DMO Sample Clauses

DMO. Option 3 Freedom-of-Choice Option 4 PPO Max Option 5 Active PPO – High Option Option 6 Passive PPO 1500 Option 7 Consumer Directed Dental Fund Voluntary Plans: Option V2 DMO Option V3 Freedom-of-Choice Option V4 PPO Max Option V7 Consumer Directed Contributory Out-of-State PPO Plan (if applicable): Low Option Medium Option Voluntary Out-of-State PPO Plan (if applicable): Low Option Life, Accidental Death & Dismemberment, & Disability Coverage Selections Groups with 10 to 50 eligible employees may select one, two or three options for Life, Accidental Death & Dismemberment and Disability, with a minimum requirement of three employees in each option. If more than one option is selected, describe each class of employees, indicate the amount selected for each class and attach a list of employee‌ names with each class designation. (Limited to 3 classes. The highest option selected can be no more than 5 times the lowest option.) Class 1 Class 2 Class 3 All Groups Life & Disability Life & Disability Life & Disability Life or Packaged Plan Life or Packaged Plan Life or Packaged Plan $10,000 $15,000 $20,000 $50,000 Low Medium High $10,000 $15,000 $20,000 $50,000 Low Medium High $10,000 $15,000 $20,000 $50,000 Low Medium High Additional options for Groups with 10 – 50 eligible employees $75,000 $100,000 $125,000 $75,000 $100,000 $125,000 $75,000 $100,000 $125,000 Class Description Optional Dependent Term Life (Available only to groups with 10 to 50 eligible employees.) Yes No Please keep a copy of this application for your records. If the application is accepted by Aetna it becomes part of the issued Group Agreement and/or Group Policy. Effective DateActual effective date will be assigned by the Aetna underwriting department if application is approved. Requested effective date (may be the 1st or 15th of the month only): Group Ownership Information – OPTIONAL (This information is designed for the purposes of data collection and will not be used for underwriting.) Check one or both if applicable: Woman Owned Business Minority Owned Business (indicate status below): African American or Black Hispanic or Latino Asian Other Business Eligibility Is your company a subsidiary of another company, an affiliate of another company, or under common control with another company? Yes No Does your company file state or federal taxes with any other company(ies) on a combined or consolidated basis? Yes No If Yes is checked for any of the above questions, complete and submit Aetna’s As...
Sample 1
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