Common Contracts

IAC DENTAL PLANS EMPLOYER APPLICATION AND TRUST ADOPTION AND PARTICIPATION AGREEMENT

June 18th, 2007

• Filed
  June 18th, 2007

EMPLOYER INFORMATION Legal Name of Employer: Applicant’s Phone Number: Federal Tax ID No. Nature of Business: SIC Code: Billing Address: City: State: Zip Code: Street Address (if different from above): City: State: Zip Code: Name of Subsidiaries, Divisions. Locations or Affiliates to be Covered: Name and Title of Employer Plan Administrator/Human Resources Contact: Phone Number: ( ) Fax Number: ( ) Proposed Effective Date of Insurance: Advance payment of $ is submitted herewith to be applied by the Company to premiums for insurance when and if issued. ELIGIBILITY Eligible Classes: Hours Per Week (Minimum 30 hours per week)□ All Full Time Employees□ Other Number Eligible Note: Permanent part-time employees who average 30 hours per week can be considered eligible for coverage. Any excluded classes of employees? □ Yes □ NoIf yes, give details New Hire Waiting Period:□ None□ 30 days□ 60 days□ 90 daysEmployees become eligible for dental benefits the first dayof the month following the emp