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HomeMy WebLinkAboutC11-347 Lincoln National Life Insurance Application J. The Lincoln National Life Insurance Company Office Use Oniy Group Insurance Service Office 8801 Indian Hills Drive Omaha, Nebraska 68114.4066 APPLICATION FOR GROUP INSURANCE is hereby made to THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (the Company). A, NAME AND ADDRESS 1. Applicant's Full Legal Name (exactly as to be shown in Group Policy): ECk31e Coun Gtot/ern men +- 2. Main Office Address (physical location and group situs state): Street 500 8 rt3CICI Way City E l e State CO Zip Qjl to 3 I Phone N (9/1))328-8 4#( ) E•Mail Address d iartra. Kali k:a @° (if available) e- Slecouniy. uS B. REOUESTED COVERAGES The following Group Insurance is applied for as specified in the sold case proposal(s). Complete the requested Effective Date for each covers B. [t'I'ife & AD &D with Effective Date 1 - 1 - 12 L'Uoluntary Life with Effective Date t - -l"Z Lung Term Disability with Effective Date 1 - I - 1 2 ❑ Voluntary Life & AD &D with Effective Date ❑ Short Term Disability with Effective Date ❑ Voluntary Long Term Disability with Effective Date ❑ Dental with Effective Date ❑ Voluntary Short Term Disability with Effective Date 41 ❑ Accident with Effective Date ❑ Vy�t�untary Dental with Effective Date i rVoiun+nin 1 —I IZ- C, BUSINESS INFORMATION 1. Nature of Business (Please specify): GovErnr.n er.-I- _ t Years in Business * Federal Tax ID# -j(- 2. Business is Organized As (select one): ❑ Corporation ❑ Non-Profit Organization ❑ Partnership ❑ Proprietorship E6ther f�p tre',rnrY, - r 1 - 3. Financial Risk (If Yes to any part, please explain below.) ❑ Yes ❑ No Has Applicant ever filed for bankruptcy? ❑ Yes ❑ No Does Applicant anticipate ceasing or materially reducing active business operations? ❑ Yes ❑ No Has Applicant opted out (or do they anticipate opting out) of Workers' Compensation? Explanation: 4. Binder payment submitted: Amount $ (if applicable) D. REPLACEMENT COVERAGE [(/Yes ❑ No Will all or part of this coverage replace any similar coverage? If Yes, provide details of the prior plan below and enclose a copy of each inforce contract to be replaced. Coverage Type Prior Carrier Name Prior Plan Effective Date Termination Date Group Li /A p4 D _Sun I. I - I- o R I Z -31 -1 / enrol LTD tr /I Vo►unfrity Li fP /A-Di 1) 6L2•APP.02110 w DRIVING COLORADO: I is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance c pang who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding attempting defraud the policyholder or claimant with regard to a settlement or award from insurance proceeds shall be reported to the Colorado Division of insurance whin the Department of Regulatory Services. DC: It is a trine to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment aidlor fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. KENTUCKY: Any person who knowingly and with the intent to defraud an insurance company or other person files an application for insurance containing any materially alse information or conceals, for the purpose of misleading, information containing any fact material thereto, commits a fraudulent insurance act, which is a rime. LOUISIANA & RODE ISLAND: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW MEXICO Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for • surance is guilty of a crime and may be subject to civil fines and criminal penalties. OHIO: A perso commits insurance fraud, if he or she submits an application containing a false or deceptive statement with the intent to defraud (or knowing that he or she i helping to defraud) an insurance company. PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application or statement of claim containing any aterially false information or conceals for the purpose of misleading, information conceming any fact material thereto, commits a fraudulent insurance act, hich is a crime and subjects such person to criminal and civil penalties. TENNESSEE WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the ompany. Penalties include imprisonment, fines and denial of insurance benefits. OTHER STAT zs : A person may be committing insurance fraud if he or she submits an application containing a false or deceptive statement with the intent to defraud (or k owing that he or she is helping to defraud) an insurance company. F. AGREEM. T. The Applicant hereby applies for group insurance. The information in this Application is true and correct to the best of the Applicant's knowledge and , elief. It forms the basis for this request for group insurance. Omission or misstatement of known information on this Application could affect the validity of a y insurance issued and cause the denial of an otherwise valid claim. The Applicant understands that the requested group insurance wit: (a) be issued only if the requested insurance is acceptable to the Company and is legally permissible; (b) be issued under a