AGENT CHECKLIST Complete copies of the following forms must be submitted: 1. 2. 3. 4. 5. 6. 7.
s s s s
Completed and signed request for participation. A signed proposal indicating the desired plan and benefits. Completed and signed enrollment forms and/or waiver forms for all eligible employees and dependents. If replacing prior group coverage, a copy of prior bill including premium and covered employees’ names. Please include a dental certificate or plan booklet. Firm’s business check, made payable to John Alden G.T. Most current employer wage and contribution report filed with state unemployment department. Groups of fewer than three employees without an employer wage & contribution report, must submit their most current business federal tax return. For example: a) b) c) d) e) If a sole proprietor, Form 1040 & schedule C. If a farmer, Form 1040 and schedule F. If a corporation, Form 1120. If an S corporation, Form 1120S with schedule K-1 for each shareholder. If a partnership, Form 1065 with schedule K-1 for each partner.
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AGENT INFORMATION
(PO boxes are not acceptable for mailing purposes. Please use street address.)
Primary agent name _______________________________________________________________________________________ John Alden Agent No. ___________________________________________________ Commission split _______________% Agency/Company name ___________________________________________________________________________________ Street address __________________________________________________________ Suite No. _______________________ City ___________________________________________ State _________________________ Zip ______________________ Phone No. ( ) ______________________________________ Fax No. ( ) ____________________________________
SECONDARY AGENT INFORMATION (if any) Secondary agent name ____________________________________________________________________________________ John Alden Agent No. ___________________________________________________ Commission split _______________% Agency/Company name ___________________________________________________________________________________ Street address __________________________________________________________ Suite No. _______________________ City ___________________________________________ State _________________________ Zip ______________________ Phone No. ( ) ______________________________________ Fax No. ( ) ____________________________________
FOR OFFICE USE ONLY
NSMC SALES REP NAME
REP NO.
SALES OFFICE
Form HC-1001-3 (Rev. 8/2001)
4
Premium billing type preferred: s Monthly s Quarterly
Requested Effective Date: ______________
TO AVOID DELAYS IN PROCESSING, ALL AREAS MUST BE COMPLETED.
JOHN ALDEN HEALTH REQUEST FOR PARTICIPATION IN JOHN ALDEN GROUP TRUSTS
EMPLOYER INFORMATION Company Name ____________________________________________________________________________________________
(Full Legal Name of Firm)
Address ___________________________________________________________________________________________________
(Street) (City) (County) (State) (Zip Code)
Contact Person __________________________________________________ Phone No. (
(Title)
) ________________________ ) ________________________ ) __________________________ s S Corp.
Owner __________________________________________________________ Phone No. ( Fax No. ( Type of Ownership: s Proprietorship s For Profit s Partnership s Non-profit s C Corp. s Gov’t Agency
s Other ______________________________________________________________________________ Fed. Tax ID No. ___________________________ Does your firm have more than one tax ID no.? s Yes s No If yes, list all and give reasons for more than one. ______________________________________________________________ Nature of business/articles sold, manufactured, or services rendered _____________________________________________ How long has the company been operating? ___________________________________________________________________ For firms with fewer than four eligible employees, all eligible employees must enroll; for firms with four or more eligible employees, at least 75% of all eligible employees must enroll. However, at least 50% must enroll. If employer pays 100% of premium, all eligible employees must enroll. All firms, once approved, must continue to meet these requirements to be able to continue the group insurance plan. 1. How many people, including yourself, are currently employed by your business? ___________________________ 2 A. How many are full-time/eligible (regularly scheduled to work 30 hours per week) and on your payroll? ___________ B. How many are full-time/regular not on your payroll, such as contracted/1099 employees paid via temporary agency or leasing company? ________________________________ C. How many are part-time/not eligible? _______________________________ 3. Is there a class of employees that you are not including? s Yes s No Please explain: _____________________ _________________________________________________________________________________________________________ 4. Select a waiting period for all employees enrolling for insurance after the effective date: s 30 days s 60 days s 90 days
This waiting period applies to all employees enrolling for insurance after the group’s effective date and cannot be changed more than once every 12 months. If you do not select a waiting period, a 30-day waiting period will automatically be selected for your group.
Continued on back Form HC-1001-3 (Rev. 8/2001) 1
John Alden is a Fortis Health member company
5. Are you waiving the waiting period for all employees enrolling for the group’s effective date? s Yes
s No
6. How many group medical/dental insurance carriers have you had coverage with over the last 24 months? __________ Name of most recent prior carrier(s)_________________________________________________________________________ Ortho benefits included? s Yes s No s Yes s No Major services (i.e. root canal, periodontics, etc.) covered?
Policy No _____________________________ Effective Date _________________ Termination Date ___________________
Please include a copy of most recent prior bill for both medical and dental plans. Also, include your dental certificate or plan booklet.
