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HomeMy WebLinkAboutC97-079 Congress Life Insurance CompanyC’9?•1945PlanOptions:t.PPLICATIONFORGROUPINSURANCEismadeto-CONGRESSLIFEINSURANCECOMPANYMINNETONKA,MINNESOTAExt.:CoveredEmployees:EffectiveDate:0TypeA.(12/12)TypeC.(12/24/24)RiderOptions:TypeE.COPAYMENTS:$0$5IJ$100$15$20$25I$30IIOther2.PARTICIPATIONAND/ORUNDERWRITINGREQUIREMENT:MinimumNumberofEnrolledEmployeesRequired-25.1Non-Contributory(allemployeesarecovered).0Contributory(employeeselectstobecoveredandpaysalloraportionofpremium).3.ELIGIBLEPERSONS:Regularfull-timeEmployeesworking30ormorehoursperweek.following30daysofEmployment.following60daysofEmployment.following90daysofEmployment.firstofthemonthfollowing30daysofEmployment.firstofthemonthfollowing60daysofEmployment.firstofthemonthfollowing90daysofEmployment.other1stofmouthcoincidentwithornextfolloidateofemployment.EAGLECOUNTYCompanyName:Address:ContactPerson:Telephone:No.ofEmployees:TaxD:500BROADWAYEAGLECO$1631CityStateZipSUEEATON970-328-8793300fax:970-328-77871.DESCRIPTIONOFGROUPINSURANCEREQUESTED:VOLUNTARYI/1/97ciciPrime0PrimePlusTypeB.(12/12/24)TypeD.(24/24/24)WaitingPeriodOptions:ciEmployeesmustbeactivelyatworkofEffectiveDateofcoverage,ifnot,coveragewillbeeffectiveonthefirstdayofthemonthfollowingreturntoactiveemployment.GHA-l143CL1 UpdateonlyTapeUpdateonlyDisk__________8.ANYADDITIONAL1NFORMATIONNEEDEDFORUNDERWRITTNGORADMINISTRATION:ItisagreedthatthePolicywillbecomeeffectiveatratestobedeterminedbyUs,providedtheapplicationisacceptedbyUs.TheApplicantdeclaresthattothebestofitsknowledgeandbeliefthestatementsandanswersabovearecompleteandtrue.Applicant:C4.EFFECTIVEDATEREQUESTED:5.PREMIUMS:Thefirstmonth’spremiumduewithissuanceofthePolicy.Ailadditionalpremiumsdueonthefirstofeachcalendarmonth.•InitialPremiumAmount___________Received__________•PremiumTiers&RatesMATERIALSONLYInsuredOnly5.08Insured+18.88Insured+Children9.64Insured+Family13.20Composite•InitialEligibilityProvidedEnrollmentCards____Received:__________PaperListingReceived:___________MagneticTapeReceived:___________Disk______________Received:____________Other_____________________•MonthlyBilling&OngoingEligibiliSummaryBilling______ListBillingOther_______________________Eligibility:CompleteTapeCompleteDisk_____________________UpdateonlyPaperCompletePaperListw/exceptionsCompletePaperListw/oexceptions6.RENEWAL:CoverageisrenewableuntilterminatedaccordingtotheprovisionsofthePolicy.7.SPECIALiNSTRUCTIONS:OPENENROLLMENTBEiNGHELDNDECEMBERDatedat:_________thisAuthorizedSignature/Title:dayof,1991GHA-l143CL2