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Utah health insurance applicat... Page 1 of 5 Utah Small Employer Health Insurance Application July 2009 D. WAIVER OF COVERAGE Complete this section for yourself if waiving and/or any of your dependents for whom you are waiving coverage. UTAH SMALL EMPLOYER HEALTH INSURANCE APPLICATION OFFICE USE ONLY Policy / Group No. REASON FOR ENROLLMENT mark all that apply New Group Newborn Loss of Coverage Open Enrollment Marriage Court Order New Hire Divorce Other New Application Re-apply Dependent Addition Date of Event COBRA / Utah mini-COBRA / Alternative Coverage for Employee Dependent Employer Name Effective Date PEC New Hire Waiting Period Length of COBRA continuation coverage 18 mos. 36 mos. Other Original Qualifying Event Date Qualifying Event Date Coverage Medical Dental Vision Self COVERAGE REQUESTED Spouse Child ren COBRA Utah mini-COBRA Alternative Coverage A. EMPLOYER INFORMATION Employer Hire Date Location Is this a division Yes Rehire Date No If Yes name of parent company Name Last Marital Status First Legally Married Single MI Widowed Home or other Phone Hrs/Week Domestic Partner Apt. Address Job Title City State Business Phone Spouse s Business or other Phone Spouse s Employer Zip Driver s License Number Email Address C. ENROLLING EMPLOYEE / SPOUSE / DEPENDENTS attach separate sheet if necessary In the section below list yourself and all eligible family members to be included under coverage. Social Security for internal use only Name Last First MI Date of Birth No lbs. Dependent Rx M/F Age Weight HICN Eligible family members include spouse natural child stepchild adopted child child placed for adoption and child for whom you are appointed as legal guardian by the court. To be eligible for coverage children must be under the age of 26 unmarried and dependent upon you for 50 percent of their financial support. Financial dependency is not required for courtordered child coverage. Any dependent not listed will not be considered for coverage. You may not enroll dependents if you are waiving except children subject to a Qualified Medical Child Support Order. If you decline enrollment in this plan for yourself and/or any of your dependents including your spouse because of other health care coverage you may in the future be able to enroll the omitted individual s in this plan provided that you request enrollment within 30 days after the other coverage of the individual s ends. Decline enrollment includes omission of the individual from this application* In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents provided that you request enrollment within 30 days after the marriage birth adoption or placement for adoption the Special Enrollment Period. Please complete type of health care coverage for the employee and all eligible members who have other health care coverage by completing type of health care coverage i*e* group individual or other Medicare Medicaid V. A. H. I. P. etc*. All eligible family members must be listed in this section or the ENROLLING EMPLOYEE / SPOUSE / DEPENDENTS section* Persons waiving coverage.

Globe life insurance applicati... Globe Life And Accident Insurance Company Administrative Office: Globe Life Center, Oklahoma City, Oklahoma 73184 Group Enrollment Form for Accidental Death Policy Benefit Amount Payment Type $3,000

Earthquake cea application for... CALIFORNIA EARTHQUAKE AUTHORITY EARTHQUAKE INSURANCE APPLICATION INSTRUCTIONS POLICY EFFECTIVE DATE AND EXPIRATION DATE Provide CEA policy effective date and expiration date. CEA Earthquake Insurance Application Instructions 01/2012 Revision Earthquake Insurance Application Effective Date Applicant Information Applicant First Name Co-Applicant if applicable Last Name Middle Initial Number and Street Address City State Work Home Unit ZIP Code County Companion Policy Information Participating Insurer Type of Policy Homeowner Dwelling Coverage A Limit Renters Homeowners/Dwelling Fire Basic Program Rating Territory Year Built Construction Type Number of Stories in building Including Basement Is there unrepaired structural earthquake damage to the dwelling Frame Other Number of Chimneys Square Footage Foundation Type Roof Type Raised Slab Composition Tile Wood Shake Yes No If yes DO NOT BIND and explain in Remarks Dwelling secured to foundation Cripple walls braced with plywood or equivalent NOTE Inspections are required on all properties with existing non-structural i.e. cosmetic earthquake damage. Expiration date must be the same as the expiration date of the companion policy. APPLICANT Complete all requested information for applicant s including Name s Telephone number s Street address of physical location of insured property Mailing address if different from street address of property s physical location COMPANION POLICY INFORMATION Name of Participating Insurer Policy number of companion policy Dwelling limit i*e* Coverage A of companion policy if companion policy has dwelling limit Expiration date of companion policy Type of companion policy POLICY TYPE RATING AND COVERAGE INFORMATION Identify CEA policy type based on the type of companion policy as follows Homeowner Companion policy must be either a Homeowners HO-1 2 3 5 or 8 or equivalent Dwelling Fire building Landlord building or Mobilehome policy. o M anufactured Hom e M obilehom e Written on CEA Homeowner Policy form however requires unique rating information* Condominium i*e* Common Interest Development Companion policy must be a Condominium Unit Owners HO-6 or equivalent policy. Renters Companion policy must be a Renters HO-4 or equivalent Mobilehome tenant policy Dwelling Fire contents only or Landlord contents only policy. Complete all information requested under the applicable CEA policy type. Select desired CEA policy limits and coverage options. PAYMENT OPTIONS Select payment option Annual or Installments SEND BILL TO Select who should receive the bill Insured or Mortgagee ADDITIONAL INTERESTS Complete information requested for each additional interest including Type o Additional insured or o Loss payee Name and address Loan number if applicable REMARKS Include any additional remarks as needed* SIGNATURE Secure the applicant s signature on the application the date and time the application is completed* Provide the producer s name address and license number. Is the home reinforced by an earthquake resistant bracing system or installed upon an approved foundation system certified by the California Department of Housing and Community Development Water heater secured to building frame Option Two 75 000 AND Loss of Use Coverage D 25 000 50 000 100 000 No deductible for this coverage if Coverage A deductible is met.

