Case 4:11-cv-00940-JEJ Document 1-1

Filed 05/17/11 Page 1 of 1

MEMBERSHIP STATUS
In order to be considered a subscriber or dependent under this coverage with Capital, an individual must meet certain eligibility requirements and enroll (apply) for coverage within a specific timeframe. There is a limited period of time to submit an enrollment application for initial enrollment and enrollment changes. Subscribers should consult with the contract holder to determine the specific timeframes applicable to them. Subscribers who fail to submit an enrollment application within these specific timeframes may not be allowed to enroll themselves and/or their newly eligible dependents until the next open enrollment period. Subscribers should refer to the Timelines for Submission of Enrollment Applications section of this Certificate of Coverage for more details.

ELIGIBILITY
Individuals must meet specific eligibility requirements to enroll or to continue being enrolled for coverage, unless otherwise approved in writing by Capital in advance of the effective date of coverage. Subscriber An individual must meet all eligibility criteria specified by the contract holder and approved by Capital to enroll in this coverage as a subscriber. This criteria includes meeting all requirements to participate in the contract holders health benefit program, including compliance with any probationary or waiting period established by the contract holder. Dependent - Spouse An individual must be the lawful spouse of the subscriber to enroll in this coverage as a dependent spouse. Capital reserves the right to require that a spouse of a subscriber provide documentation demonstrating marriage to the subscriber, including, but not limited to, marriage certificate, court order or, joint statement of common law marriage as determined by Capital. Dependent Domestic Partner An individual must qualify as the domestic partner of the subscriber to enroll in this coverage as a dependent domestic partner. Domestic partners cannot be the same gender. Capital reserves the right to request documentation evidencing the domestic partnership by submission of proof of three (3) or more of the following documents:
x x x x x x

a domestic partnership agreement; a joint mortgage or lease; a designation of one of the partners as beneficiary in the other partners will; a durable property and health care powers of attorney; a joint title to an automobile, or joint bank account or credit account; or such other proof as is sufficient to establish economic interdependency under the circumstances of the particular case.

Form C00505818PO10710

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