Laserfiche WebLink
• � ' POLICY INFORMATION <br /> Effective Date of Policy: / � �� � o � <br /> Employee's Waiting Period: � <br /> �_� �aY�s) I <br /> ❑ Month(s) 'i <br /> ❑ Other(describe) I, <br /> Eligibility: �� <br /> � 30 hours (Standarc� , <br /> ❑ Other number of hours ' <br /> Effective Date of Coverage (choose one): <br /> ,�On the day following completion of the waiting period <br /> ❑ On the first day of the policy month following completion of the waiting period <br /> ❑ Other (explain) <br /> Definition of Earnings: <br /> Earnings include: ❑ Commissions O Bonuses ❑ Overtime Pay <br /> ❑ Other(describe) <br /> EMPLOYER CONTRIBUTION PERCENTAGE For Employee / oo % <br /> PER COVERAGE(S) For Dependents -p %** <br /> Section 125 <br /> Does this plan allow employees to deduct premium contributions before taxes and/or <br /> are employees given benefit choices under a Section 125 Cafeteria Plan? <br /> ❑ Yes �'No <br /> Effective date of coverage following subsequent enrollment periods (MM/DD): <br /> If yes, which coverage should be included in our standard Section 125 contract <br /> provisions? <br /> If yes, what is the Salary Determination Date? <br /> (Classification change should be on the date following the open enrollment.) <br /> Dependent Information <br /> *** Dependent eligibility to age: � � <br /> *** Full-time students to age a3 (Standard full-time student—to age 23, 24, 25) <br /> ** Does not apply to STD or LTD <br /> "`* Does not apply to STD, LTD or Employee Life <br /> 10/27/04 . 3 of 5 <br />