________________________________________

City: ________________________________________ State: ______ Zip: _________________

Phone #: ____________________ Email: __________________________________________

Marital Status: q Married/ Oregon-Certified Domestic Partnership q Single

D ate of Marriage/Oregon-Certified Domestic Partnership: __________

Common Enrollment Plans underwritten by Regence BlueCross BlueShield of Oregon and LifeMap Assurance Company: (If an employer offers common enrollment dental and/or vision benefits, employees & dependents will automatically be enrolled in those benefits if they enroll in medical benefits.) q Market Plan ____ q Foundation Plan ____ q HSA Plan ____ Voluntary Enrollment Plans underwritten by LifeMap Assurance Company: q Vol Dental q Vol Vision

Building Industry Insurance Trust (BIIT)Employee / Subscriber Application

Page 1

Select PlanMedical Dental Vision Relationship Last Name First Name M.I. Social Security Number or

Individual tax payer ID number (ITIN) Birth Date

(mm/dd/yyyy)Gender

M/F

q q q Employee / /

q q q Spouse/Domestic Partner / /

q q q Child / /

q q q Child / /

q q q Child / /

Note: Only plans being offered by the employer may be selected for enrollment. Dependents may only enroll in benefits in which the employee is also enrolled.

BIIT-R Combo App 03/20

If any dependent child(ren) being added is/are covered under another plan and the natural parents are divorced or separated, State regulations require that we ask the following:Name of parent with custody (if parents have dual custody, indicate): ________________________________________________________________________________________________If divorced, did the court establish financial responsibility for the child(ren)’s health care? q Yes q No (Please provide a copy of the divorce decree maintenance agreement outlining coverage specifications.)If YES, please specify the name and address of the parent with responsibility: __________________________________________________________________________________________ _

Do you or any of your dependents applying for coverage have coverage with any health care plan? q Yes q No Will coverage remain in effect? q Yes q NoIMPORTANT: If you or any of your dependents applying for coverage have coverage with any health care plan, you MUST complete the information below.

OTHER CURRENT OR PRIOR INSURANCE COVERAGE: Other Insurance Company Name:____________________________________________________ Other Insurance Company Phone #:____________________________________

Other Insurance Company Full Address: ________________________________________________________________________________________________________________ Policyholder’s Name::__________________________________ Policyholder’s Birth Date:____/____/____ (mm/dd/yyyy) Policy Holder’s Member ID# or Social Security #:__________________________

Group Name & Policy #: ______________________ Effective Date of Coverage: ____/____/____ Intended Termination Date of Coverage: ____/____/______ Reason for Termination:___________________ Persons covered by prior insurance (list names and date of birth for each): ________________________________________________________________________________________________

Type of CoverageType of Coverage:: q Medical q Pharmacy q Dental qVision q Medicare Type of Policy: qGroup q Individual q Medicaid q Medicare Part A q Medicare Part B q Other:____________________

If employee or dependents have Medicare, what was the begin date for Part A:_____________ Part B:_____________ Medicare HIC# with Alpha Suffix:_______________________Name of Person covered by Medicare ____________________________________________ Reason: q Disability q Over Age 65 q End Stage Renal Disease

Mail or Fax to:EPK & Associates, Inc. - 15375 SE 30th Place #380 - Bellevue, WA 98007

Phone: 800-545-7011 - Fax 425-641-8114

Anti-Fraud Provision: I have provided these answers as part of the application procedure required by the issuer to enroll in coverage and I certify that all information completed on this form is true, correct and complete. I understand that the issuer will rely on each answer in making coverage and rating determinations. For the protection of all members, fraud or misrepresentation of material fact by me for the purposes of defrauding the issuer may result in the issuer taking any action allowed by law or contract, including termination or rescission of coverage and/or denial of benefits, and/or could subject me to prosectuion for insurance fraud.

