Darwin J. Albers & Peggy L. Albers - Page 7




                                        - 7 -                                         
               On April 25, 2001, Mr. Albers completed a preprinted                   
          application form entitled “Application for Individual Health &              
          Life Insurance” (Mr. Albers’s Wellmark application).  In that               
          application, Mr. Albers applied to Wellmark/Blue Cross Blue                 
          Shield of South Dakota (Wellmark) for a so-called Blue Select               
          health insurance policy to cover himself, Ms. Albers, and their             
          dependent children.  In Mr. Albers’s Wellmark application, Mr.              
          Albers identified himself as “Applicant”, Ms. Albers as “Spouse”,           
          and each of their children as a “Dependent”.  The portion of Mr.            
          Albers’s application entitled “Enrollment Information” stated in            
          pertinent part:                                                             
          1.  The Plan I am applying for is:  *  CLASSIC BLUEBLUE SELECT   Are you also applying for the
          (PLEASE CIRCLE ONE)             .  Plan I   Plan II$500     $750     $1,000Supplemental Accident Option?
          +    Plan III   Plan IV          $2,500    $5,0009Yes   :No   N/A on Plan A   
          *   Plan A   Plan B                            or B                         
          2.  This request for coverage is for:  (check all that apply)3.  This application is for:  (check all that apply)
          :Self  :Spouse  :Child(ren)         :New Enrollment  9Change  9Adding/Removing
                                              Dependents                              
          4.  Indicate how you wish to be billed:  (check all that apply)             
          9 Monthly [Automatic Account Withdrawal required; complete form M-3506(U)]   9Quarterly   :Semi-annually   9Annually
          9 Automatic Account Withdrawal (complete form M-3506(U) Authorization for Automatic Account Withdrawal)
          5.  The amount you are submitting for health insurance is:       $229.10 (Make check payable to Wellmark Blue Cross and Blue
          Shield of South Dakota)                                                     
                              *       *       *       *       *       *       *       
          Is any portion of the premium or benefits paid by or on behalf of the small group employer?  Yes (reason) _______    :No
          Is the health benefit plan part of a plan or program for purposes of Section 125 or 106 of the IRS code?   9Yes   :No
                              *       *       *       *       *        *       *      
          7.  Creditable Coverage.  Does any person named on this application have health care coverage now or did they have it within
          the last 63 days?  9No :Yes, complete the following:                        
            Type of Policy - Company or                                               
                Individual  Covered IndividualEffective DateTermination DateInsurance CompanyID Number       
                Family Ind.     All      7-8 yrs.   issue   Am. Republic              




               4Mr. Albers circled “$2,500” under the “Blue Select” plan              
          for which he was applying.                                                  
               5The word that appeared before the word “issue” is not                 
          legible.                                                                    
               6The “ID Number” shown was Mr. Albers’s Social Security                
          number.                                                                     





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Last modified: November 10, 2007