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• - ' PREMIUM ADMINISTRATION INFORMATION I <br /> Billing Option: �J Home Office List Bill �1 Self-Administered Bill <br /> (Class 6 only) <br /> NOTE: List bil/is only option for denta/groups and/or coverages for groups <br /> under 50 lives. <br /> Class Definitions: (1) Fire fighters and police officers ($25,000) <br /> �2� General Service employees ($10,000) <br /> (3� Library General Service employees ($5000) <br /> �4� Management employees (annual salary +$5000) <br /> If more than one division �5) City Manager (3 x annual salary) <br /> (6) Voluntary life for management employees <br /> Bill each division separately (mail to Division address) (�) dependent life <br /> Bill each division se aratel mail to Polic holder address <br /> p Y � Y ) <br /> Does billing need to be broken into Department? If so, please provide name(s) of <br /> departments. (Also note on Roster/Enrollment forms �1� <br /> NOTE: If no division or department breakdown is needed, billinq will be <br /> alphabetical. <br /> BOOKLET INFORMATION <br /> Booklets should be sent to: ❑ Policyholder <br /> ,�'Broker/Consultant <br /> ❑ Group Office <br /> Administration Kit and Supplies should be sent to: ❑ Policyholder <br /> �roker/Consultant <br /> ❑ Group office <br /> 10/27/04 4 of 5 <br />