HomeMy WebLinkAboutExhibit8Employer Application
Group Dental Coverage
Provided by United HealthCare Insurance Company
Company Name:
Address:
Plic,k(y)t
_`66&( aim A(ie: 9i',
State: Zip Code: -3 ) j 30
Fax Number: of ' 7
� ' _ t / J /_ �) ��J
E-Mail Address of Contact: - ' / tl Onei
EMPLOYER INFORMATION
City
Phone Number: 3c _ 7( I7 //
Contact Name: ��JJ [�— / J / (�
UtinGoct f ,' eAMCi ek
tGt nt4 ‘ , t�
Organization Type: ❑ Corporation 0 Partnership ❑ Sole Proprietor 0 Political Subdivision'
'Submit legal opinion or minutes from Board Meeting along with application showing consent.
Other
Full Legal Name of Employer.
Include names of subsidiaries or affiliated companies
Employer Identification Number (Tax ID): 59 61d) t) I5 Subject to ERISA? 0 Yes 0No
Has your firm ever filed for or is it in the process of filing for bankruptcy? 0 Yes No
DENTAL PLAN PARTICIPATION AND SELECTION
Did the group h ve dental coverage for the past If yes„game of prior dental carrier:
[12] months? ,Yes 0 No /►i�
Requested effective date of coverage: 1 / 1 / All effec a dates must be first of the month.
Total number of employees on payroll:
Total number of full time/eligible employees (EE):
Multi Site: 0 Yes
Number of Locations:
Locations:
Number of COBRA participants in total group:
Number of Retirees in total group:
Dental Plan Selected: c (r1 In_j
Rates and Contributions
Tier Structure
Rates
Number of Enrolled
Employees
Employer
Contribution %
Employee
Contribution %
Single Tier
EE
Two Tier
EE
ili IC} t 1
! OV3
Family
3 , 5D,
j 0 VW
Three Tier
EE
EE+ One
Family
Four Tier
EE
EE+ One
EE+ Child(ren)
Family
Amount of Binder Check:
...This check must accompany the group application.
D-APP 9/01
BILLING AND CONTACT INFORMATION
Please provide the information below if different than above for billing purposes and plan administration.
Address
City:
State:
Zip Code:
Contact Name:
Phone:
Fax:
E-Mail Address:
I understand and agree that the first month's estimated premium and fully completed enrollment information for all eligible
persons requesting insurance coverage must be submitted with this application BEFORE action is taken on this
application. Coverage is not in effect unless and until I receive notification of acceptance from the Company. If this
application is declined, the Company will return the premium deposit submitted with the application. If my coverage is
approved, premium is payable monthly in advance.
I understand and agree that failure to pay premium when due will be considered a default in premium payment, and that
the Company will terminate coverage following a grace period (time extension for payment of premium) of [31) days from
the date of nonpayment of premium. If the coverage is terminated by the Company for nonpayment of premium, I will still
owe, and the insurance company will collect, premium, for the grace period. I understand that coverage may also be
terminated for other reasons as provided in the group policy.
I represent and agree that all the answers and statements in this request are full, complete and true, to the best of my
knowledge and belief, and understand that the said answers and statements form the basis upon which coverage will be
made effective. I understand that the material omissions or misrepresentations could result in voiding or reformation of
coverage.
I agree that the company shall be entitled -rely-on the mo
employees and their depe dents'in pr iding coverage
notifying the Company pro ptly of an c es in this
dependents, including the ddition of ne lye ibte eml
rrent information in its possession regarding eligibility of
policy. I understand and agree that I am responsible for
that may affect the eligibility of employees of their
dependents.
Authorized Officer's Nam •t
V...."
-�. C� i � G`
Title: x
/-
Authorized Officer's Sign
lure:
Date:
Agent Name:
Date:
Agent Signature:
Date:.
Agent Number:
D-APP 9/01