HIPAA Special Enrollment Provisions: If I have waived enrollment and completed a “Waiver of Insurance Form” for myself or any of my dependents (including my spouse) because of other health insurance or group health plan coverage, I may in the future be able to enroll the waived individuals in this plan, provided I request enrollment within 30 days after the other coverage of the individual(s) ends due to loss of eligibility or an employer’s ceasing to contribute toward that other coverage. In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my dependents, provided that I request enrollment within 30 days after the marriage, or within 60 days after the birth, adoption, or placement.

Release of Information Provision (HIPAA Disclosure & Privacy): I authorize any source to release to the issuer, any medical, health, employment, and/or insurance information requested for any enrolled member. I acknowledge and understand that the issuer may request or disclose health information, other than psychotherapy notes (for which a separate authorization will be used), about me or my enrolled dependents from time to time to faciliatate health care treatment or payment, to assist with business operations necessary to administer health care benefits, or as required by law.

For more information about such uses and disclosures, including uses and disclosures required by law, please refer to the Notice of Privacy Practices. A copy is available from our website at www.epkbenefits.com or by phone at (800) 545-7011 or (425) 641-7762.

Medical coverage underwritten by: Regence BlueCross BlueShield of Oregon 100 SW Market Street, Portland, OR 97201

Dental, Vision and Life insurance LifeMap Assurance Companycoverages underwritten by: 200 SW Market Street, Portland, OR 97201

Employee Assitance Program offered by: First Choice Health 600 University St, Suite 1400, Seattle, WA 98101

Page 2

EMPLOYEE SECTION: Employee Social Security Number: _____________________

First Name: _______________________ Middle Initial: ____ Last Name: ________________________

Please use this page, if necessary, to enroll additional dependents.

Addtional Dependents Continued from First Page

BIIT-R Combo App 03/19

Building Industry Insurance Trust (BIIT)Employee / Subscriber Application

Page 3

Select PlanMedical Dental Vision

Relationship Last Name First Name M.I. Social Security Number or Individual tax payer ID number (ITIN)

Birth Date(mm/dd/yyyy)

GenderM/F

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

q q q Child / /

NONDISCRIMINATION NOTICE

01012017.04PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Regence does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Regence: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, and accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages If you need these services listed above, please contact: Medicare Customer Service 1-800-541-8981 (TTY: 711) Customer Service for all other plans 1-888-344-6347 (TTY: 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our civil rights coordinator below: Medicare Customer Service Civil Rights Coordinator MS: B32AG, PO Box 1827 Medford, OR 97501 1-866-749-0355, (TTY: 711) Fax: 1-888-309-8784 medicareappeals@regence.com Customer Service for all other plans Civil Rights Coordinator MS CS B32B, P.O. Box 1271 Portland, OR 97207-1271 1-888-344-6347, (TTY: 711) CS@regence.com

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F HHH Building Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Language assistance

01012017.04PF12LNoticeNDMARegence

ATENCIÓN: si habla español, tiene a su disposición

servicios gratuitos de asistencia lingüística. Llame al

1-888-344-6347 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言

援助服務。請致電 1-888-344-6347 (TTY: 711)。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ

trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-

344-6347 (TTY: 711).

주의: 한국어를 사용하시는 경우, 언어 지원

서비스를 무료로 이용하실 수 있습니다. 1-888-

344-6347 (TTY: 711) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad. Tumawag sa 1-888-344-6347 (TTY:

711).

ВНИМАНИЕ: Если вы говорите на русском языке,

то вам доступны бесплатные услуги перевода.

Звоните 1-888-344-6347 (телетайп: 711).

ATTENTION : Si vous parlez français, des services

d'aide linguistique vous sont proposés gratuitement.

Appelez le 1-888-344-6347 (ATS : 711)

注意事項：日本語を話される場合、無料の言語支

援をご利用いただけます。1-888-344-6347

（TTY:711）まで、お電話にてご連絡ください。

D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-888-344-6347 (TTY: 711.)

