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Prepaid Business Legal Plans document sample

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									                                                                  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.

                                                                                                    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.
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
                       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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