2015-185A - Laserfiche WebLink

Home Browse Search

Fond dJ YiYtln ems' U An Independent Licensee of the Blue Cross and Blue Shield Association Please Type or Print — Must be completed in full. _ Administered by: HM Life Insurance Company Sales Administration P 0 Box 535061, Suite P6411 Pittsburgh, PA 15253-5061 Tel: 800-328-5433 Fax: 412-544-3298 APPLICATION FOR STOP LOSS INSURANCE • ' Il•T'TIsN Full Legal Name of Group (to appear on Policy) Indian River County Board of County Commissioners - Key Contact Person Jason Brown Tax ID Number 59-6000674 Business Telephone Number 772-226-1214 City Fax Number 772-770-5331 Email jbrown@ircgov.com Internet Address 1801 27th Street Address City Vero Beach State FL Zip Code + 4 32960 Delivery Address (if different than above) City State Zip Code + 4 Nature of Business General government, nec SIC Code 9199 ❑ • Corporation ❑ Partnership Government ❑ Other*: *If an Association, Trust or Charitable Organization, a copy of the bylaws and/or trust is required with the submission of the application. If a union, or if union employees are covered, a copy of the collective bargaining agreement is required with the submission of the application. Affiliates to be insured? ❑ Yes* ■ No *If "yes," complete the table below, attaching additional sheets if necessary. AFFILIATE#1 Full Legal Name Nature of Business Address City State Zip Code AFFILIATE #2 Full Legal Name Nature of Business Address City State Zip Code AFFILIATE #3 Full Legal Name Nature of Business Address City State Zip Code Do you have existing coverage? ❑ Yes* ❑ No *If "yes," who is the carrier. 23717-608 (R6/13) Page 1 of 3 Applicant's Initials.