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documents/insurance/auto/state_farm_coverage_rejection_2016.md

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+---
+type: insurance document
+category: coverage rejection acknowledgment
+person: Lu, Yanxin & Xuewei Jiang
+date: 2016-12-21
+source: state_farm_coverage_rejection_2016.jpg
+---
+
+# Texas Uninsured/Underinsured Motorists and Personal Injury Protection Coverages
+
+**(Acknowledgment of Coverage Rejection)**
+
+**Insurer:**
+- State Farm Mutual Automobile Insurance Company
+- State Farm Fire and Casualty Company
+- State Farm County Mutual Insurance Company of Texas
+
+---
+
+**Uninsured/Underinsured Motorists Coverage** protects persons insured who are legally entitled to recover damages from owners or drivers of uninsured or underinsured motor vehicles because of bodily injury or property damage caused by accident. (The underinsured portion applies only when an insured person's damages are greater than the at-fault driver's available liability coverage. We pay the amount that the insured person's damages exceed the at-fault driver's available liability coverage, but never more than the amount of the insured person's covered damages or the limit of liability of this coverage.)
+
+**Personal Injury Protection Coverage** pays, regardless of fault, necessary medical and funeral expenses for bodily injury caused by a motor vehicle accident. It also pays eighty percent of lost income or the reasonable expenses incurred to replace services ordinarily performed by an injured person who is not employed for the care and maintenance of the family or household while that person is unable to perform these services.
+
+Uninsured/Underinsured Motorists Coverage and Personal Injury Protection Coverage are not available on any vehicle described in the policy that is not insured for Liability Coverage.
+
+**I acknowledge that in accordance with the laws of the State of Texas** *(check all that apply):*
+
+- ☐ 1. I have been given the option to reject both the bodily injury and property damage portions of Uninsured/Underinsured Motorists Coverage, and I reject such coverage. *(If you check box 1, do not check box 2.)*
+
+- ☐ 2. I have been given the option to reject both the bodily injury and property damage portions of Uninsured/Underinsured Motorists Coverage, and I reject only the property damage portion of such coverage. *(If you check box 2, do not check box 1.)*
+
+- ☒ 3. I have been given the option to reject Personal Injury Protection Coverage and I reject such coverage.
+
+I understand and agree that, unless a named insured requests such coverage in writing, this Acknowledgment of Coverage Rejection shall be:
+
+(1) binding on all persons insured under the policy; and
+
+(2) applicable to this policy of insurance, to any reinstated policy, to any supplemental to a reinstated policy, or to any renewal policy issued by the same insurer or an affiliated insurer.
+
+---
+
+| Field | Value |
+|---|---|
+| Application/Policy Number | 329 1808-D24-53A |
+| Named Insured(s) | LU, YANXIN & XUEWEI JIANG |
+| Date | 12/21/2016 |
+
+**Signature:** *(signed)*
+
+---
+
+**Form:** 1003462 TX.9
+**Document ID:** 2002 140877 202 11-18-2014

