Common Contracts
2 similar Trust Participation Agreement contracts
Employer Trust Participation AgreementTrust Participation Agreement • September 23rd, 2015
Entity - Employer Information: Entity Name: Street Address: City, State, Zip: County: Telephone#: ( ) _ Executive Contact: Email Address: Entity Type: Proprietorship (Schedule C or Occ. Lic.) Corporation (Business License)Government (Letter) Partnership/LLC (Form 1065)Union (Letter) Non-Profit/Religious (Letter) All applying entities must attach the requested letter or document when initially applying for coverage. Seniors Choice Coverage Information: Requested Effective Date (1st day of the month): Total number of full-time and part-time employees: Total number of retirees 65 or over with Medicare Parts A and B: Have you employed 20 or more full-time or part-time employees,20 or more weeks in the current or previous calendar year? Yes No(If yes, active employees eligible for the employer sponsored group health plan are not eligible for Seniors Choice) Seniors Choice Plan Selection: Medical & Prescription Medical Only Prescription OnlyMedical Plan Selection:$0 Deductible Plan $500 Ded
Employer Trust Participation AgreementTrust Participation Agreement • September 23rd, 2015
Entity - Employer Information: Entity Name: Street Address: City, State, Zip: County: Telephone#: ( ) _ Executive Contact: Email Address: Entity Type: Proprietorship (Schedule C or Occ. Lic.) Corporation (Business License)Government (Letter) Partnership/LLC (Form 1065)Union (Letter) Non-Profit/Religious (Letter) All applying entities must attach the requested letter or document when initially applying for coverage. Seniors Choice Coverage Information: Requested Effective Date (1st day of the month): Total number of full-time and part-time employees: Total number of retirees 65 or over with Medicare Parts A and B: Have you employed 20 or more full-time or part-time employees,20 or more weeks in the current or previous calendar year? Yes No(If yes, active employees eligible for the employer sponsored group health plan are not eligible for Seniors Choice) Seniors Choice Plan Selection: Medical & Prescription Medical Only Prescription OnlyMedical Plan Selection:$0 Deductible Plan $500 Ded
