Common Contracts
1 similar Employer Group LTD Trust Participation Application & Agreement contracts
ContractEmployer Group LTD Trust Participation Application & Agreement • October 11th, 2004
Employer Group LTD Trust Participation Application & AgreementP. O. Box 1650 Type Or Print In Black InkLittle Rock, AR 72203 H.O. Use Only Group # Effective Date 1. Legal Name of Employer Taxpayer ID# 2. Mailing Address of Policyholder City State Zip+4 3. Street Address of Policyholder (if different from above) City State Zip+4 4. Name of CEO, President or Owner of Company Name of Insurance Contact at Company Telephone Fax Number 5. Nature of Business Effective as of 12:01 a.m. SIC Code Billing Mode 6. Number of Employees Eligible Enrolled Number of new employees in the waiting period and not eligible for coverage at this time Number of family members of partners or officers working for the firm 7. Waiting PeriodPremium Due Date following completion of Day following completion of NOTE: The waiting period will never be less than 30 days for Present and Future Employees. Employer Contribution % 8. Eligible Employees All Fulltime EmployeesAll Fulltime Employees except 9. Amount of In
