Common use of Validations Clause in Contracts

Validations. Groups completing the Employer Risk Assessment Form may skip Sections A & B. A. Serious Medical Conditions: As an employer are you aware of any employee or dependent of an employee, including those not enrolling for coverage, who has been diagnosed or treated for a serious health problem such as AIDS, HIV positive status, Alzheimer Disease, Cancer, Diabetes, Heart Attack or Heart Disease, Hemophilia, Kidney Disease, Mental Illness or Substance Abuse? _Yes _No If yes, provide details below. (Attach separate sheet of paper if needed) Patient Name Aggregate Dollar Amount of Claims Dates of Service Describe Illness or Condition B. Has anyone within the past 24 months been hospitalized, institutionalized or missed work due to any disability or work related injury? □Yes □No If yes, provide details below. C. Is anyone currently COBRA eligible/enrolled? □Yes □No If yes, provide details below. D. Are there any retirees who meet the eligibility requirements AND are members of a formal retirement program? □Yes □No If yes, provide details below. Name Social Security # Age at Retrmnt Date of Rtrmnt Date of Hire Avg. Hrs. Worked Per Week Prior to Rtrmnt

Validations. Groups completing the Employer Risk Assessment Form may skip Sections A & B. A. Serious Medical Conditions: As an employer are you aware of any employee or dependent of an employee, including those not enrolling for coverage, who has been diagnosed or treated for a serious health problem such as AIDS, HIV positive status, Alzheimer Disease, Cancer, Diabetes, Heart Attack or Heart Disease, Hemophilia, Kidney Disease, Mental Illness or Substance Abuse? _o Yes _o No If yes, provide details below. (Attach separate sheet of paper if needed) Patient Name Aggregate Dollar Amount of Claims Dates of Service Describe Illness or Condition B. Has anyone within the past 24 months been hospitalized, institutionalized or missed work due to any disability or work related injury? □o Yes □o No If yes, provide details below.. Patient Name Describe Illness or Condition C. Is anyone currently COBRA eligible/enrolled? □o Yes □o No If yes, provide details below.. Name Social Security # Beginning Date Expiration Date Qualifying Event D. Are there any retirees who meet the eligibility requirements AND are members of a formal retirement program? □o Yes □o No If yes, provide details below. Name Social Security # Age at Retrmnt Date of Rtrmnt Date of Hire Avg. Hrs. Worked Per Week Prior to Rtrmnt