group Policy or Policies in the language customarily used by the Company; (c) be subject to the Company's usual underwriting requirements (including Evidence of Insurability, if applicable); (d) be subject to all exclusions and limitations of the Policy; and (e) take effect on the date determined by the Company. I The Applicant nderstands that no agent or broker has the authority to guarantee the acceptability of the requested insurance. The effective date of insurance for w ich an employee is required to submit satisfactory Evidence of Insurability will be determined in accord with the Policy's terms, and will be subject to the A tive Work requirement. The Applicant agrees not to: (a) colle or pay premiums (other than the Binder Premium, if any) for such insurance, before receiving the Company's notice of approval; or ct (b) distri ute material describing Policy coverage to persons to be insured, without the Company's prior written consent. If dental insurance is requested, the Applicant 'agrees to provide employees and dependents notice of any applicable continuation rights, required by federal COBRA law or any similar state continuation law. Premium rate quotes were based an data submitted to the Company. Final premium rates will be determined byte actual composition of the group. This application and the. Binder payment, if any, constitutes the consideration for any Policy issued. After receipt of the P licy, payment of the premium is deemed acceptance of the Policy's terms. If this Application is approved, it will be made a part of any Policy issued. Writing Agent � , / Signed by Applicant's Authorized Representative: Or Broker's Signature k I,, — z ; , 4_ , - rrr 1140 -: Typed or Printe� Name �.IAS+'1 P r • c'Q.t1hA�d5P.t , !� License Numbet I5?,75 1 State GD .1,v'`i S N � yped or Printed Name, w 4E -Title 0.4-44-1C0/4- State Signed Colorado - Date (if r / 1 Must be signed prior to Effective Date GL2•APP.02(1c PARTICIPATION AGREEMENT The Lincoln National Life Insurance Company (herein called the Company] Complete only if applying for coverage under The Lincoln National Life Insurance Company Voluntary Insurance Trust. Note: Do not complete in AL, MN or MS. Application is hereby made to become a Participating Employer under The Lincoln National Life Insurance Company's Voluntary Insurance Trust, based on the following statements plus the attached application for group insurance coverage. The Group Employer named below (herein called the Employer) understands that if Voluntary Group Term Life and AD &D or Disability Income insurance is requested and approved, such Employer will become a Participating Employer under The Lincoln National Life Insurance Company Voluntary Insurance Trust, sitused in Kansas City, Missouri. The Employer agrees to the terms of the Trust Agreement, each group policy issued to the Trust under which the Employer's employees become insured, and any amendments to them. The Employer understands that group certificates will be supplied and agrees to distribute them to each employee enrolled in the program. After receipt of the group certificates, payment of premium is deemed acceptance of the policy's terms. The Employer agrees to be responsible for at premiums payable with respect to any of my employees who will be insured under the policy. The Employer agrees to honor and administer on a timely basis the written payroll deduction request of each participant, in the amount required to pay the necessary premium to keep coverage in-force. Payroll deductions will be remitted to the Company on a timely basis, in accord with the billing schedule agreed upon. The Employer agrees to promptly furnish the Company any information reasonably required to administer the coverage and claims under it. The Employer understands that participation in the program may be terminated at any time by giving prior written notice to the Company. The effective date of termination will be the date the notice is received by the Company's Group Insurance Service Office, or on any later date stated in the notice. The Employer understands that the Company may terminate the Employer's participation based on the fallowing circumstances: a) at the end of the grace period during which the required premium has not been paid; b) on any premium due date on which participation in the program falls below a minimum level of 10 employees; c) on any premium due date when the Employer has failed to perform any duties related to the policy in good faith; d► on any premium due date after the premium rate has been in effect for at least 12 months (or any longer Rate Guarantee period agreed upon by the Company). The Employer understands that the Company may change any premium rate: a) when there is a change in the terms of the policy, or in the factors bearing on the risk assumed; b) when the policy liability is changed as a result of a change in federal, state or local law; c) when a division, subsidiary or