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insurance program, however, this enroliment opportunity is not available unless the Eligible Person requests <br /> enrollment within sixty(60) days after such coverage ends. <br /> Late Enrollment: An Eligible Person may apply for coverage, Family coverage or add dependents if he/she did not <br /> apply prior to his/her Eligibility Date or did not apply when eligible to do so. Such person's Coverage Date, Family <br /> Coverage Date, and/or dependenYs Coverage Date will be a date mutually agreed to by the Claim Administrator and <br /> the Employer. <br /> Open Enrollment: � Yes ❑ No <br /> An Eligible Person may apply for coverage, Family coverage or add dependents if he/she did not apply prior to <br /> his/her Eligibility Date or did not apply when eligible to do so, during the Employer's Open Enrollment Period. <br /> • Specify Open Enrollment Period: Three tier PPO Porgram only: Group Numbers: P22347-P22348-P22349- Bi- <br /> Annually <br /> Such person's Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be a date mutually <br /> agreed to by the Claim Administrator and the Employer. Such date shall be subsequent to the Open Enrollment <br /> Period. <br /> 8. Extension of benefits due to Temporary Layoff, Disability or Leave of Absence: <br /> Temporary Layoff: 0 days Disability: 0 days Leave of Absence: 0 days <br /> However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with any applicable <br /> federal or state law. <br /> 9. COBRA Auto Cancel? ❑ Yes � No <br /> Member's COBRA/Continuation of Coverage will be automatically cancelled at the end of the member's eligibility <br /> period. <br /> ASO STATUS <br /> 1. Group Status: Renewing ASO Account <br /> 2. If a former HCSC Insured Group is converting to ASO, on what basis? <br /> Basis: Select from Pull Down <br /> LINES OF BUSINESS <br /> . . . . . - . . . <br /> � Participating Provider Option � Outpatient Prescription Drugs: <br /> ❑ Point of Service (BlueChoice) � Outpatient Prescription Drug Program <br /> ❑ Blue Choice Select � Covered under the medical benefit <br /> ❑ Comprehensive Major Medical ❑ Dental <br /> ❑ Base Plus � Blue Care Connection� <br /> HCSC IL GEN ASO BPA Rev. 9.1.10(On-line Version) page 3 <br />