documents/insurance/auto/state_farm_steer_clear_2016.md

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+---
+type: insurance document
+category: auto insurance discount qualification and coverage rejection
+person: Yanxin Lu, Xuewei Jiang
+date: 2016-12-21
+source: state_farm_steer_clear_2016.pdf
+---
+
+# Page 1: Statement for Qualification for Steer Clear® Discount
+
+**Insurer:**
+- State Farm Mutual Automobile Insurance Company
+- State Farm County Mutual Insurance Company of Texas
+
+| Field | Value |
+|---|---|
+| Policyholder's Name | Yanxin Lu |
+| Qualifying Driver('s) Name(s) | Xuewei Jiang |
+| Policy Number | 329 1808-D24-53A |
+
+## Steer Clear Discount Initial Requirements
+
+1. All drivers under 25 have maintained an accident-free and moving violation-free driving record in the past three years,*
+2. All drivers under 25 have completed the educational and driving log requirements in good faith, and
+3. All private passenger automobiles in the household are insured with State Farm Automobile Insurance Company or State Farm County Mutual Insurance Company of Texas.**
+
+## To Maintain Steer Clear Discount
+
+1. All drivers under 25 continue to maintain an accident-free and moving violation-free driving record.*
+2. All drivers under 25 should complete Second Education material received prior to 21st birthday.
+
+## Applicant's Statement
+
+I have met the initial requirements for the Steer Clear safe driver discount and understand that I will lose the discount if I am involved in an at-fault accident or receive a moving violation. I understand that when I reach the age of 25 I will no longer qualify for this discount.
+
+| Field | Value |
+|---|---|
+| Signature of Qualifying Driver | *(signed)* |
+| Date | 12/21/2016 |
+| Signature of Qualifying Driver (2) | — |
+| Date (2) | — |
+| Signature of Qualifying Driver (3) | — |
+| Date (3) | — |
+| Signature of Parent/Guardian/Named Insured (if qualifying driver is under age 18) | — |
+| Date | — |
+| Agent Name and Code | — |
+
+*In some states, certain accidents and moving violations may not disqualify you.
+**In some states, this requirement does not apply.
+
+**Form:** 1002294 | 138728.1 08-17-2012
+
+---
+
+# Page 2: Texas Uninsured/Underinsured Motorists and Personal Injury Protection Coverages
+
+**(Acknowledgment of Coverage Rejection)**
+
+**Insurer:**
+- State Farm Mutual Automobile Insurance Company
+- State Farm Fire and Casualty Company
+- State Farm County Mutual Insurance Company of Texas
+
+**Uninsured/Underinsured Motorists Coverage** protects persons insured who are legally entitled to recover damages from owners or drivers of uninsured or underinsured motor vehicles because of bodily injury or property damage caused by accident. (The underinsured portion applies only when an insured person's damages are greater than the at-fault driver's available liability coverage. We pay the amount that the insured person's damages exceed the at-fault driver's available liability coverage, but never more than the amount of the insured person's covered damages or the limit of liability of this coverage.)
+
+**Personal Injury Protection Coverage** pays, regardless of fault, necessary medical and funeral expenses for bodily injury caused by a motor vehicle accident. It also pays eighty percent of lost income or the reasonable expenses incurred to replace services ordinarily performed by an injured person who is not employed for the care and maintenance of the family or household while that person is unable to perform these services.
+
+Uninsured/Underinsured Motorists Coverage and Personal Injury Protection Coverage are not available on any vehicle described in the policy that is not insured for Liability Coverage.
+
+**I acknowledge that in accordance with the laws of the State of Texas** *(check all that apply):*
+
+- ☐ 1. I have been given the option to reject both the bodily injury and property damage portions of Uninsured/Underinsured Motorists Coverage, and I reject such coverage. *(If you check box 1, do not check box 2.)*
+
+- ☐ 2. I have been given the option to reject both the bodily injury and property damage portions of Uninsured/Underinsured Motorists Coverage, and I reject only the property damage portion of such coverage. *(If you check box 2, do not check box 1.)*
+
+- ☒ 3. I have been given the option to reject Personal Injury Protection Coverage and I reject such coverage.
+
+I understand and agree that, unless a named insured requests such coverage in writing, this Acknowledgment of Coverage Rejection shall be:
+
+(1) binding on all persons insured under the policy; and
+
+(2) applicable to this policy of insurance, to any reinstated policy, to any supplemental to a reinstated policy, or to any renewal policy issued by the same insurer or an affiliated insurer.
+
+---
+
+| Field | Value |
+|---|---|
+| Application/Policy Number | 329 1808-D24-53A |
+| Named Insured(s) | LU, YANXIN & XUEWEI JIANG |
+| Signature | *(signed)* |
+| Date | 12/21/2016 |
+
+**Form:** 1003462 TX.9
+**Document ID:** 2002 140877 202 11-18-2014

