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40 <br />40 <br />ELI <br />UNUM. Group Client Information Sheet <br />The Company's Legal Name Indian River County Board of County Commissioners <br />(Include punctuation and any abbreviations that apply) <br />Mailing Address: 1840 25th Street Vero Beach, FL 32960 <br />Effective Date: 10-1-2000 Employer Tax T.D.#: 59-6000674 <br />Type of organization: ❑ Employer ❑ Trust ❑ Association ❑ Partnership <br />❑ Corporation M Government Segment ❑ Sub -Chapter S Corporation❑ Other <br />Name Address (Cjlly/State/Zinl <br />a Divisions: See Attached <br />❑ Subsidiaries: <br />❑ Affiliates: <br />Please confirm sold rates: LTD Life AD&D Dep. Life <br />STD Dental <br />Premium Mode O Monthly {Standard) CI t)ther # tit pay periods per yt ar <br />Billing Correspondent: Claim Correspondent (if different): <br />Name: See Attached Listing Name: See Attached Listing <br />Phone Number: Phone Number: <br />Fax Number: Fax Number: <br />Decision -maker for the company's employee benefits: Board of County Commissioners <br />BASIC MONTHLY EARNINGS: ❑ Salary Only ❑ Salary & Commissions ❑ Salary & Bonuses* <br />❑ Salary, Commissions & Bonuses* ❑ W-2 w/Bonuses* ❑ W-2 without Bonuses ❑ Other (please specify) <br />