FAKATOKANGA’I: Kapau ‘oku ke Lea-

Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai

atu ha tokoni ta’etotongi, pea te ke lava ‘o ma’u ia.

ha’o telefonimai mai ki he fika 1-888-344-6347 (TTY:

711)

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski,

usluge jezičke pomoći dostupne su vam besplatno.

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom: 711)

ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ គឺអាចមានសំរារ់រំបរ ើអ្នក។ ចូរ ទូរស័ព្ទ 1-888-344-6347 (TTY: 711)។

ਧਿਆਨ ਧਿਓ :ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹ,ੋ ਤਾਂ ਭਾਸ਼ਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮਫੁਤ ਉਪਲਬਿ ਹੈ। 1 -888-344-6347 (TTY: 711) 'ਤ ੇਕਾਲ ਕਰੋ।

ACHTUNG: Wenn Sie Deutsch sprechen, stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfügung. Rufnummer: 1-888-344-6347 (TTY: 711)

ማስታወሻ:- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፤ በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው:- 711)፡፡

УВАГА! Якщо ви розмовляєте українською

мовою, ви можете звернутися до безкоштовної

служби мовної підтримки. Телефонуйте за

номером 1-888-344-6347 (телетайп: 711)

ध्यान दिनहुोस:् तपार्इलं ेनेपाली बोल्नहुुन्छ भने तपार्इकंो दनदतत भाषा सहायता सेवाहरू

दनिःशलु्क रूपमा उपलब्ध छ । फोन गनुुहोस ्1-888-344-6347 (दिदिवार्इ:

711

ATENȚIE: Dacă vorbiți limba română, vă stau la

dispoziție servicii de asistență lingvistică, gratuit.

Sunați la 1-888-344-6347 (TTY: 711)

MAANDO: To a waawi [Adamawa], e woodi ballooji-

ma to ekkitaaki wolde caahu. Noddu 1-888-344-6347

(TTY: 711)

โปรดทราบ: ถา้คุณพูดภาษาไทย คุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โทร 1-888-344-6347 (TTY: 711)

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີ ພ້ອມໃຫ້ທ່ານ.

ໂທຣ 1-888-344-6347 (TTY: 711)

Afaan dubbattan Oroomiffaa tiif, tajaajila gargaarsa

afaanii tola ni jira. 1-888-344-6347 (TTY: 711) tiin

bilbilaa.

شمای برا گانیرا بصورتی زبان التیتسه د،یکنی مصحبت فارسی زبان به اگر: توجه .دیریبگ تماس (TTY: 711) 6347-344-888-1 با. باشدی م فراهم

Language assistance

01012017.04PF12LNoticeNDMARegence

6347-344-888-1ملحوظة: إذا كنت تتحدث فاذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم TTY: 711)هاتف الصم والبكم )رقم