Louisiana department of insura... L O U I S I A N A D E P A RT M E N T JAMES OF INSURANCE J. D O N E L O N COMMISSIONER INSTRUCTIONS FOR APPLICATION TO ACT AS A SPECIALTY INSURER IN THE STATE OF LOUISIANA GENERAL INSTRUCTIONS This

Commercial automobiletruckers... National Casualty Company Home Office: Madison, Wisconsin Adm Office: 8877 Gainey Center Dr. Scottsdale, Arizona 85258 Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio

Group life portability insuran... Standard Insurance Company Continued Bene?ts 800.378.4668 Tel 800.331.3397 Fax 920 SW Sixth Avenue Portland OR 97204 Group Life Portability Insurance Application INSTRUCTIONS PLEASE READ CAREFULLY

Travelsafe insurance bluecross... Blue Cross Center, 8000 Makati Avenue, 1200 Makati City, Metro Manila, Philippines Tel. No.: +63 2 899-8001 Fax No.: +63 2 899-5389; +63 2 325-0637 Email: travel sales bluecross.com.ph Website: www.bluecross.com.ph

2013 demonstration jump insura... Demonstration Jump Insurance Application 1) Terms: For each exhibition, a completed Demonstration Jump Insurance Application AND payment should be received at least 3 days before the intended jump

State of california department... If an active Public Insurance Adjuster qualification exists fees and signed renewal certification and Branch Office Certificate if applicable must be date your license expires. Insurance. ca.gov under Online Services. Check license type s you are renewing Current Fee AJ Adjuster Per Qualified Manager Branch Office Certificate ea Starting with June 2013 Renewals PJ Public Adjuster Renewal Application Certifications 1. If an active Insurance Adjust...

Utah health insurance applicat... UTAH SMALL EMPLOYER EMPLOYEE HEALTH INSURANCE APPLICATION OFFICE USE ONLY Policy / Group No. REASON FOR ENROLLMENT mark all that apply New Group Newborn Loss of Coverage Open Enrollment Court Order Marriage New Hire Dependent Addition Divorce New Application Other Military Leave of Absence USERRA COBRA Utah mini-COBRA Length of continuation coverage 12 mos. Attach a separate sheet if necessary. Will coverage continue Employer group Governmental Name of Individual Insurer List policyholder name insurer name and phone number Spouse/Domestic Partner Page 1 of 3 Date of Coverage MM/YY Start Date End Date Type of Coverage Check all that apply Individual Medicare Other Utah Small Employer Health Insurance Application January 2014 E. ACKNOWLEDGMENT AND SIGNATURE I agree to abide by the insurer s enrollment provisions. 18 mos. 36 mos. Other Original Qualifying Event Date Qualifying Event Date Date of Event Effective Date New Hire Waiting Period WAIVER OF COVERAGE Individuals waiving coverage complete Waiver of Coverage. A. EMPLOYER INFORMATION Employer Is this a division Yes No If Yes name of parent company Name Last First MI Job Title Employment status Full-time Owner/business partner Retired Other Marital Status Legally Married Single Divorced Widowed Hrs/Week Hire Date / Rehire Date Domestic Partner Home Address Apt. City State Zip Mailing Address Home/Cell Phone Business Phone Email Address If you are American Indian or Alaska Native provide the state and name of your federally-recognized tribe C. ENROLLING EMPLOYEE / SPOUSE / DOMESTIC PARTNER / DEPENDENTS List yourself and all dependents applying for coverage. Attach a separate sheet if necessary. Name Last First Middle Social Security for insurer use only Date of Birth MM/DD/YYYY Spouse/ Dependent Check with your employer to determine if domestic partner coverage is available. Gender Male Female Tobacco Use Yes No D. CURRENT COVERAGE INFORMATION Please indicate for EACH person listed on this application any health care coverage Medicaid or Medicare currently in effect. This will be used to determine if benefits will be coordinated* Each person applying for coverage must be listed below. If no health care coverage is in effect indicate NONE* If coverage is provided for a dependent from a previous marriage or relationship please attach a copy of the court documentation that shows who is responsible for the dependents health care coverage so that the insurer can determine whose coverage is primary. I understand that coverage cannot start until after the waiting period. I authorize my employer to act as my agent in all matters of administration of the group program* I acknowledge that I have had the opportunity to waive coverage for myself and any eligible dependents. If the policy contains a voluntary arbitration provision ANY MATTER IN DISPUTE BETWEEN YOU AND THE INSURER MAY BE SUBJECT TO ARBITRATION AS AN ALTERNATIVE TO COURT ACTION PURSUANT TO THE RULES OF THE AMERICAN ARBITRATION ASSOCIATION OR OTHER RECOGNIZED ARBITRATOR A COPY OF WHICH IS AVAILABLE ON REQUEST FROM THE INSURER* THE INSURER SHALL BEAR THE COSTS OF ARBITRATION FILING FEES ADMINISTRATIVE FEES AND ARBITRATOR FEES* OTHER EXPENSES OF ARBITRATION INCLUDING BUT NOT LIMITED TO ATTORNEY FEES EXPENSES OF DISCOVERY WITNESSES STENOGRAPHER TRANSLATORS AND SIMILAR EXPENSES WILL BE BORNE BY THE PARTY INCURRING THOSE EXPENSES* ANY DECISION REACHED BY ARBITRATION SHALL BE BINDING UPON BOTH YOU AND THE COMPANY.

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