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40 <br />C <br />®M WAITING PERIOD: <br />Present Employees: Are all cuaftlt employees covered as of the effective date? ❑ No Y] Yes <br />If no, do they have the same waiting period as future hires? ❑ No ❑ Yes <br />Future Employees: coinciding with or next following: <br />❑ —days of active employment or <br />❑ ,months of active employment <br />❑ No Waiting Period <br />The day fottpwlne completion of: <br />-2.0—days of active employment <br />❑ months of active employment <br />payroll Billed Cayes Only <br />First pay period following: <br />❑ _days of active employment or <br />❑ months of active employment <br />Are employees in other states/countries covered? E No ❑ Yes - List employees by state/country on census. <br />ELIGIBILITY: <br />6 All Full -Time Active Employees Class 1: <br />❑ Other: Class 3: <br />Class 2: <br />Class 4: <br />3o Minimum number of hours the employees must work to be covered <br />PRIOR COVERAGE: Does this plan replace other coverage? KJ Yes ❑ No <br />Type of Coverage Effective Date Termination Date Prior Carrier Name <br />VLTD 10-1-94 10-1-2000 Florida Combined Life <br />(Attach a copy of the prior plan's contract or employee booklet.) <br />CONTRIBUTIONS: ❑ The EMPLOYER pays 100% of the cost 9 The EMPLOYEES pay 100% of the cost <br />❑ 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: ❑ Policyholder �-] Broker ❑ 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 assignzd by the plan sponsor? PN5 <br />How are the fiscal record maintained? ❑ Calendar Year <br />❑ Policy Year is last day of year ❑ Fiscal Year is last day of year <br />Day/Month Day/Month <br />Septernber 12, 2000 <br />Policyholder Signature Fran B. Adams, Chairman Date <br />