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Front and Back

1

1. Ramah Darom Election Form 16

2

Sheet1

2

2. Notice of Special Enrollment Rights - including CHIP

3

Employee Signature Date

3

3. SBC Humana NPOS 14 Simplicity #13 10.1.16

4-5

63:

4-5

SBC_Non2017

4-5

1: SBC_Non2017

4-5

2: SBC_Flow_Pagex

6-7

3: SBC_Flow_Pagex

8-9

4: SBC_Flow_Pagex

10-11

5: SBC_Flow_Pagex

12-13

6: SBC_Flow_Pagex

14-15

7: SBC_CoverageSampleNon2017

16-17

8: SBC_Questions_Non2017

18-19

4. SBC Humana NPOS 14 $2000 100-70 #67 10.1.16

20-21

64:

20-21

SBC_Non2017

20-21

1: SBC_Non2017

20-21

2: SBC_Flow_Pagex

22-23

3: SBC_Flow_Pagex

24-25

4: SBC_Flow_Pagex

26-27

5: SBC_Flow_Pagex

28-29

6: SBC_Flow_Pagex

30-31

7: SBC_CoverageSampleNon2017

32-33

8: SBC_Questions_Non2017

34-35

5. SBC Humana NPOS 14 Simplicity #12 10.1.16

36-37

60:

36-37

SBC_Non2017

36-37

1: SBC_Non2017

36-37

2: SBC_Flow_Pagex

38-39

3: SBC_Flow_Pagex

40-41

4: SBC_Flow_Pagex

42-43

5: SBC_Flow_Pagex

44-45

6: SBC_Flow_Pagex

46-47

7: SBC_CoverageSampleNon2017

48-49

8: SBC_Questions_Non2017

50-51

6. Humana Vision Plan

52

7. DMO-PPO Opt _3 FOC with ortho Plan Summary

55

8. HumanaVitality - One Pager

60

9. Humana Telemed Flyer

61

10. Mobile App Flyer

63

11. LTD_3259315_All Active Full Time Employees_bsum

64

12. BscLif_All Active Full Time Employees_bsum

67

13. 2016 Annual Health Plan Notices

70

Notice of Extended Coverage to Participants Covered Under a Group Health Plan

70

14. 2016 Marketplace Notice

73

PART B: Information About Health Coverage Offered by Your Employer

73

15. CHIP Notice 1-31-2016

75

16. Medicare D Creditable Drug coverage 2015

78