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HomeMy WebLinkAboutC09-051 Sun Life FinancialSun ~.i~e Assu~~nce Co~~any of Canada ,~~1,,; Application for Group Accidental Death s~~ .,= Life Fmtancial~" and Disrn~mberment Insurance Applicant C~rganixation Please PR11uT clearly. Legal Name Eagle County Government Main Address 500 Broadway City Eagle Nature of Business Municipal G©vemment 5#a#e ~.. Zip Cade CC) ~ 81631 subsidiaries or Ai~iiates to be Included Legal Name Address Nature of Business Legal Name Address Nature of Business (~ If yott need more space, check here and attach a separate page. Eligible Empioyees Eligible Classes 'Waiting Period 1 }Regular Full-Time Employees 3} Elected O~cials 2} Regular Part-Time Employees l~ Number afi Eligible Emplayees an the Effective Date Minimum Warlc Week 470 Class 1 & 2. 30 hrs /Class 3: 10 hrs. Are Retirees Eligible? ... . ................................................ ^ Yes i~ 2~tca Specify days car mcanths ' 1} 1st of mo. coincident wlfollowing date of hire; 2} 1st of mo. coincident wlfoliowing 90 days required for ne~v ~~ emplayees to be eligible far benefits. C~-~rrent emplayees zvhca have not satisfied the waiting period will receive Credit far past service to ctatnplete the waiting pericad. ~~ ~ at s 5 ~ " l+~ tad ~•- XGR18/859 Pagelaf~ SLPC 4543 CC? 4l©2 Benefits Requested __-- Emp oyee AD&ft ~ Dependent ADf~tD Spouse t7nly ^ 1+arTjily Coverage [f' Additl4RS Reglte5te#~ BeieaVeInentf/UttnSeting i~ Business T°ravet ^ Child Care ^ ~ornirlt3n ACCId2'nt t;omtnan Carrier ^ Dependent Edttcatian Spouse Only Child t~nly ^ Spouse anti Child Disappearance Felonious Assault ^ Helmet Rehabilitative?'raining ^ Regal rtat~nn ^ Seat Belt ^ Seat Belt/r~ir Rag (~` Surgical Reattachment ----~ ~~ ^ Authoriixatfion txretttve Date {rrs/d/'y) 11"1 JC#9 Amount Paid with this AppCicativn Subject to approval by Sun Lafe Assurance t:tatl~pany of Canada, We Witt issue a Croup Pralicy with insurance coverage to become effective an the effective Date. T'he Applicant agrees to provide Sun Life Assurance Company of Canada with a current census, as o#~ the Effective Date, of all eillployees wtto have elected AI3~D anti are enrolled for caverage.'1"his infclrmatian is required na sooner than the Effective I}a#e and no later than 15 days after the Effective mate. Employees not actively at work otl tlae Effective Elate wilt anly be insured as required by taw ar as approved in writing by Sun i,ife Assurance Company of Canada. This Application will be attached to and is made part of the group i'olicy. Counters ned by (lice ed a ident Agent] X Name and Address of Aget:tf Broker Fir~Y ~~ iNi 1 ~ it,+trY's ~'. ~+>man ..~ ~iCnr~nc,-n t~rti.~S In ~~gn of Authn ' d Representative f Applicant Organization 1*tame and Witte Place and Date of Signing _ ~~ Eagle, Ct) '12/17t2Ctt)$ ~ ~.~._. .Fraud Warrtin~ tt is unlac4fut to knowingly provide false, incatnplete, or misleading facts or information to an insurance company tar the purpose of defrauding or attempting to defraud tl~te company, Penalties may include imprisantnent, fines, denial of insurance, and civil damages. Any insurance company clr agetlt of an insurance company wlto knowingly provides false, incomplete, ar misleading facts or information to a policyholder ear claimant for the purpose of defrattciing ar attempting to defraud the policyholder ar claimant with regard to a settlement ear award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of P.egtilatory Agencies. Sur, Life Assurance Company of Canada is a member of the Sun Life Financial group of companies. ~2i?02 Sun Ufe Assucnnce Company of Canada, Wellesley Hills. hAA p248a. All rights reserved. Sun Life Financial and the globe symbol are service marks of Sun life Assurance Company of Canada. __ __ .. XGRI8/&b9 Page 2 or 2 5LPC 4543 CO 4/02