HomeMy WebLinkAbout1999-154SECTION II 1 SUPPLEMENTARY INFORMATION Aft questions must be answerers
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
Guardian or The Guardian Insurance and Annuity Company, Inc.? 0 Yes IX No It "yes", furnish name of employer, plan number and date of
cancellation.
2. Name o1 present or prior group carrier: ADP Dental (Approx. 80 EE's) Cancellation Date:
What coverages are now or were in force? 111 Llfe 10 Medical I%Dental 0 Prescription Drug ❑ Vision
p Short Term Disability M Long Term Disability {Please attach copies of booklef and current billing statement)
3. Forplans requesting life fnstsrance.
Is the disability waiver of premium' benefit to be included? ❑ Yes 4 No
Will this insurance replace any existing lite insurance or annuity? N/A a Yes ® No
A. It present carrier provided life' Insurance, are extended benefits provided in case of disability? N/A 0 Yes ❑ No
5. To the best of your knowledge are any employees or dependents currently disabled? If "yes', please indicate: ❑ Yes ❑ No
0 actively at work G on disability leavelclaim El other (please provide details on flack of form) N / A
6. For plans with fess than 100 eligible employees: To the best o1 your knowledge has any employee or dependent Cl Yes 0 No
within the past threw years, been treated for or diagnosed as having: cancer; heart disease; kidney disorder. stroke or
other serious disease? N/A
7. For plans with less than 100 eligible employees: To the best of your knowledge has any employee or dependent Ia Yes 0 No
been diagnosed as having AIDS or AIDS Belated Complex?
S. For plans wifsr less than 500 eligible employees: To the best of your knowledge has any employee or dependent,
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
greater for plants with more than 100 eligible employees)? N/A
WITNESSED ON THE REVERSE SIDE
TION FOR A
��j� r
�/ l e Guavillaii'
S€'EVFIC
NON MEDICAL PLAN
.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„
OF GROUP INSURANCES
Q
I PO 6'112,
PO 410. 2,,080 1'{}Hr-H611 Pr) rh+:
11 anyques rens h ac ion' o rs oim were answered "yes`, please provide an explanation using the additional space below. Refer to the
specific question number, and give details including names where appropriate. It additional space is needed, use a separate sheot of paper, and
refer to the question number. Be sure to sign, date and have it witnessed.
Question No. Explanation
Insurance to be Issued: "N" for non contributory or "C" for contributory. If "C" Indicate % of employee contribution..
Employee: I Life % I Dental C °F loo I Vision % I STD % I LTD %
Dependent: i Life
1) Agent Name: Duncan Chalmers, CLU Code: Guardian. Agency: Code;
Agent
Sheet
City State Zip Code
For file insurance only: To the best of your knowledge, will this insurance roplace any existing life insurance or annuity? c Yes = No
Agent Signature: Soc. Sec. # License # Tax ID #
-12) Agent Name: °/T Code: — Guardian Agency: Code:
Agent Address:
Street City stale 25p Code
For life insurance only: To the best of your knowledge, will this insurance replace any existing life insurance or annuity? Yes t No
Agent Signature: Sec. Sec. # License fl Tax ID #
Sales
Sales Representative
Code
SECTION V I AGREEMENT
Request for participation In A Certain Trust Agreement
The undersigned Planholder engaged primarily in the industry described in Section I, hereby requests that it be approved as a partiCipant in the Trust
,slablished by other Planholders engaged in the same industry for the purpose of purchasing insurance for the benefit of their employees and
equesis inclusion as a participant under the Group Insurance Plan(s) issued to the Trustee for the plan(s) of insurance shown in Sr cljon Ill.
2onditfone of Agreement
I is understood that no individual shall become insured while not actively at work on a full-time basis, and only full-time employees shall be eligible.
- ull-time employee means one who regularly works at least the number of hours in the normal work week established by this Planholder (but nol
ass than 30 hours per week) at his Planholder's place of business. It is further understood that no agent has power on behalf of the Guardian. Life
•asurance Co. of America to make or modify any request or application for insurance, or to bind said Insurance Company by making any promise or
epresentation or by giving or receiving any information. It is further understood that no insurance will be effective until the pian is accepted in wrifing
V the Insurance Company. No contract of insurance is to be implied in any way on the basis of the completion and submission of the specifications
,hown on both sides of this form.
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,
ncomplete or misleading information is guilty of a felony of the third degree".
have reviewed the stalemeMs. made by me on this application. and they are Irue and complete.
Signature and Title of Officer,.
'artier or Proprietor. Date-, 5/25/99
Fran B. Adams', Vicb Chairman
'rint Name of Officer, Partner
it Proprietor
,ignature of Witness
ly and Slate Where Signed: ---j+{Lacjt,_j
Date:�l s/rr