HomeMy WebLinkAboutAflac Insurance Co-9/26/2016GROUP MASTER APPLICATION
Application is hereby made to:
CONTINENTAL AMERICAN INSURANCE COMPANY
PO Box 84078, Columbus, GA 31993-4078
800.433.3036
City of Waterloo
By
Full Legal Name of Proposed Policyholder
Waterloo, IA
Of
City and State in which the Master Policy will be Issued (situs state)
Including (if applicable)
(Any Subsidiaries/Affiliates/Divisions)
REPRESENTATIONS ARE MADE AS FOLLOWS:
General Employee Requirements
CI A full-time Employee is one who works 30 hours or more per week. An Employee must be Actively at Work on the
date he applies for coverage and on the date his Certificate of Insurance becomes effective. An Employee must complete
2 months of continuous service to be eligible for coverage.
CI Number of eligible Employees: 540
El The minimum number of enrolled Employees necessary to keep the Group Policy in force*: 25 Payors
X17: GROUP ACCIDENT
COVERAGE REQUESTED
Series 7800 ID 24 Hour
Application Reason: ❑ New Policy ❑ Change to Existing Policy #
❑ Other
Class of Eligible Employees:
tEl Regular full -time Employees at least age 18
Plan: El 1
Optional Features: N/A
The requested Effective Date is 01/01/2017.
Rates are guaranteed for year(s) from the Group Policy Effective Date.
Premium Contributions: Percentage to be paid by Employee
Percentage to be paid by Employer %
Will this Group Accident Policy replace any existing Group Accident Policy? Yes❑ No❑
If yes, provide carrier and policy number:
GROUP CRITICAL ILLNESS Series 21000
Application Reason: 0 New Policy 0 Change to Existing Policy #
0 Other
Class of Eligible Employees:
Regular full -time Employees at least age 18
Optional Features: With Cancer: I] yes
Health Screening Benefit: 0 yes
The requested Effective Date is 01/01/2017.
Rates are guaranteed for year(s) from the Group Policy Effective Date.
Premium Contributions: Percentage to be paid by Employee
C01204
Percentage to be paid by Employer
Will this Group Critical Illness Policy replace any existing Group Critical Illness Policy? Yes❑ No❑
If yes, provide carrier and policy number.
Q GROUP DISABILITY INCOME (Employee Only) Series C5O000 Class B
Application Reason: n New Policy ❑ Change to Existing Policy #
❑ Other
Class of Eligible Employees:
Regular full -time Employees at least age 18
Optional Features: 0 Non -Occupational
Elimination Period: 14/14 Benefit Period: 3 Month
Percentage of Income Replacement: 60 %
The percentage of income replacement may vary for state-sponsored disability programs for Employees who reside
in: California, Hawaii, New Jersey, New York, Puerto Rico, Rhode Island
The requested Effective Date is 01/01/2017.
Rates are guaranteed for year(s) from the Group Policy Effective Date.
Premium Contributions: Percentage to be paid by Employee
Percentage to be paid by Employer
Will this Group Disability Income Policy replace any existing Group Disability Income Policy? Yes❑ No❑
If yes, provide carrier and policy number
If this coverage will replace any existing Aflac individual policy, please be aware that it may be in the insureds' best
interest to maintain their individual guaranteed -renewable policy with Aflac via direct bill. Insureds may contact Aflac for
an explanation of their options for both continuation or cancellation of any existing coverage.
GENERAL AGREEMENT
The applicant agrees to transmit the total premiums under the group policy to Continental American Insurance Company
at its Home Office when due. The applicant agrees to accept the terms and provisions of the group policy, including its
exhibits, riders, endorsements or amendments, if any. No agent or other person except an officer of the Company can
make or change any contract or agreement on behalf of Continental American Insurance Company.
Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal
offense and subject to penalties under state law.
Representative
of the Policyholder
'r--
s
(Signature)
,., ;
/
ill/, _
Date
cl P Z L _ I b
& ..\k n
(Printed Name)
Title
KG-A.-V:3,�
State of Signature
Ti --o w C1/4 -
C01204