Insurance Sponsored Plan

INSURANCE SPONSORED PLAN

Plan Sponsor Information

Administrator Phone:     Administrator Email:

Applicant / Insured Information

Date of Birth:     Phone:     Email:

Policy Details

Policy Number:     Policy Type: Health Life Disability Dental Vision Other:

Coverage Amount / Benefit Limit:     Deductible:     Premium:

Policy Period: From to

Eligibility & Covered Classes

Covered Classes (select all that apply): Full-time employees Part-time employees Seasonal employees Retirees Dependents

Coverage Options & Contributions

Coverage Option: Individual Family Dependents Only

Payment Frequency: Monthly Quarterly Annually Other

Exclusions and Limitations

The plan excludes coverage for losses arising from intentional acts, criminal conduct, pre-existing conditions as defined in plan documents, cosmetic procedures except when medically necessary, experimental treatments, and items specifically listed as excluded in the certificate of coverage. Additional limitations, waiting periods, and benefit maximums apply as set forth in the plan terms.

I acknowledge that I have received and read the exclusions and limitations and understand that eligibility and benefits are subject to the plan document and any applicable employment policies. Acknowledged

Beneficiary Designation (for life/disability benefits)

Primary Beneficiary 1:    Relationship:    Percentage:

Primary Beneficiary 2:    Relationship:    Percentage:

Contingent Beneficiary:    Percentage:

Dependents / Covered Individuals

Claims and Documentation

Date of Loss / Event:     Estimated Loss Amount:

Required Documentation Checklist: Police report (if applicable) Medical records Repair estimate / receipts Photographs

Premium Payment Authorization

By signing this form I authorize the Plan Sponsor to deduct employee premium contributions from payroll as indicated and to remit employer contributions described above. I understand that premium amounts may be adjusted in accordance with the plan terms and that failure to remit employee contributions may result in termination of coverage.

Payroll Deduction Authorization: Authorized

Certifications, Acknowledgements & Governing Provisions

I certify under penalty of law that the information provided in this Insurance Sponsored Plan application is complete and true to the best of my knowledge. I understand that intentional misrepresentation or omission of material facts may result in denial of benefits, rescission of coverage, and/or disciplinary action including civil or criminal penalties where applicable.

I understand that enrollment, coverage, and benefits are governed by the plan document, certificate of coverage, and any applicable collective bargaining or employment agreements. The Plan Sponsor reserves the right to amend, modify, or terminate the plan in accordance with its terms. Disputes under this plan will be resolved in accordance with the claims and appeal procedures set forth in the plan documents and governed by applicable law.

By signing below, I authorize the Plan Sponsor and its designated administrator to obtain and release medical or other records reasonably necessary to administer claims and benefits, subject to applicable privacy and confidentiality rules.

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