Laserfiche WebLink
UNUM. <br />UNUM Life Insurance Company of America <br />Portland, Maine 04122 <br />APPLICATION FOR GROUP INSURANCE <br />Name of Applicant Indian River County Board of County Commiss i»Hers <br />Address: 1840 25th Street <br />Vero Beach <br />(City) <br />applies to the UNUM Life Insurance Company of America, for: <br />O Group Life Benefits <br />O Group Accidental Death and <br />Dismemberment Benefits <br />(Street) <br />Florida <br />32960 <br />(State) <br />(Zip) <br />di Group Long Term 0 Group Short Term Disability Benefits <br />Disability Benefits <br />0 Group Long Term Care Benefits <br />Is there any group life insurance plan In force or being applied for on some or all employees? 0 Yes 0 No <br />If yes, complete the following or list the prior carriers: <br />Employee Class <br />Maximum Amounts <br />Name of Carrier <br />Effective Dates <br />Termination Dates <br />All Full <br />Time <br />Florida Combined Life Ins. Co <br />10-1-94 <br />10-1-00 <br />If the Insurance Company approves this application, a policy will be issued. The applicant agrees that acceptance of the policy will be an approval of the policy <br />'terms. The Policy Specifications will be made a part of the policy along with a copy o1 this form. <br />Gated at <br />on September 12, 2000 <br />Producer Name: Ronald R. McCall, II <br />(Please Print) <br />SS//Tax ID/:65-0551801 State ID #: A169993 Policy Effective Date: 10-1-2000 <br />Indian River County Board of County Commissior:ers <br />(Applicant) <br />By: QM A C <br />Fran $. Adams, (Signature and Title) haiaeC��--� <br />Producer Signature: / - ' <br />PRODUCER INFORMATION: For commission purposes, please list the brokers/agents for this application. Use full names, including complete business names. <br />To ensure proper payment of commissions, include each producer's tax identification number (social security number or corporate tax Id) and state <br />identification number where applicable. If more than one producer, please be sure to specify the split %. For corporate producers, please specify the signing <br />representative's name and ID /'s. <br />PLEASE PRINT ALL INFORMATION CLEARLY <br />Producer Name SSN / Tax IDN <br />(Please print lull name) <br />State IDN <br />(where applicable) <br />Split % age <br />(Must total 100%) <br />1. Ronald R. McCall. II 65-0551801 A169993 100% <br />2. <br />3. <br />4. <br />UNUM Producer N <br />(II known) <br />Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application, containing any false, <br />incomplete, or misleading information is guilty of a felony of the third degree. <br />1361.96 it <br />