Small Business Participating Employer Agreement Sample Contracts
SMALL BUSINESS PARTICIPATING EMPLOYER AGREEMENTSmall Business Participating Employer Agreement • February 20th, 2007
By completing this Small Business Participating Employer Agreement (the “Agreement”), the Proposed Participating Employer (“Employer,” “You” or “Your”) named below requests participation in the Group Benefits Insurance Trust for Employers in General Services Industries (“Trust”) for insurance coverage issued under one or more insurance policies (“Policy” or “Policies”) issued to the Manufacturers and Traders Trust Company, located at 1350 I Street, NW, Suite 200, Washington, DC 20005, as Trustee. The Policiesare issued by Hartford Life and Accident Insurance Company (“We”, “Our”, or “Us”). CUSTOMER NUMBER(S): EMPLOYER INFORMATION: Enter information exactly as it should appear in the certificate. Full legal name of Employer: Address: Street and number City State Zip County Contact: □ Mr. □ Ms. Last First Phone: ( ) Fax: ( ) Federal Tax ID Number: E-mail: Coverage Requested: The proposed insurance coverage(s) is/are those You elected in the Proposal of Employee Benefits (the “Proposa