Common Contracts
1 similar null contracts
ContractFebruary 15th, 2023
West VirginiaConsolidated Public Retirement Board (CPRB)601 57th Street SE, Suite 5Charleston, WV 25304304-558-3570 or 800-654-4406www.wvretirement.com Retired Public Safety Officer Insurance Carrier Agreement (ICA) Section 1: Insurance Carrier Information Instructions: The purpose of this form is to enroll as an insurance carrier in the Retired Public Safety Officers Insurance Payment Program for direct payment of insurance premiums as allowed under Internal Revenue Code Section 402(l) and WV Code § 5-10D-6a. Read “About the ICA Form” on page 2 before completing this form. Legal Name of Insurance Carrier Federal EIN Number Daytime Telephone Number Payment Mailing Address City State Zip Code Physical Location Address City State Zip Code Contact Name Contact Email Address Section 2: Terms of Agreement Between Insurance Carrier and CPRB • This agreement is between CPRB and the insurance carrier named above.• The insurance carrier, identified in Section 1, agrees to participate in the