affiliate is added, removed, or relocated; • d) when the number of insured employees has changed by 25% or more since the Rate Guarantee period began; e) on any premium due date after the expiration of the Rate Guarantee period agreed upon by the Company. SIGNATURE I have read and understand the agreement above and will comply with the agreement as stated. I have reviewed, understand and agree to the proposal, rate structure, and enrollment strategy presented to me by the Company representative. I understand that no agent, broker or field representative has any right to bind the requested coverage, alter the terms of the policies or enrollment materials, adjust any claim for benefits, or waive any of the Company's rights or requirements. Group Employer Name & ID FGtgje C ryty 6 OVex nrntrN4 JJ ,, JJ � �^ av r * 111 i Printed Name of Authorized Company Officer \ Signatur. ' horized Company Officer 0)-0d re_MAA1 ��(I Title Date VPA2007 The L ncoln National Life NOT ACTIVELY -AT -WORK SUPPLEMENT Office Use Only - ID 11 Insura co Company To th best of your knowledge, do you have any Employees who are currently Not Actively -at- Work* 'The N Actively -at -Work disclosure does not Include time away from work for reasons such as vacation, an approved tempor ry leave of absence for non - medical reasons, or an approved Family or Medical Leave that is not due to the Employ e's own health condition. [l1 Yes ❑ No If yes, please list each employee and explain below (i.e., currently out on disability, maternity, worker's compensation, sabbatical, etc). , Employee Name Date of Disability or Last Day Reason(s) Worked tn∎ elkle Ar app, IS I't 1 a c., t■ 0 w TR i 1 vies J t t t i 1E k skcr rncv\ - 5�,.ket.i rv--4- to (l ct 1 a o't .--0 \c.01-Q(' n t V1Y \ W, \1 cx_krriS i k a I k I` ,\,c_ Kvtvv L10t-NS 10 1" ' ilIl -- yY\i'aA Please ote: Lincoln Financial Group Proposals and Contracts include language requiring that all eligible employees be AO -1y -At -Work. Please refer to the Group Proposal for Actively -At -Work definition. If any Individual does not meet th: Actively -At -Work requirement and it is not properly disclosed, coverage may not be available on the effectly: date of coverage- A thor zed Gro p Contact Signature Date AA Market ng Representative Signature Date 1 i APP- SUPP21.1N1 09109 0:Common/I -team Phase II /Sold Case Training/Administration Sheet.doc The -Lincoln National Life ADMINISTRATION & BENEFITS SUPPLEMENT Office Use Only - ID # Insurance Company Group ID: Fa91e Colt +y GOvernmer►t • Enrollment Number f Eligible Employees: c ensus Lr Enrollment Forms_volun+ay IQ� g 3qfo Replacing Coverage? If Yes, Please provide us with prior plan booklets. Main Contact: 1. Administrator Billing /Admin Contact: ❑ Contact Group Administrator Email Address: direct 2. Billing /Mailing Address ❑ Physical Addres [►}different Address: P.O . Box 850 Eag le CO g1 (p 3 1 3. Anniversary Date The Anniversary date for the coverage will be annually beginning one year from the effective date of the coverage unless requested otherwise. 4. Minimum Hours (Standard is 30 hours per week) (Ei fed Opic apt& — recgcrti I e oc. . op hr5 Ofd Current Employees: 42f h'�t 90day€ (Puri-- Future Employees: Ludt - KO:0 5. Waiting Periods _Obeys ❑ Months d Years -hn'e) ❑ Days ❑ Months ❑ Years ❑ Eligible on effective date OR ❑ Must complete the above waiting period from their date of h ❑ 1st day of employment Employee (!"un - [] " 1st day of the insurance month coinciding with or next following completion of the eligibility waiting period 6. Effective Date* - Hio (Subject to Active In 1st day of the insurance month following completion of the eligibility waiting period !� P`t►'�1" } i tn� Work Rule) ❑ The day following completion of the eligibility waiting period Ft r54 O# morr'h ❑Other Ca ac( . 4- •a�'f'h e n�e>< s �o I Iou)i AO 9 b *An individual's Voluntary coverage, if elected, will not take effect until the 1st of the month46Ilowing approval of the enrollment form, based upon any evidence of insurability required, and receipt of the first premium. The effective date will be delayed for an employee who is not actively at work or a dependent whose activities are limited due to sickness or injury on the date coverage would otherwise take effect. 7. Excluded Classes Retirees, temporary, seasonal and part-time employees working less than the Minimum Hours selected are standardly excluded. What would you like to include in your employees' salaries (Earnings determined on last day worked): 8. Definition of ' Sala Earrings ry ❑ Commissions Averaged over 12 Months ❑ Bonuses Averaged over 36 Months ❑ Overtime ❑ Prior Years W2 ❑ Applicant is subject to ERISA [and is responsible for distributing SPDs for its employee benefit plans] ❑ Applicant is not subject to ERISA The Certificate can serve as the SPD, if certain plan information and a Statement of ERISA Rights are added. A sample can be provided, if requested. ❑ Yes, please provide a combined SPD /Certificate at no additional cost. Plan information is provided below. ❑ No Plan Year Ends On (month & day): '. 