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GROUP APPLICATION GENERAL INFORMATION: Name of Group: Phone: Address: Fax: City/State/Zip # of Eligible Employees County: Group Tax ID# CONTACTS: (Please include titles) Administration: Title: Email: Enrollment: Title: Email: Billing: (name & location) ELECTRONIC ENROLLMENT: Yes No AUTOMATIC DEDUCTION OF PREMIUMS: Yes No - If yes, please attached a voided check. ELECTRONIC BILLING: Yes No - Email: ELIGIBILITY INFORMATION: Dependents will be covered through the end of the birth month or calendar year. -Primary dependents covered to age: AND -Full-time students covered to age: OR IRS dependents covered to age: PLAN DESIGN AND RATES: Plan # Effective Date: Renewal Date: Preventive % Rates: Basic % $ Contract Maximum (per member, per contract period) $ Employee Major % $ EE + 1 Deductibles: (per contract period) $ Family Orthodontic $ Lifetime Ortho Maximum (per member) Chamber Plan: Yes No If Yes, name of chamber: Note: All chamber information will be verified with designated chamber before group is installed. CONTRIBUTION LEVEL: Employer pays: Employee pays: BROKER INFORMATION: Name: *Firm: Address: Phone: City/State/Zip Fax: Email Address: Tax ID# Is the firm incorporated? Yes No *Commission will be paid to the firm unless otherwise agreed upon.
GROUP APPLICATION
-Primary dependents covered to age: AND
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