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HomeMy WebLinkAboutAgreement_General_09/28/2007 (2)SPECIFICATIONS FOR A ^ NoMeasl Regional office O Midwest Regional Office ^ western Regional O(rica ^ Bridgewater IXfice NON MEDICAL PLAN C UA R D 1 A N M PO Box 26040 PQ Box 8012 PO Box 245A PO Box 425 Leh;ghValteyPA18002-6040 AppletonW154912-8012 Spokane WA 99210-2454 E.BridgawalerMA02333-0425 OF GROUP INSURANCE Please Print GROUP PLAN NUMBER {Guardian Use Only) ® New Plan ^ Change of Plan Requested effective date: 10!1!06 SECTION I PLANWOLDER INFORMATION Planholder Name {full legal name of com any} P Village of Tequesta Tax I.D. # 59.6044081 Main Address {street, city, state, zip) 250 Tequesta Dr., Suite 300, Tequesta, FL 33469-0273 Mailing Address {street, city, state, zip} Same Name of Correspondent & Title: Phone No: 561-515-5200 Robbie Russo HR Generalist Fax No. 561-575-6203 Type of organization: ^ Corporation ^ Partnership ^ Proprietorship ®Other {explain) Municipality Include eligible employees who work: ®30 Hrs/Wk ^ Other Number of full-time employees: No. of full-time employees to be insured: Total number of employees: Are all full-time employees to be included? ©Yes ^ No Indicate class or classes to he excluded: Premium Paid ©Monthly ^ Quarterly ^ Annual ^ Semi Annual For plans with less than 10 employees: ^ GOM ^ Annual Deposit $ 3,994.40 Nature of business (specify} Municipalilty Date Est. 50+ year SIC: Affiliates, subsidiaries or branches (legal name & location) Nature of business! T e of Or anization No. of full-lime emp's in #his com an No- of full-lime emp's to be insured nla SECTION II SUPPLEMENTARY INFORMATION {All questions must be answered) 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 Guardian or The Guardian Insurance and Annuity Company, Inc.? ^Yes ~ No If °yes", furnish name of employer, plan number and date of cancellation: 2. Name of present or prior group carrier: FL Municipal Trust Cancellation Dale: 9!30!06 What coverages are now or were in force? ^ Life ^ Medical Q Dental ^ Prescription Drug ^ Vision ^ Short Term Disability ^ Lang Term Disability (Please attach copies of booklet and current billing statement} 3. For plans requesting life insurance: Is the disability waiver of premium benefit io be included? ^Yes ^ No Will this insurance re lace an existin life insurance or ennui! 7 'Pt ^Yes ^ No 4. if present carrier provided life insurance, are extended benefits provided in case of disability? ~.A ^Yes ^ No 5. To the best of your knowfedge are any employees or dependents currently disabled? If "yes°, please indicate: [] Yes ©No ^ actively at work ^ on disability leave/claim ^ other (please provide details on back of form} For plans with less than 900 eligible employees: To the best of your knowledge has any employee or dependent within the past three years, been created for or diagnosed as having: cancer, heart disease; kidney disorder, stroke or ^Yes f ~ No other serious disease? . Por plans with less than 100 eligible employees: To the best of your knowledge has any employee or dependent, ^Yes ~] No been diagnosed as having AIDS or AIDS Related Complex? For plans with 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 ^Yes ,[~ No or greater for plans with more than 100 eligible employees)? if any questions in Section II of this form 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. If additional space is needed, use a separate sheet of paper, and refer to the question number. Be sure to sign, date and have it witnessed. Question No. Explanation SECTION III COVERAGE ELECTION Insurance to be issued: "N" for non contributory or "C" for contributory. If "C" indicate % of employee contribution. Employee: Life % Dental N % Vision % STD % LTD Dependent: Life % Dental C % Vision SECTION IV AGENT INFORMATIONlSIGNATURE 1) Agent Name: Steven tJlsen iD0% Code: Guardian Agcy: Code: Agent Address: 5015 Flagler Dr., Suite 600, West Palm Beach, FL 334D1 Street City Slate Zip Code For life insuranc !y: To the best of your knowledge, will this insurance replace any existing life insurance or annuity? ^ Yes ^ No Agent Signature ~~'-"~----- Soc. Sec. # 363-82-3260 Tax ID # 94.3130804 2) Agent Name: % Code: Guardian Agcy: Code: Agent Address: Street City Stale Zip Code For life insurance only: To the best of your knowledge, will this insurance replace any existing life insurance or annuity? ^ Yes ^ No Agent Signature Sales Office Sac. Sec. # Tax ID # Sales Representative Code SECTION V AGREEMENT Request for Participation !n 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 established by other Planholders engaged in the same industry for the purpose of purchasing insurance for the benefit of their employees and requests inclusion as a participant under the Group Insurance Plans} issued to the Trustee for the plan{s) of insurance shown above in Section II1. Conditions of Agreement It 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. Full-time employee means one who regularly works the number of hours in the normal work week established by this planhalder {but not less than 30 hours per week) at his Planho-der=s place of business. It is further understood that no agent has power on behalf of The Guardian Life Insurance Co. of America to make or modify any request or application for insurance, ar fo bind said Insurance Company by making any promise or representation or by giving or receiving any information. It is further understood that no insurance will be effective until the plan is accepted in writing by 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 shown on both sides of ibis 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, incomplete or misleading information is guilty of a felony of the third degree". i have reviewed the statements made by me on this application, and they are true and complet . Signature and Title of Officer, Partner or Proprietor: ,1/t G ~.Q- ..vim---~ Dater ~ o~ Print Name of OfficE ar Proprietor: Signature of Witnes Rate: ~ .~ ~~C-' ro City and State Where Signed: Tequesta, FL The Guardian Llfe Insurance Company of Amartca ^ t4aMOast Regonal Office fl MitM~est Regional Dlfica C1 Western Regronaf 014ce ^ i3ridgerfater Office G UA R D I A N ~ E ed penater MA 02333-0425 ~ ° ~ V~ ey PA 18002-6040 App eton wt 54912-a012 Spokane WA 99210-2454 CONSENT FOR DELIVERY OF ELECTRONIC PLAN DOCUMENTS I, ~~Gy.+t~Et- ~t~Z D , an authorized representative of ~~1. [~,~~ C`~~ ~EQ~~~i~ , ~ reap Name) consent to the electronic delivery of insurance certificates, riders/policies issued by Guardian in connection with the group plan by the following: PDF file via a-mail: Please provide a-mail address: 1~~USSL~ ~~ E T[~. I ^ PDF file on a floppy disk: Please provide mailing address: l understand that Guardian will provide one paper copy of each certificate and riderlpolicy for this plan in addition to the electronic documents. By signing this consent, I, on behalf of the Planholder, agree to the following: (1) make an electronic version of the applicable certificate readily available to each covered person; (2) produce and distribute paper copies of the certificates to any covered person who does not have ready access to the electronic version of the certificate; (3) make electronic certificates available to covered persons, in the following way(s) (e.g. company Intranet under Employee Benefits) : _ ~~,~-~ c9F ~ GtUE- ~ ~-rn? (4) maintain the integrity of the information contained in the plan documents and will not alter the content in any way. In the event of any conflict, the terms and conditions set forth in the riderlpolicy, as issued by Guardian, will determine benefits. Dated: p(- ~ "yte BY~ 1 f \~C1'rI~CL.~ Cr7il2.'z-~ Print Title: Planholder's Name: y ~ul~taG~ ~F ~C-_©U6S~ Plan # T~~ GG-Di3902 {3103}