Laserfiche WebLink
� � 3 ' ERISA INFORMATION <br /> . <br /> Three-digit Plan Number <br /> ERISA plan year begins (Month/Day) <br /> Is the Policyhoider the Plan Administrator? �Yes <br /> ❑ No <br /> IF THE POLICYHOLDER IS NOT THE PLAN ADMINISTRATOR, PLEASE <br /> COMPLETE THE FOLLOWING: <br /> Plan Administrator <br /> Name <br /> Address <br /> City, State, Zip Code <br /> Telephone Number <br /> Is the Policyholder the Agent of Service? J�es <br /> ❑ No <br /> IF THE POLICYHOLDER IS NOT THE AGENT OF SERVICE, PLEASE COMPLETE <br /> THE FOLLOWING: <br /> Agent of Service for Legal Process <br /> Name <br /> Address <br /> City, State, Zip Code <br /> Telephone Number <br /> 10/27/04 5 of 5 <br />