GROUP STATUS SHEET/APPLICATION Acct Exec.
( ) New Group ( ) State(s) Involved ( ) Renewal
( ) Sub Location ( ) Changes ( )...
2 of 2
GDA 6/02
TABLE OF ALLOWANCES:
Applies to Type I Yes No
BENEFIT OPTIONS: IN-NETWORK OUT-OF-NETWORK INDEMNITY
Type I ...
3 of 3
GDA 6/02
RATES:
Managed Care
Two rate: EE $ EE & Family $
Standard 3 rate: EE $ Two Party $ Three Party $
Four rate...
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Direct Compensation Plan Group Application

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Direct Compensation Plan Group Application

  1. 1. GROUP STATUS SHEET/APPLICATION Acct Exec. ( ) New Group ( ) State(s) Involved ( ) Renewal ( ) Sub Location ( ) Changes ( ) Termination ( ) Other GROUP INFORMATION: Name of Group: Phone: ( ) Mailing Address: Street City State Zip Billing Address: Street City State Zip Name of Administrator: Phone: ( ) 1 of 1 GDA 6/02 Address: Street City State Zip Eligibility Contact: Title: Phone No.: Fax No.: TYPE OF INDUSTRY: PROGRAM/BENEFITS: Plan Design: Ortho: Adult Option: ( ) Yes ( ) No Dependent Children to Age Full Time Students to Age Ortho Takeover: ( ) Yes ( ) No E & L’s: (FOR ADMINISTRATIVE USE ONLY) PROPOSED EFFECTIVE DATE: Term of Agreement: From: To: CENSUS DATA: Total Number of Employees Total Number of Eligible Employees Total Number of Ineligible Employees Total Number of Employees Enrolled in other Program (If Applicable) Total Number of Employees Enrolling in Program Distribution by Dependency Status: One Party Two Party Three Party + Composite BENEFIT INFORMATION: INDEMNITY: ( ) NO ( ) YES If yes, name of other Program/Carrier PPO: ( ) NO ( ) YES If yes, name of other Program/Carrier DUAL CHOICE: ( ) NO ( ) YES If yes, name of other Program/Carrier TAKEOVER: ( ) NO ( ) YES If yes, name of other Program/Carrier BENEFIT WAITING PERIOD: Type I [0] months Type II [0] months Type III [0] months Type IV [0] months TOTAL ANNUAL MAXIMUM BENEFIT & MAXIMUM DEDUCTIBLE PER FAMILY Annual Maximum Benefit $ Number of Deductibles per Family
  2. 2. 2 of 2 GDA 6/02 TABLE OF ALLOWANCES: Applies to Type I Yes No BENEFIT OPTIONS: IN-NETWORK OUT-OF-NETWORK INDEMNITY Type I Provided Not Provided Deductible (Types 1-4) Deductible Waived Type 1 Coinsurance Percentage Type II Provided Not Provided Coinsurance Percentage Type III Provided Not Provided Coinsurance Percentage Type IV Provided Not Provided Coinsurance Percentage Orthodontics Lifetime Maximum $ $ $ CONTRACT OPTIONS: Deductible Carryover Credit for Prior Coverage A Deposit of $ is herewith made to apply on the first payment under the policy(ies) if issued (amount equal to estimated first onth premium payable). If the insurance risk is not accepted the deposit will be returned.m PLAN REQUIREMENTS: Eligibility should be submitted to Administrator prior to the 20th of the month. Eligibility # of Months: # of Days: Hours / Week: Effective: Day following completion of eligibility ( ) 1st day of the month following completion of eligibility ( ) Date of Hire ( ) 1st day of the month following Date of Hire ( ) Waive on initial enrollees? Yes ( ) No ( ) Who is eligible? All Employees ( ) Class or Employees (specify below) Retired Employee ( ) Spouse ( ) Domestic Partner ( ) Dependent Children to Age ( ) Students to Age ( ) Specified Class: The insurance for eligible employees will become effective on the date requested on the application provided that: at least 50% of the eligible employees must be covered if on a contributory basis, or; 75% on a non-contributory basis, or; 15% on a voluntary basis. Provided that not less than eligible employees have made application for the insurance, coverage will be effective on the requested date.
  3. 3. 3 of 3 GDA 6/02 RATES: Managed Care Two rate: EE $ EE & Family $ Standard 3 rate: EE $ Two Party $ Three Party $ Four rate: EE $ EE + Spouse $ EE + Child(ren) $ EE + Spouse + Children $ Super Composite: $ Other (specify type and amount): $ PPO/Indemnity Two rate: EE $ EE & Family $ Standard 3 rate: EE $ Two Party $ Three Party $ Four rate: EE $ EE + Spouse $ EE + Child(ren) $ EE + Spouse + Children $ Super Composite: $ Other (specify type and amount): $ EMPLOYER CONTRIBUTION: Employee: % Dependent: % Other: PAYMENT MODE: ( ) Monthly ( ) Other ADMINISTRATIVE INFORMATION BILLING INFORMATION Eligibility information will be provided by: Provide a printed copy of billing to group? Yes ( ) No ( ) ( ) Magnetic media (specify type tape, cartridge diskette, other) ( ) Enrollment cards ( ) Other (specify) Mail initial ID Cards and E.O.C.’s to: Enrollees Group COMMENTS: AGENT (CONSULTANT/BROKER): Agent (Consultant/Broker) Address: Street City State Zip Agent’s TIN or SS# State License # Phone No.( ) Fax Phone No.: ( ) Commission: % The program shall become effective only upon issuance of a written agreement executed by a duly authorized officer of Nevada Pacific Dental. The statements in this application are deemed to be representations and not warranties. Any misrepresentation, omission, concealment of fact or incorrect statement which is material to the acceptance of risk may prevent recovery if had the true facts been known to Nevada Pacific Dental we would not in good faith have issued the contract/agreement at the same premium rate. IT IS UNDERSTOOD AND AGREED THAT THIS GROUP STATUS SHEET BE MADE A PART OF SUCH AGREEMENT. EXECUTED THIS DAY OF , [2002] FOR THE APPLICANT AT (City/State) BY: AUTHORIZED SIGNATURE TITLE ACCEPTED THIS DAY OF , 2002 BY: NAME/TITLE DATE

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