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Reliance Standard Life PRELIMINARY APPLICATION FOR GROUP INSURANCE <br /> Insurance Company <br /> 1. Prospective Policyholder: C1TI OF ��,p�TUR.. 1,1,1,�1JQ1� <br /> (Exact Legal Name) <br /> 2. Federal Employer ldentification Number: �'� �-' 6 C?O/ "3 D � <br /> 3. Complete address: `.� ��F��j t< AoJd��tS C vJ �12�, �c�l =L ACD�U Co Zbr'�'� <br /> (Stre ddress) City and State) (County) (Zip Code) " <br /> Executive Correspondent .�'�� R.� ��aw� Title ��S►c. 1"'�w a��e�2 Phone_��"t� `i2�►.��o� <br /> Routine Correspondent 21�h� r ,a�,Z�1.N-�- Title s�c �nfi 3 TPhone �('j, y2L?. ,2 �''�� <br /> Mailing Address(If different) <br /> 4. Nature of business: (If Association: purpose,when formed) �rA n„ C��P��Ty <br /> 5. The prospective policyholder is a X corporation,_partnership,_proprietorship,_union, <br /> association,_other(specify) <br /> 6. INDICATE AFFILIATES OR SUBSIDIARIES TO BE COVERED, IF ANY: <br /> (Include divisions only if all are not to be included) N(y� <br /> No. of Employees by Coverage <br /> Name and Location Nature of Nature of <br /> Relationship Business Life AD&D W I LTD AR STOP Other <br /> LOSS <br /> 7. POLICY TO BE ISSUED IN THE STATE OF :� 8. Requested Effective Date: �O�l I 20i0^7 <br /> (If other than state of ApplicanYs main office, explain in REMARKS) (Month) (Day) (Year) <br /> 9. COVERAGES APPLIED FOR: X Life,ZC AD&D,_WI,_LTD,_VAR,_STOP LOSS,_OtherVC)t. UFE <br /> 10. Is any group insurance now in force or currently being applied for on the Proposed Insureds?�yes no <br /> If yes, (A) Indicate in Remarks: name of carrier;type of coverage; effective date; brief benefit description; <br /> eligibility; etc. <br /> (B) Provide prior experience, including premiums and incurred claims(or paid claims and claim reserves at <br /> start and end of period.) <br /> 11. Is it proposed to terminate or change any existing group insurance coverage? k yes_no <br /> If yes, indicate in REMARKS: name of carrier;type of coverage, and date of termination, or date and type of change. <br /> 12. Are all Proposed Insureds actively at work?_yes_no If not, please list the following for employees not <br /> actively at work: <br /> NAME DATE OF BIRTH LAST DAY WORKED FACE AMOUNT REASON FOR ABSENCE <br /> SEF ATTACHED LIST. <br /> REMARKS: <br /> This Preliminary Application is subject to the acceptance and approval in writing by Reliance Standard Life Insurance <br /> Company at the Administrative Offices in Philadelphia, Pennsylvania; and nothing contained herein shall be binding upon <br /> said Company until this Preliminary Application is so approved. $ has been paid herewith. It will be applied toward <br /> the first premium due on the policy or policies if any be issued. Such issuance is subject to the:terms; conditions; <br /> limitations; and exceptions of the policy or policies if any be issued. <br /> Name of A ent or Broker of Record (print or type) Share by <br /> �NIJKE�CDIYIPRN`1 l�n % (authorizedsignature) <br /> % y� <br /> % 1�� , `U�N t� � �12 <br /> (title or-Rosition with Applicant) <br /> Print or type name of Broker's firm, if applicable Dated at �eG�A �L �l l �No 1 S <br /> �E�IJK6� C,OMPAt�N �NC. Date bG`��b�2 2 � 2G�l7'7 <br /> Group <br /> by Agency O�ce <br /> (authorized signature) (Title) <br /> L -8209-1088 <br />