HomeMy WebLinkAbout1571 - ~ ,
~ ~
• -
• . FILcO ANC RECORbEb'1
Vii. l±~C~E C+~UNTY. FLA.'
_ 4+40069
'79 APR 6 AN I i : 7 •
EXHIBIT "A" ~ _
-
- - --.,.-~~..:s:-~.~...::.~-__.-__-_:,.. _ ~ ---~=>~•j..~~;a.~.~:::~-~11.~F1.~,.~1i~ i.'T ~JURT
I. EN_PLOYEE'S NAHE (?LEASE FRIt:T IN 6LOCK LETTERS IN 1xKl 4 • 2. SOCIAL SECURITY 3. DATE OF 614TH II
i ri:-S/~~ Its'is' l2_al wlooL[ /AITIAI 12ti1
i NO. I:a.aal
a. SEX
S. GATE Or= 6. BASIC ANNUAL 7. PRESENT OCCUPATION
ALE Er;1PLOYRt~NT SALARY~~
FEMALE c ~ - 5~'~•
8. C04nLET[ ONLY IF PLAN PAOYIJES OCPEMCENTS It:SU4At:CE
00 YOU 1tiSH TO IN_ SURE YOUR ELIGIBLE DEPENDENTS?
NO YES IF YES, IttDICATE GATE OF B:RfM OF WIF[/CUSBAN9-- -
9A. BENEFICIARY-TIIE R16NT TO CHANGE THE B~I:EFICIARY IS RESERYEO ` ;
- KAME Oi BEKEfIC1ARY tCwsr, ?ISSr, wloo~[ IIiIrIAU 9B. RELATIONSHIP - , $
ji 7 / •TO; MPLOTEE
-
- ERIPLOYEE•S STATEMENT OF HEALTH
10, HEI6MT - IFFY INCHES WEIGHT - lBS CHECK
11. HAVE YOU EYCR NAO /:FART TROD°LE, M.IGH BLWD PITESSURE, ALBUMIN 03 SUvAk IN YO{IR URINE, r[s xo ~r
TUDEP,CULOSIS. CANCER OR TUMORS OR ULCEkST f
12. ARE YOU HOW IN 6009 NEALTNd - I
t3.
HAVE YOU HAO ANY ILLNESS OR HAS A DOCTOR ATTENDED YOU DURING THE LAST S YEARSI I~
1{. ARE YOU ACTUALLY AT WOP.K FULL TIME IA MINIMUM OF 30 HOURS PER MEEK) AND FOR FULL PAY FOk TOVA -
EMPLOYERT
1E. f~
i IF TILE ANS'nER TO OV~STIOl1 12 IS k0 OR, 11 OR 13 IS YES, GIVE PRRTICULARS BELOW INDICATR~G NATO^nE, DATE,
DURATIO:1 OF ILLNESS A::D ATl[/:DIk6 RNYSICIA!/'S NAME AND ADDP,E~S-
~ ~ _ -
~
I -
i
4 ~ .F
I tE. 1 HEREBY REOV__°ST EROUP It:SURAKCE FOY RI'rSSli A.YD IF THE PLAN P?O/IOES'OEPEYQENTS 1::>U.TAt:CE, FOP. I.IY ~
0[PENQEtITS IfiDiCt--TED ABOYE A::O HEA£liY AUTHORIZE ?tt C~tiLOYER CA SUCCESSOi TO MAKE DED~:TIOYS FRO!.S IJ.Y j
[ARgINGS OF TNF P.EQjIP.EO CO:iTRIBUTIOtIS, IF I.NY. TO I.PPLY TC+~ARO THE PP.ENIUMS FOR THE ItISURA!ICE PAJVID.D ,
FCR 1[T THE POLICY OF iROUP INSURANCE ISS9ED TO MY ERI?COYER 8Y THE TRAYEL[RS INSURANCE C01?.?AKY. t~
1 N:REBY NEo(~C:-~!T /.!ID AGr2EE THAT ALL THE ANSWERS AYD STATE4l:fITS IN THIS REOJEST ARE FUL F
T%3~, 10 TH'_ BEsT OF MY Y.NOMrIfDGE AY.D D_LICF, AVD UIiDERSTA}D TIrAT THE SAID Ah57rERS AKD STATEI.:nNTS fOARt
iNE BASIS trPON WHICH IF:SUAAVCE YtllL 6!i 1/AOE EFF~CTIYE, '
EMPLOYEE'S /j -
III ,c • t ! Ci DATE / /
' t7~.ERIPLOYER'S n<.14E /7B.POLICY I:U)6EcR la-a 17t, REASON FOR REQUEST
L 11.6? 116-171 _ ~ 1~-'
1 .r NEW ENROLLI[ENT ~ - / • ` _ F
J / / ~ J CItA1:GE IH STA!US -
) _ ENDORSER?EIIT 6Y TFiF' TP.AVELEI:S IF:SURAt:CE COt~I.VANY =
r RC2JEST IS EFF[CTIYF DALE. pF IPSYCANCE lib•ial Ui-sbl AStT, OF [1P
} 1 ACCEPTED ' IOYEE LIFE It15. }7-eb-7c - -
J • ~ - ~ ~ Isassl
i AE1f:TED li I:OT AWAY iRJ!J. Y'Dit"/. D'JE TO OISA:ILITT, !B SA DT CL iY Ch ~
~ s
3 1 OTHEi.N!SE THE CAiE OF F:TU!rl Tp WCRC. S ! ` ~ i
1 -
Aril, prw.l. ca. :I-:E TRAVELr',RS ItISUFtLNCE CO.dPANY C
~ _
, , .
s t kE ~ -ict Yrrt:?rrf BT v- ~ O! T! ~ ~ i -t
OUEST FOIL GicOUr (NSUF:AKG£
t GI'~~7g-` NEM 12-7r, Pp.Ir.TEO Iti U.S,A, THE TkAVELERS INSURANCE COIr.PAt;y
i ~ -