Common Contracts
1 similar Organization Participation Agreement contracts
ContractOrganization Participation Agreement • September 17th, 2019
ORGANIZATION PARTICIPATION AGREEMENT Billing Acct# ________________ (A) O RGANIZATION INFORMATION (Must complete all sections) Organization Name: Region: Contact Person: Location: Mailing address: Area: City: State: Zip: Telephone number: ( ) Fax number: ( ) Email address: Federal tax ID number: Total number of actively employed individuals consistently working 30 or more hours a week: _______________ (B) ORGANIZATIONEFFECTIVEDATE OF NEW COVERAGE– Begin selected plans on ___/_01_/2023 Indicate what date you would like the above selected plans to be effective. Month Day Year Note: Do not discontinue present coverage until you have received confirmation of your coverage effective dates.(C) ORGANIZATIONWAITINGPERIOD For the selected plans below, the following Waiting Period should apply to new applicant30-Day Waiting Period–Coverage begins first day of the month following thirty (30) days of employment 60-Day Waiting Period–Coverage begins first day of the