9. ERISA (SPD) Plan Numbers (3 digit # starting with "5" 501,502,etc...): ❑ Life ❑ STD ❑ LTD ❑ Dental or Voluntary Dental ❑ Voluntary Life ❑ Voluntary STD ❑ Voluntary LTD Plan Administrator or Fiduciary: 0 Same as Applicant ❑ Other as shown below Name/Title Phone( ) Address City State Zip Agent for Service of Legal Process, Plan Trustees, Relevant Union Contract, if applicable: Plan Fiduciary Responsibilities: The Lincoln National Life Insurance Company cannot be named a Plan Administrator and shall not be responsible for any tax or legal reporting aspects of the employer's plan. The employer is responsible for compliance with tax, employment and fringe benefits laws, and for obtaining any necessary counsel from their own tax and legal advisors. The Lincoln National Life Insurance Company's obligations are governed solely by the Policy. The Lincoln National Life Insurance Company has the sole discretionary authority to determine eligibility and to administer claims in accord with its interpretation of policy provisions, on the Plan Administrator's behalf. • APP - SUPP -LNL 11/07 Q:Common/l -team Phase II /Sold Case Training/Administration Sheet.doc 1.111.11 Employer premium contribution will be funded from: 11. Funding ❑ General Assets ❑ Section 125 /Cafeteria plan - this is usually utilized for the medical and dental 12. Subsidiary andlor Division I formation t N Any employees working in CA, HI, NJ, NY, or RI? If so how many, in what states, and how many covered by state disabili plan? (The Company cannot write state disability plans in anv state.) 13. Location ')f Employees ❑ Yes o Any employes working or residing outside the United States? If so how many, where, expected return dates? ❑ Yes [No O P( 14. If electing STD: We will print W2's for any employees that go out on a Short Term Disability claim, at no additional cost. W2 Printing ❑ Yes ❑ No Certificates are available on -line. Do you want a paper supply of certificates? . 15. Certificates ❑ Yes ❑ No BILLING OPTIONS L1 List ❑ Self ❑ Do you use an 16. Billing: We will provide you a monthly You provide to us on a monthly AggregatorNendor? bill with each employee's cost basis # of lives, volume, and This is an entity that you contract with broken out premium with a backup census. to handle your billing administration. ❑ A- Z ❑ Sort Bill ❑ Separate Billing - 17. List Billing Set Up: Employees will be listed Employees can be broken into Employees can be placed in separate alphabetically with 1 total, this groupings providing subtotals and billing locations; you can have is 1 bill a grand total; this is 1 bill numerous bills VOLUNTARY PROGRAM The Voluntary program will take effect on the 1st of the month following approval of the application and acceptance of enrollment forms meeting the minimum participation requirements. 19. Class Description 1141l Full -Time Employees rrother '• r - m' €r'i 0 (6 S Lv1 Employee Voluntary Term Life* - Other benefits to be in luded: [a Employee Voluntary AD &D Spouse Voluntary Term Life ** ( 1--01/4.r.c 20. Voluntary Program lot Employee Voluntary AD &pp with Accident Pius Spouse Voluntary Term Life & AD &D ** Options (Er\ t-e:L ,Ced) [Dependent Child Life (no stand - alone) ** s Rpej] *Benefit amounts in $10,000 increments unless requested otherwise: ❑ $5,000 ❑ $1,000 ❑ Other * *Employee Life Must be included ❑ Voluntary Short Term Disability (Choose one) tJ t o ❑ Employee Choice - up to 2 benefit option plan designs may be selected below. 1 ❑ Employer Choice -1 benefit option plan design may be selected below. Elimination Period: Benefit Duration: Benefit Percentage: ❑ 1 -day injury /8 day sickness ❑ 13 weeks ❑ 50% ❑ 8 -day injury /8 day sickness ❑ 26 weeks ❑ 60% ❑ 15 -day injury/15 day sickness 0 Voluntary Long Term Disability (Choose one) ❑ Employee Choice - up to 2 benefit option plan designs may be selected below. �'r Employer Choice -1 benefit option plan design may be selected below. Elimination Period: Benefit Duration: Benefit Percentage: I 1 ❑ 90 days ❑ 2 years ❑ 50% ❑ 180 days. ❑ 5 years ❑ 60% ❑ To Age 65 ❑ Voluntary Dental (Choose one) ► i 1 A ❑ Indemnity Plan ❑ PPO Plan (where available) ❑ Scheduled Dental Plan Designs will be as specified in the sold case proposal. REMARKS APP - SUPP -LNL 11107 Q:Common /I -team Phase II /Sold Case Training/Administration Sheet.doc A W N " GIE • o 1. r ' y i.V 07 .7 O pC • R 33 - 2 2 Hwp 0. � a C G i �, ( 7 2 C t r O O 3 ' Z • V 3 • g a ': c m r 3 3 0 c g; 1 z s Aso Z "1 a x r 'Z. 'Z •3 S c A, CO 3 m a 3 a i" e K Lt. H w 3 s N N N co O O N 49 O O r,, iv D t 0 0 N - '9 u ..a N H r1 . , O o -0 m N 3 i -4 ^ , N W C 0 W A O ���ww W M , ,Y -C t w w a <: 0 CD "e n 3: 02 N > > N 3 0 • o r. a' z 0 N , p' ▪ fn O p ` � C CI H. : � W ":` D ,0,� c m and m m s N 40+ O d d' 2 m a m m5m - '(. 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