Form Gr 902 Ny - Application For Group Insurance
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3RESET FORM
application
for group insurance
See reverse side for additional information.
New York, NY
1. Applicant’s legal name ________________________________________________________________________________________
2. Doing business as _____________________________________________________________________________________________
3.
10. Dependent Participation:
Employer contributes ______% of dependent premium.
P.O. Box / ZIP Code
Tied-to-Medical (All eligible dependents covered on
employer’s medical plan must be insured, except those
Street Address
listed under excluded classes or locations.)
Non-Contributory (Policyholder contributes 100% of
City / State / ZIP
premiums. All eligible dependents must be insured,
except those listed under excluded classes or locations.)
Contributory (Policyholder is required to contribute to the
Phone No.
Fax No.
employee premium and must contribute at least 25% of
the total employee and dependent premium.)
E-mail Address
Tax I.D. No.
Voluntary (Policyholder does not contribute toward
4. What is the nature of your business or industry?
premium, 100% contribution by employee.)
11. Section 125 Plan
Election Period _______________________________________
Plan Year ___________________________________________
5. Eligibility
Total Number of Eligible Employees . . . . . . . . . . ___________
12. Employee welfare benefi t plans that are subject to ERISA must
satisfy various reporting, disclosure and related obligations.
Employees in Waiting Period . . . . . . . . . . . . . . . ___________
These require ments include the provisioning of a Summary
6. Are any classes or locations excluded? . . . . . . .
Yes
No
Plan Description or SPD. The certifi cate of coverage can serve
as an SPD if certain information is additionally disclosed. Please
Are domestic partners included? . . . . . . . . . . . .
Yes
No
check one of the following (failure to respond shall be consid-
Are retirees included? . . . . . . . . . . . . . . . . . . . .
Yes
No
ered a positive response for A. and a negative response for B.).
(If yes, please use reverse side for explanation.)
A.
Plan is subject to ERISA (complete question 12.B.)
7. Are any subsidiary and/or affi liated
Plan is NOT subject to ERISA — Church or Govt.
companies to be insured? . . . . . . . . . . . . . . . . .
Yes
No
employer or other safe-harbor exception
(If yes, please use reverse side to list name and location.)
(see DOL Reg. §2510.3-1(j))
8. How many hours per week
B.
Applicant requests that Ameritas Life Insurance
equals full time employment? . . . . . . . . . . . . . ___________
Corp. of New York prepare a SPD for its dental
and/or vision plan . . . . . . . . . . . . . . . . . .
Yes
No
9. Employee Participation
If yes, the company is to prepare a SPD. The following
Employer contributes ______% of employee premium.
information is required under ERISA and MUST be
included in the SPD.
Tied-to-Medical (All employees covered on employer’s
medical plan must be insured, except those listed under
Plan No. _________ Plan Fiscal Year End Date________
excluded classes or locations.)
Plan Administrator:
Non-Contributory (Policyholder contributes 100% of
Name: ________________________________________
premiums. All employees must be insured, except those
listed under excluded classes or locations.)
Address: ______________________________________
Contributory (Policyholder is required to contribute to the
City, State, ZIP _________________________________
employee premium and must contribute at least 25% of
Phone No._______________ Plan Fiscal Year_______
the total employee and dependent premium.)
Please Note: Applicant remains responsible for ensuring
Voluntary (Policyholder does not contribute towards
that SPD form provided by Ameritas Life Insurance
premium, 100% contribution by employee.)
Corp. of New York is complete and accurate and
satisfies applicable laws and regulations. Moreover,
applicant remains responsible for providing its plan
participants with SPD updates as required by appli-
cable law and regulations.
GR 902 NY Rev. 1-09
Page 1 of 3
091911L
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