HomeMy WebLinkAbout2000-26740
40
ELI
UNUM. Group Client Information Sheet
The Company's Legal Name Indian River County Board of County Commissioners
(Include punctuation and any abbreviations that apply)
Mailing Address: 1840 25th Street Vero Beach, FL 32960
Effective Date: 10-1-2000 Employer Tax T.D.#: 59-6000674
Type of organization: ❑ Employer ❑ Trust ❑ Association ❑ Partnership
❑ Corporation M Government Segment ❑ Sub -Chapter S Corporation❑ Other
Name Address (Cjlly/State/Zinl
a Divisions: See Attached
❑ Subsidiaries:
❑ Affiliates:
Please confirm sold rates: LTD Life AD&D Dep. Life
STD Dental
Premium Mode O Monthly {Standard) CI t)ther # tit pay periods per yt ar
Billing Correspondent: Claim Correspondent (if different):
Name: See Attached Listing Name: See Attached Listing
Phone Number: Phone Number:
Fax Number: Fax Number:
Decision -maker for the company's employee benefits: Board of County Commissioners
BASIC MONTHLY EARNINGS: ❑ Salary Only ❑ Salary & Commissions ❑ Salary & Bonuses*
❑ Salary, Commissions & Bonuses* ❑ W-2 w/Bonuses* ❑ W-2 without Bonuses ❑ Other (please specify)
40
C
®M WAITING PERIOD:
Present Employees: Are all cuaftlt employees covered as of the effective date? ❑ No Y] Yes
If no, do they have the same waiting period as future hires? ❑ No ❑ Yes
Future Employees: coinciding with or next following:
❑ —days of active employment or
❑ ,months of active employment
❑ No Waiting Period
The day fottpwlne completion of:
-2.0—days of active employment
❑ months of active employment
payroll Billed Cayes Only
First pay period following:
❑ _days of active employment or
❑ months of active employment
Are employees in other states/countries covered? E No ❑ Yes - List employees by state/country on census.
ELIGIBILITY:
6 All Full -Time Active Employees Class 1:
❑ Other: Class 3:
Class 2:
Class 4:
3o Minimum number of hours the employees must work to be covered
PRIOR COVERAGE: Does this plan replace other coverage? KJ Yes ❑ No
Type of Coverage Effective Date Termination Date Prior Carrier Name
VLTD 10-1-94 10-1-2000 Florida Combined Life
(Attach a copy of the prior plan's contract or employee booklet.)
CONTRIBUTIONS: ❑ The EMPLOYER pays 100% of the cost 9 The EMPLOYEES pay 100% of the cost
❑ Both the employer and the employees pay for the plan:
Percentage of Employer Contribution: % for employee coverage
% for dependent coverage
Forward Booklets to: ❑ Policyholder �-] Broker ❑ Other
Physical Address for Delivery: The McCall Agency, Inc. 1120 20th Place, Vero Beach, FL 32960
ERISA Information:
What is the plan number assignzd by the plan sponsor? PN5
How are the fiscal record maintained? ❑ Calendar Year
❑ Policy Year is last day of year ❑ Fiscal Year is last day of year
Day/Month Day/Month
Septernber 12, 2000
Policyholder Signature Fran B. Adams, Chairman Date