I agree that I (we) shall abide by the provisions of coverage in the policy under which I (we) are enrolled. I understand that it is my responsibility to report any changes in the eligibility of my dependents. I understand that any claims asserted by myself or my dependents against NetCare Life & Health Insurance company or any provider, whether based in tort, contract or otherwise (including profession liability) are subject to binding arbitration. I have read the benefit brochure and any questions pertaining to the NetCare Health Plan has been answered satisfactorily. I (we) hereby authorize my employer to deduct any required costs for the program from my wage. I have had the opportunity to review the group comprehensive medical expense insurance policy issued to the employer, and agree that I (we) will be bound by the terms and conditions therein contained.
Fraud Warning Notice: Any person with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits a request for enrollment, or files a claim containing a false or deceptive statement is guilty of insurance fraud.