HomeMy WebLinkAboutAFLAC Agreement-9/26/2016GROUP MASTER APPLICATION
Application is hereby made to:
ffac®
CONTINENTAL AMERICAN INSURANCE COMPANY
P0 Box 84078, Columbus, GA 31993-4078
800.433.3036
City of Waterloo
By
Full Legal Name af Proposed Policyholder
Waterloo, IA
Of
City and State ri which the Master PoIicy will be ssued (situs state)
Ineluding (if applicable)
(Any Subsidiaries/Affiliates/Divisions)
REPRESENTATIONS ARE MADE AS FOLLOWS:
General Emplovee Requirements
JJ 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 appfles for coverage and on the date his Certificate of Insurance becomes effective. An Errployee must complete
2 months of continuous service to be eligible for coverage.
L Number of eIigibe Employees: 540
fli The minimurn number of enrolled Empioyees necessary to keep the Group Pohcy in force*: 25 Payors
COVERAGE REQIJESTED
GROUP ACCIDENT Series 7800 l 24 Hour
Application Reason: 9 New Policy 0 Change to Existing Policy #
0 Other
Class of Eligible Employees:
l Regular fuJi -time Employees at Ieast age 18
Pian: PJ 1
Optional Features: N/A
The requested Effective Date is 01101/2017.
Rates are guaranteed for year(s) from the Group Poiicy Effective Date.
Premium Contributions: Percentage to be paid by Employee %
Percentage to be paid by EmpIoyer
Will this Group Accident PoIicy rep/aoe any ex/sting Group Accident Po/icy? Yes U NoU
/fyes, provide carrfer and poficy number:
l{ GROUP CRITICAL ILLNESS Series 21000
Application Reason: [1 New Pohcy 0 Change to Existing Policy #
0 Other
Class of EligibIe Empioyees:
Z1 Regularfull -time Empioyees at least age 18
Optional Features: With Cancer: FE yes
Health Screening Senefit: lF yes
The requested Effective Date s01/01/2017.
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❑ Noll
If yes, provide carrier and policy number.
jW GROUP DISABILITY INCOME (Employee Only) Series C5O000 Class B
Application Reason: ri New Policy F1 Change to Existing Policy #
❑ Other
Class of Eligible Employees:
Regular full-time Employees at least age 18
Optional Features: 17 Non -Occupational
Elimination Period: 14/14 Benefit Period: 3 Month
Percentage of Income Replacement: 60 %g
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 01/0112017.
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? YesO NoLJ
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 understate law.
Representative
Date
of the Policyholder &VA- . 4�Mr t-- L
(Pdnted Name) (Signa(ure)
Title
State of Signature
KC"Aoy,
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