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• <br />• <br />WAITING PERIOD: <br />Present Employees; <br />Are all aim& employees covered as of the effective date? 0 No lb Yes <br />If no, do they have the same waiting period as future hires? 0 No 0 Yes <br />Future Employees; Lf ojthe month coinciding with or next following: <br />O days of active employment or <br />0 _,months of active employment <br />0 No Waiting Period <br />Are employees in other states/countries covered? No <br />ELIGIBILITY: <br />a All Full -Time Active Employees Class 1: <br />O Other: Class 3: <br />The day followlne completion of: <br />D 30 days of active employment <br />0 months of active employment <br />Payroll Billed Cases Only <br />First pay period following: <br />0 days of active employment or <br />O _months of active employment <br />0 Yes - List employees by state/country on census. <br />30 <br />Class 2: <br />Class 4: <br />Minimum number of hours the employees must work to be covered <br />PRIOR COVERAGE: <br />Does this plan replace other coverage? <br />Sl Yes 0 No <br />Type of Coverage <br />Effective Date <br />Termination Date <br />Prior Carrier Name <br />VLTD <br />10-1-94 <br />10-1-2000 <br />Florida Combined Life <br />(Attach a copy of the prior plan's contract or employee booklet. <br />CONTRIBUTIONS: 0 The EMPLOYER pays 100% of the cost SI The EMPLOYEES pay 100% of the cost <br />0 Both the employer and the employees pay for the plan: <br />Percentage of Employer Contribution: % for employee coverage <br />% for dependent coverage <br />Forward Booklets to: 0 Policyholder 411 Broker 0 Other <br />Physical Address for Delivery: The McCall Agency, Inc. 1120 20th Place, Vero Beach, FL 32960 <br />ERISA Information: <br />What is the plan number assign:A by the plan sponsor? PN5 <br />How are the fiscal record maintained? 0 Calendar Year <br />0 Policy Year is last day of year 0 Fiscal Year is last day of year <br />Day/Month Day/Month <br />l <br />Policyholder Signature Fran B. Adams, Chairman <br />September 12, 2000 <br />Date <br />
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