Market Plan: Foundation Plan: HSA Plan: Middle Initial: First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of MarriageOregonCertified Domestic Partnership: Last NameEmployee: First NameEmployee: MIEmployee: Social Security Number or Individual tax payer ID number ITINEmployee: Gender MF: Last NameSpouseDomestic Partner: First NameSpouseDomestic Partner: MISpouseDomestic Partner: Social Security Number or Individual tax payer ID number ITINSpouseDomestic Partner: Gender MF_2: Last NameChild: First NameChild: MIChild: Social Security Number or Individual tax payer ID number ITINChild: Gender MF_3: Last NameChild_2: First NameChild_2: MIChild_2: Social Security Number or Individual tax payer ID number ITINChild_2: Gender MF_4: Last NameChild_3: First NameChild_3: MIChild_3: Social Security Number or Individual tax payer ID number ITINChild_3: Gender MF_5: s Name: Relationship: s Birthdate: Percentage of Benefit: s Address: CityStateZip: Phone Number: DATE: Group Name: Group Number: Division Number: Group Phone Number: Intended Effective Date: undefined: undefined_2: Date of Hire: Date of Rehire: Date Changed from Parttime to Fulltime: Average Hours Per Week: If yes date employee satisfied eligibility requirements: undefined_3: undefined_4: Date: Name of parent with custody if parents have dual custody indicate: If YES please specify the name and address of the parent with responsibility: Other Insurance Company Name: Other Insurance Company Phone: Other Insurance Company Full Address: Policyholders Name: Policyholders Birth Date: undefined_5: undefined_6: mmddyyyy Policy Holders Member ID or Social Security: Group Name Policy: Effective Date of Coverage: undefined_7: undefined_8: Intended Termination Date of Coverage: undefined_9: undefined_10: Reason for Termination: Persons covered by prior insurance list names and date of birth for each: Type of Policy Group Individual Medicaid Medicare Part A Medicare Part B Other: If employee or dependents have Medicare what was the begin date for Part A: Part B: Medicare HIC with Alpha Suffix: Name of Person covered by Medicare: Employee Social Security Number: First Name_2: Middle Initial_2: Last Name_2: Last NameChild_4: First NameChild_4: MIChild_4: Social Security Number or Individual tax payer ID number ITINChild_4: Gender MF_6: Last NameChild_5: First NameChild_5: MIChild_5: Social Security Number or Individual tax payer ID number ITINChild_5: Gender MF_7: Last NameChild_6: First NameChild_6: MIChild_6: Social Security Number or Individual tax payer ID number ITINChild_6: Gender MF_8: Last NameChild_7: First NameChild_7: MIChild_7: Social Security Number or Individual tax payer ID number ITINChild_7: Gender MF_9: Last NameChild_8: First NameChild_8: MIChild_8: Social Security Number or Individual tax payer ID number ITINChild_8: Gender MF_10: Last NameChild_9: First NameChild_9: MIChild_9: Social Security Number or Individual tax payer ID number ITINChild_9: Gender MF_11: Last NameChild_10: First NameChild_10: MIChild_10: Social Security Number or Individual tax payer ID number ITINChild_10: Gender MF_12: Last NameChild_11: First NameChild_11: MIChild_11: Social Security Number or Individual tax payer ID number ITINChild_11: Gender MF_13: Last NameChild_12: First NameChild_12: MIChild_12: Social Security Number or Individual tax payer ID number ITINChild_12: Gender MF_14: Last NameChild_13: First NameChild_13: MIChild_13: Social Security Number or Individual tax payer ID number ITINChild_13: Gender MF_15: Last NameChild_14: First NameChild_14: MIChild_14: Social Security Number or Individual tax payer ID number ITINChild_14: Gender MF_16: Last NameChild_15: First NameChild_15: MIChild_15: Social Security Number or Individual tax payer ID number ITINChild_15: Gender MF_17: Last NameChild_16: First NameChild_16: MIChild_16: Social Security Number or Individual tax payer ID number ITINChild_16: Gender MF_18: Last NameChild_17: First NameChild_17: MIChild_17: Social Security Number or Individual tax payer ID number ITINChild_17: Gender MF_19: Last NameChild_18: First NameChild_18: MIChild_18: Social Security Number or Individual tax payer ID number ITINChild_18: Gender MF_20: Last NameChild_19: First NameChild_19: MIChild_19: Social Security Number or Individual tax payer ID number ITINChild_19: Gender MF_21: Last NameChild_20: First NameChild_20: MIChild_20: Social Security Number or Individual tax payer ID number ITINChild_20: Gender MF_22: Last NameChild_21: First NameChild_21: MIChild_21: Social Security Number or Individual tax payer ID number ITINChild_21: Gender MF_23: Last NameChild_22: First NameChild_22: MIChild_22: Social Security Number or Individual tax payer ID number ITINChild_22: Gender MF_24: Check Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: 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