documents/insurance/medical/jiang_medical_insurance_card.md

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+---
+type: insurance
+category: medical-insurance-card
+person: Jiang, Erica (Xuewei)
+provider: Aetna
+source: jiang_medical_insurance_card.png
+---
+
+# Medical Insurance Card - Erica Jiang (Xuewei)
+
+## Member and Network Information for Providers
+
+| Field | Value |
+|-------|-------|
+| Group # | 16426 |
+| Network | Aetna Network |
+| Member | YANXIN LU |
+| Member ID | 3928092626 |
+| Dependent | XUEWEI JIANG |
+| Network | Aetna Choice POS II |
+| Plan | EPO |
+| Claims Payor | Mertian Health |
+| | For Subscriber, see reverse |
+
+### Cost Share
+
+| Service | Cost |
+|---------|------|
+| Office Visit | $15 |
+| Specialist | $15 |
+| Urgent Care | $15 |
+| ER | $110 |
+| INV OOP $6,000/Family | |
+
+---
+
+## Pharmacy Plan
+
+| Field | Value |
+|-------|-------|
+| Logo | CVS Caremark |
+| RXPCN | ADV |
+| RXBIN | 004336 |
+| RXGRP | RX2543 |
+
+---
+
+## Providers Only
+
+| Field | Value |
+|-------|-------|
+| Provider Service | 888 632 3862 |
+| Precertification | 866 415 6831 |
+| Member | 844 246 4511 |
+| Pre-Certified Svc | 877 344 3256 |
+
+---
+
+## Member Support
+
+| Field | Value |
+|-------|-------|
+| Call Insurance Company Concerns at | 844 287 3866 |
+| www.aetna.com | |
+| if member accessible | |
+| Download Aetna Mobile to send a secure message with questions about eligibility, claims and plan benefits. | |
+| Available by phone 24/7 | |
+
+---
+
+## Claims Submission / Appeals
+
+**Mail All Claims & Correspondence to:**
+Mertian Health, PO Box 853921
+Richardson, TX 75085-3921
+
+**EDI:** AetnaMyMedAdv/EnvisionChange
+Healthcare 41124 or MedAdvantage/
+Health 17181
+
+**Mail All Appeal Correspondence to:**
+Mertian Health, PO Box 27881
+Philadelphia PA 19134-2881
+
+---
+
+## Precertification
+
+For a referral to see a specialist, a primary care doctor may require precertification. Without precertification, you may have a higher copay. For a list of services that require precertification and to request precertification, call 866.415.6831 or comply with your plan's precertification requirements. To determine if a service requires precertification, Call Progyny at 844.734.8586 to Pre-certify and enhance any fertility benefits.
+
+---
+
+## Elected into the NY Pool
+
+Aetna participating Doctors and Hospitals are independent providers and are neither agents nor employees of Aetna.
+
+**Network:** First Health Network

documents/insurance/medical/lu_medical_card.md

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+---
+type: insurance-card
+category: medical
+person: Yanxin Lu
+source: lu_medical_card.png
+---
+
+# Yanxin Lu — Aetna Medical Insurance Card
+
+## Member and Network Information for Providers
+
+| Field | Value |
+|-------|-------|
+| Group # | 16424 |
+| Member | YANXIN LU |
+| Member ID | 3928092626 |
+| Network | Aetna Choice POS II |
+| Plan | EPO |
+
+### Copays
+
+| Service | Copay |
+|---------|-------|
+| Office Visit | $15 |
+| Specialist | $15 |
+| Urgent Care | $25 |
+| ER | $100 |
+| INN OOP | $3,000 |
+
+- **Claims Payer**: Meritain Health
+- For Submission, see reverse
+
+## Pharmacy Plan
+
+| Field | Value |
+|-------|-------|
+| RXBIN | 610014 |
+| RXPCN | ADV |
+| RXGRP | RX2336 |
+
+**Pharmacy**: CVS Caremark  
+**Pharmacy Member**: 844.248.4511  
+**Pharmacy Provider**: 800.364.6331
+
+## Providers Only
+
+| Field | Value |
+|-------|-------|
+| Provider Service | 866.761.3018 |
+| Precertification | 866.415.6831 |
+| Non-Physician | $42 |
+
+## Member Support
+
+| Field | Value |
+|-------|-------|
+| Call | 844.287.3866 |
+| Website | mymeritain.apcbcbs.com |
+
+Download Acrcolade Mobile to send a secure message with questions about eligibility, claims and plan benefits.
+
+Extras available by phone 24/7.
+
+## Claims Submission / Appeals
+
+**Mail All Claims & Correspondence to:**  
+Meritain Health, PO Box 853921  
+Richardson TX 75085-3921  
+EDV: WidER/Endpoint/ChangeHealthcare  
+at 47424 or MascoCapGroup/Health 1933
+
+**Mail All Appeal Correspondence to:**  
+Meritain Health, PO Box 27651  
+Golden Valley MN 55427
+
+## Precertification
+
+Pre-authorization is required before a primary care doctor may refer to another physician. Some services may require precertification. Without pre-approval, you may be responsible for some or all costs. Please review or comply with your plan's precertification requirements listed on the back of this card.
+
+Call Progyny at 844.734.8366 to pre-certify and enhance any fertility benefits.
+
+## Elected into the NY Pool
+
+The Plan Sponsor and Hospitals are independent providers and are neither agents nor employees of Aetna.
+
+**Network**: First Health Network