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SECTION II 1 SUPPLEMENTARY INFORMATION Aft questions must be answerers <br />1. Has this firm or any of its affiliates, either under Its present name or under any other name, ever applied for group insurance with The <br />Guardian or The Guardian Insurance and Annuity Company, Inc.? 0 Yes IX No It "yes", furnish name of employer, plan number and date of <br />cancellation. <br />2. Name o1 present or prior group carrier: ADP Dental (Approx. 80 EE's) Cancellation Date: <br />What coverages are now or were in force? 111 Llfe 10 Medical I%Dental 0 Prescription Drug ❑ Vision <br />p Short Term Disability M Long Term Disability {Please attach copies of booklef and current billing statement) <br />3. Forplans requesting life fnstsrance. <br />Is the disability waiver of premium' benefit to be included? ❑ Yes 4 No <br />Will this insurance replace any existing lite insurance or annuity? N/A a Yes ® No <br />A. It present carrier provided life' Insurance, are extended benefits provided in case of disability? N/A 0 Yes ❑ No <br />5. To the best of your knowledge are any employees or dependents currently disabled? If "yes', please indicate: ❑ Yes ❑ No <br />0 actively at work G on disability leavelclaim El other (please provide details on flack of form) N / A <br />6. For plans with fess than 100 eligible employees: To the best o1 your knowledge has any employee or dependent Cl Yes 0 No <br />within the past threw years, been treated for or diagnosed as having: cancer; heart disease; kidney disorder. stroke or <br />other serious disease? N/A <br />7. For plans with less than 100 eligible employees: To the best of your knowledge has any employee or dependent Ia Yes 0 No <br />been diagnosed as having AIDS or AIDS Belated Complex? <br />S. For plans wifsr less than 500 eligible employees: To the best of your knowledge has any employee or dependent, <br />within the past two years, suffered a condition which resulted in a health insurance claim of $25.000 or greater ($50,000 or CI Yes m No <br />greater for plants with more than 100 eligible employees)? N/A <br />WITNESSED ON THE REVERSE SIDE <br />TION FOR A <br />��j� r <br />�/ l e Guavillaii' <br />S€'EVFIC <br />NON MEDICAL PLAN <br />.I NdY11'1 ,l rlugWW OI IKU ',91.9 IN •1 n, Jl,uw llYxlll',I� J! i,l{,aJl0nll 011i,,�, Y I Nt,w.MIY H',kJ,lY O111r„ <br />OF GROUP INSURANCES <br />Q <br />I PO 6'112, <br />PO 410. 2,,080 1'{}Hr-H611 Pr) rh+: <br />