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The form outlines plan selection steps, correction instructions, and key contact numbers in multiple languages. It explains available network packages and premium tiers, optional rider options, and ancillary notes about pediatric dental and vision coverage through age 19. 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Health Net Dental HMO and PPO plans, other than pediatric dental, are offered and serviced by Dental Benefit Providers of California, Inc. (DBP) . Vision plans, other than pediatric vision, are underwritten by Health Net Life Insurance Company and serviced by EyeMed Vision Care, LLC (“EyeMed”) and Centene Vision Services.  \nPediatric dental HMO and PPO plans are provided by Health Net of California, Inc. and administered by DBP.  \nNeither DBP nor EyeMed are affiliated with Health Net. Obligations under dental plans, other than pediatric dental, are not obligations of, and are not guaranteed by, Health Net.  \nApplication is hereby made for a Group Service Agreement/Group Policy provided by Health Net and/or DBP, the provisions of which are to be made available to all eligible employees, as defined, and their eligible dependents desiring or requiring coverage hereunder. The following information regarding employee and/or dependent data is being submitted to allow Health Net and/or DBP to determine the eligibility of employees and/or dependents seeking enrollment.  \nWelcome to Health Net  \nSimple steps for completing the form:  \n1. Carefully review and select the plan option(s) that is/are best for your business.  \n2. Make a copy of the completed application for your records.  \nIf a correction is needed, cross out and initial each correction. Please do not use a white-out product.  \nHealth Net Medical:  \n800-522-0088 (English)  \n800-331777 (Spanish)  \n877-899053 (Mandarin)  \nHealth Net Life: 800-865-6288  \nHealth Net Dental: 866-249-2382  \nHealth Net Vision: 866-392-6058  \nPre-tax solutions (e.g., IRS code section 125 premium-only plans and Flex plans)  \nIf you are interested in learning about the tax savings potential for your employees and company, please contact Total Administrative Services Corporation (TASC) at 800-422-4661.  \n\n| For administrative use only: |  |\n| --- | --- |\n| Existing Business/Group\u003Cbr>PO Box 9103\u003Cbr>Van Nuys, CA 91409-9103 [www.healthnet.com](www.healthnet.com) | New Business/Group\u003Cbr>Please send all completed paperwork to your designated account executive or broker. |\n\nFRM066110EP00  \nSBG_GSA_CA (7/25) REV  \n1  \nThis page intentionally left blank.  \nFRM066110EP00  \nIFPHMOAPP12021 2 SBG_GSA_CA (7/25) REV  \nSmall Business  \nApplication for Group Service Agreement/Group Policy  \nImportant: If adding Dental or Vision to your existing coverage, please complete sections 1 (ancillary options), 2, 3, 4, 5, 6, 7, and 8; for all other changes to existing coverage, please complete only sections 2, 3, 4, and 7.  \n\n| 1. Health plan information |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Select a package, then select your plan(s): |  |  |  |  |  |  |  |  |  |  |  |\n| ■ Enhanced Choice ■ Other   |  |  |  |  |  |  |  |  |  |  |  |\n| Full HMO Network1 |  |  |  |  |  | SmartCare HMO Network2 |  |  |  |  |  |\n| Platinum\u003Cbr>■$0 ■$10 ■$20\u003Cbr>■$30 ■$35 |  | Gold\u003Cbr>■$30 ■$35 ■$40\u003Cbr>■$50 ■$55 |  |  | Silver\u003Cbr>■ $55 | Platinum\u003Cbr>■$0 ■$10 ■$20\u003Cbr>■$30 ■$35 |  |  | Gold\u003Cbr>■$30 ■$35 ■$40\u003Cbr>■$50 ■$55 |  | Silver\u003Cbr>■ $55 |\n| WholeCare HMO Network1 |  |  |  |  |  | Salud HMO y Más Network3 |  |  |  |  |  |\n| Platinum\u003Cbr>■$0 ■$10 ■$20\u003Cbr>■$30 ■$35 |  | Gold\u003Cbr>■$30 ■$35 ■$40\u003Cbr>■$50 ■$55 |  |  | Silver\u003Cbr>■ $55 | Platinum\u003Cbr>■$0 ■$10 ■$20\u003Cbr>■$30 ■$35 |  |  | Gold\u003Cbr>■$30 ■$35 ■$40\u003Cbr>■$50 ■$55 |  | Silver\u003Cbr>■ $55 |\n| Full PPO Network |  |  |  |  |  |  |  |  |  |  |  |\n| ■ Platinum PPO 0/5\u003Cbr>■ Platinum PPO 0/15\u003Cbr>■ Platinum PPO 250/15\u003Cbr>■ Gold PPO 0/35\u003Cbr>■ Gold PPO 350/25 |  | ■ Gold PPO 500/20\u003Cbr>■ Gold PPO 750/15\u003Cbr>■ Gold P","cbCaif5zdKIH2n04","https://ap.wps.com/l/cbCaif5zdKIH2n04","pdf",652663,"English","# Welcome to Health Net\n## Simple steps for completing the form\n## Health plan information\n## Employer group information","[{\"question\":\"How should corrections be made on the application form?\",\"answer\":\"Cross out and initial each correction. Do not use a white-out product.\"},{\"question\":\"What sections are required when adding Dental or Vision to existing coverage?\",\"answer\":\"Complete sections 1 (ancillary options) and 2, 3, 4, 5, 6, 7, and 8.\"},{\"question\":\"What is included with the medical plan regarding pediatric dental and vision?\",\"answer\":\"All medical plans include pediatric dental and pediatric vision coverage, provided under the medical plan until the last day of the month the individual turns 19.\"}]","Small Business - 2025 Application for Group Service Agreement/Group Policy - Health Net | PDF",1789786201,6]