Form Gr 902 Ny - Application For Group Insurance Page 2
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313. Waiting Period
16. The following coverages are applied for:
Employee & Dependents Benefits
_____ for those employed on or before the policy effective
Dental
Orthodontia
Vision
date.
_____ for those employed after the new policy effective date.
Other ____________________________________________
month(s)
calendar days
working days
Employee Only Benefi ts
Dental
Orthodontia
Vision
14. Effective Date and Termination Date
Other ____________________________________________
Immediate
First of Month Effective date / End of Month Termination date
This insurance shall be effective on: _____________________
(Premiums due prior to the coverage period.)
Other ____________________________________________
17. Policy and Certifi cate Delivery (select one)
A. eCert*/ePolicy (*generic cert, non-personalized)
15. Premium Payment Mode (In advance)
via PDF format sent via e-mail to:
Monthly
Quarterly
Semi-Annual
Annual
Payroll Deduction (To choose this option, employee must
via eService and member portal
pay employee and dependent premium.)
B. Paper policy/personalized certifi cates
If policy effective date is other than first of
the month, is a first of the month premium
Initial employees only
due date desired? . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Subsequently added employees
Billing Options
Note: eCert will be available on member portal for all members.
Home Office
Third-Party Administration
18. Insurance requested on this application will replace the
coverage(s) checked.
Contact Name
Coverages:
Dental
Orthodontia
Vision
Other ____________________________________________
Title
Name of Current Carrier _______________________________
Street Address
Policy No. ___________________________________________
Coverage applied for is replacing comparable coverage
City / State / ZIP
now or previously in force with another carrier.
Phone No.
Fax No.
It is intended that the insurance coverage applied for be
in addition to, supplemented by, or supplemental to any
similar coverage now in force, or to be in force, with this or
E-mail Address
any other carrier.
Termination Date
Original Effective date
Item 6: Exclusions
a. Classes, include reason for exclusion.
b. Locations, if location is different from applicant’s, list city and state.
Item 7: Subsidiary and/or affi liated companies to be insured. List names and locations.
Plan Design and Proposed Rates: ___________________________________________________________________________________
Additional Remarks: ______________________________________________________________________________________________
GR 902 NY Rev. 1-09
Page 2 of 3
091911L
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