7. Do any employees travel outside the United States or Canada, for business or pleasure, for more than 60 consecutive days a year? s Yes s No If so, list employees: __________________________________________ _________________________________________________________________________________________________________ 8. Name of Workers’ Compensation carrier ____________________________________________________________________ Policy/Certificate No ______________________________________ Do you provide Workers’ Compensation for all employees? s If no, list owners, partners, and officers not covered: Name Title (owner, partner, officer, etc.) _________________________ ______________________________ _________________________ ______________________________ _________________________ ______________________________ Yes s No
Reason not Covered ______________________________________________ ______________________________________________ ______________________________________________
9. If selecting Fortis Long Term Disability coverage, list names of employees who are related: _______________________ __________________________________________________________________________________________________________ 10. Are any present or former employees or dependents currently on or eligible to elect continuation (COBRA or other)? s Yes s No If yes, provide the following information: Name Start Date End Date Type of Continuation Reason __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ 11. Are any employees currently absent due to illness or injury, or receiving disability benefits? s Yes s No If yes, give names and details: ______________________________________________________________________________ __________________________________________________________________________________________________________ 12. What percent of the premium is employer contributing (must be a minimum of 50% of employee medical and dental costs)? AGREEMENT
I hereby request that we be approved as a participating employer under the John Alden and Praesidium Group Trust(s) agreement and hereby accept and agree to be bound by the terms of the Trust agreement. I understand that the benefits I have selected are reflected on the attached signed proposal which is part of this request for participation. I request that Group Life AD&D Insurance, and any other additional benefits elected be made available to all of my employees in accordance with the terms of the Group Insurance Policy issued to the Trust(s). I have read the John Alden Health group plans brochure, the disability plans brochure, any applicable special State Provisions Supplement, and the dental plans brochure, and understand the coverages they describe. I agree to contribute a minimum of 50% of the employee’s cost. I also agree that my firm will remit to the Trust(s) in advance all required employer payments. Enclosed are (1) the firm’s check for the initial required amount, (2) the necessary enrollment forms, and (3) any initially required evidence of insurability. To prevent a delay in issuing of coverage, all employees must submit either the enrollment or waiver form. Make all checks payable to John Alden G.T. COMPLIANCE WITH EMPLOYMENT LAWS: I understand that, as an employer, I may be subject to state and/or federal laws (such as those regarding COBRA, age discrimination, and sex discrimination in relation to pregnancy benefits.) I further understand and agree that if the insurance benefits that I have selected are contrary to any such laws, I am solely responsible for compliance with the laws, including the payment of any required benefits that are not covered by this insurance plan. I have explained to all employees that this insurance becomes effective as of the effective date approved by the insurance company. I understand the agent submitting this application represents my interests, not those of John Alden Life Insurance Company, and that the agent has no right to bind coverage, to alter the terms of the insurance coverage or application in any manner, or to adjust any claim for benefits. I understand that the medical and LTD plans contain preexisting conditions exclusions (as described in the John Alden group plans brochure and disability plans brochure.) I understand that any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statements may be guilty of insurance. fraud. Continued on next page.
Form HC-1001-3 (Rev. 8/2001) 2
________________% Medical
________________% Dental
EMPLOYEE CHOICE BUSINESS LOCATIONS
(Must have 5+ covered employees.)
Does this group have multiple physical locations? s Yes s No If yes, list the addresses of locations starting with the main group location as No. 1. List the number of employees at each location, whether or not enrolling. ___________________________________________________________________________________________________________
Main Group Location No. 1 City County State Fed. Tax ID No. No. FT Employees No. PT Employees
___________________________________________________________________________________________________________
Location No. 2 City County State Fed. Tax ID No. No. FT Employees No. PT Employees
___________________________________________________________________________________________________________
Location No. 3 City County State Fed. Tax ID No. No. FT Employees No. PT Employees
EMPLOYEE CENSUS List all employees in your company, whether enrolling for coverage or not. (Use additional paper, if necessary). List (1) all employees, owners, partners, and managers who are actively working for this firm on a regular basis, whether or not they are eligible to be covered by this plan; and (2) all employees who are not working but are currently covered under your group health insurance plan for reasons such as retirement, requirements of law, etc.
Please indicate each employee’s current status using the following status codes: F-Full-time (regularly scheduled P-Part-time (regularly scheduled C/L-Legally required continuation to work required number of hours) to work required number of hours) I-Independent contractor O-Other, please explain: __________________________________________________________________________ R-Retired
Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Hire Date
Hrs. Worked Per Week Status 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
Name
Hire Date
Hrs. Worked Per Week Status
I confirm that my company is complying with participation requirements of John Alden Life Insurance Company, as outlined in the request for participation. I verify that the information provided to John Alden Life Insurance Company is complete and truthful. I am in compliance with any federal or state health benefit plan provisions which apply to this employer group. I understand that if the above information is not complete or is not provided to John Alden Life Insurance Company in a timely manner, then coverage does not have to be offered or continued. I also understand that incomplete or untruthful information may void insurance coverage. John Alden Life Insurance Company reserves the right to request a state wage and tax statement or other documentation at any time, to verify current and future participation and eligibility.
Signature & Title _________________________________________________________________ Date _____________________
(Owner, Partner, or Corporate Officer)
Agent Signature _________________________________________________________________ Date _____________________
Form HC-1001-3 (Rev. 8/2001) 3