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. � ' ASO ACCOUNT <br /> BENEFIT PROGRAM APPLICATION <br /> Empioyer Group No.(s) �9����� Section No.(s) U►CG <br /> Employer Group Name: � �� <br /> (Specity the empk>yeR applying ta coverage.Names of subsidiary and affiliated companies mus[also be included. <br /> AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED.) <br /> Address: # � � v,,,,�.�. �'���r .� /� ���T�(1�,�� � <br /> Administrative Contact:`" � <br /> Effective Date of Coverage: ! I- �'9a <br /> 1. Eli ible Person means: <br /> �A full-time employee of the Employer. <br /> ❑ A full-time employee who is a member of���or��KK,a��a��� <br /> � f�Q,J,����1 D➢� . <br /> 2. Full-Time Employee means: <br /> � A person who is regularly scheduled to work a minimum of_��O hours per week and who is actively <br /> ❑ at work and on the payroll of the Employer. ' <br /> 3. The Effective Date of Termination for a person who ceases to meet the definition of an Eligible Person: ' <br /> ❑ The date such person ceases to meet the definition of Eligible Person. I <br /> �The last day of the calendar month in which such person ceases to meet the definition of an Eligible I <br /> Person. I <br /> ❑ I <br /> 4. ❑ The limiting age for covered unmarried children is� ; coverage is automatically terminated on the �� <br /> birthday. I� <br /> ❑ The limiting age for covered unmarried children is or if a full-time student; coverage is <br /> automatically terminated on the birthday. <br /> � ' " U�,�e '• �� l;o C.��t�a.�� a�.i-c;l.CLs,- <br /> c�''��t--he ,Y.. �:.- lJ-�-�1.-�c.�'��-E'hR_ ,k�.c..�rn.�.l.t.-��( a�--(r.7 �cLc.l�.�U. ^ U <br /> 5. The Eligibility Date for a person who becomes arYEligible Person after the Effective Date of the Employer's <br /> Health Care Plan: <br /> �The date of employment. <br /> ❑ The first day of the month following full calendar month(s)of employment. <br /> ❑ The first day of the month following the date of employment. <br /> ❑❑ The day of employment. <br /> 6. The Enrollment Period during which an Eligible Person may apply for coverage if he did not apply prior to <br /> his Eligibiliry Date or if he did not apply for Family Coverage when eligible to do so is: <br /> ❑ At any time, subject to approval of Evidence of Insurabiliry by the Claim Administrator. <br /> � �_ .�`� �-l.Cu�.e � � o Q<n�QkQ�,�,� r��.t� <br /> Such Person's Coverage Date or Family Coverage Date is: <br /> ❑ a date determined by the Claim Administrator following approval of Evidence of Insurability for such <br /> person by the Claim Administrator. <br /> �S�_ fi�:�.� .u-���-, n�.a�o• <br /> GAr10-4 HCSC Fiev.3l92 Page 1 <br />