Application for Group Benefits BEST Health Plans, Post Office Box 19721, Irvine, CA 92623-9721 Ph. 1-877-247-6778 HOME OFFICE USE ONLY: Group Number _____ Effective Date _______ GROUP INFORMATION (please print) ELIGIBILITY FOR COVERAGES (please print) Legal Business Name Annual open enrollment period? No Yes Duration (31 days max) Name of Business Are dental benefits offered under Section 125 Plan? No Yes Nature of Business Tax ID# Annual election period from / / Contact Name Ineligible classes or division (if none, please state) Title Email Address Employer contributes towards dental benefit? No Yes If yes, enter __ / Phone Number: Fax Number: __% Street Address Indicate the number of persons who are eligible for coverage and the City State Zip number enrolled Mailing Address (if different) Prior group dental coverage? No Yes Carrier Attach Invoice City State Zip Plan currently enforced? No Yes Effective Date / / Please select one of the following: Date of Termination / / Corporation Partnership Proprietorship Other (specify) Are subsidiaries included: No Yes If Yes, please attach name and addresses DENTAL COV ERAGE REQUESTED (please print) Separate billing statements required: No Yes If Yes, please provide special billing Please check plan(s) you are selecting. instructions Dental Prepaid Plans: EMPLOYEE ELIGIBILITY (please print) Each present or new employee is an “eligible employee” if she or he: Premium 300* 500* 800* Is a member of the eligible cases show n in the contract schedule, and S200** S500** S700* Is w ithin the age requirements show n in the contract schedule, has satisfied any w aiting period show n on this application, and * Minimum 2 Employees ** Minimum 15 Employees Is “actively at w ork” on the date employee becomes eligible, and Works the minimum number of hours as show n on the contract schedule. SIGNATURES Waiting periods for new employees: I, the undersigned authorized officer; certify all statements are true and complete to the First of the month following 0 days of continuous employment best of my know ledge and belief. Any person w ho know ingly and w ith intent to injure, defraud, or deceive any insurer files a statement of claim or an application conta ining any First of the month following 0 months of continuous employment false, incomplete, or misleading information is guilty of a felony of the third degree. None Other (specify) Name Title Signature Date Agent/Broker STATEMENT OF UNDERSTANDING It is understood that these products are pow ered by BEST Health Plans and underw ritten Name Date by Solstice Benefits, Inc. It is understood and agreed that the contract, if issued, shall Signature Address include the membership fees and general pr ovisions of the contract and be binding upon City State Zip the applicant and the Company. Contract and membership fees are subject to the approval of Solstice and nothing contained her ein shall be binding until this application is Marketing Manager approved and accepted at Solstice Benefits’ Home Office. Name BHP12110109 Advantage Plans are powered by BEST Health Plans, LLC and underwritten by Solstice Benefits, Inc. A licensed PLHSO under Chapter 636 F.S.
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