Delta Dental Ppo Application Form Instructions (Page 3 of 6) in pdf

CALIFORNIA EMPLOYERS ALLIANCE

29379 OLD WRANGLER RD CANYON LAKE, CA 92587

UNITED INDUSTRIAL & SERVICE WORKERS OF AMERICA

WELFARE BENEFITS TRUST FUND

AND

BARGAINING UNIT AGENCY PARTICIPATION IN

UNITED INDUSTRIAL & SERVICE WORKERS OF AMERICA

PLAN SPONSOR_________________________________CONTACT PERSON____________________

SPONSOR'S ADDRESS__________________________________________________________________

CITY, STATE, ZIP CODE________________________________________________________________

PHONE:______________________________________FAX:____________________________________

TYPE OF BUSINESS:___________________________NUMBER OF YEARS IN BUSINESS:_________

EMAIL:_______________________________________________NUMBER OF EMPLOYEES:________

I hereby apply for membership in the California Employers Alliance. As an owner/partner of the above named

business, I am applying for benefit programs made available through the California Employers Alliance at this time. It

is understood that acceptance as a member in the California Employers Alliance does not provide for automatic

acceptance for medical benefits. Under federal law participation in the California Employers Alliance and the United

Industrial & Service Workers of America Welfare Benefit Trust Fund program is subject to written guidelines and

approval by its Board of Trustees.

I hereby acknowledge that health care benefits are made available to us under a “Taft-Hartley” trust in a collective

bargaining agreement between the California Employers Alliance and the United Industrial & Service Workers of

America. If this business elects to participate in the health care benefits, through membership in the California

Employers Alliance, this business agrees to become signatory to that collective bargaining agreement. Referenced

collective bargaining agreement is held at the office of California Employer Alliance for inspection during normal

business hours and a copy will be made available for valid business purposes.

I also acknowledge and agree that a portion of the allowed benefit contribution includes California Employers Alliance

membership dues (if any) and any other fee for each employee participating in the benefit programs. The total amount

stated for the selected program includes all premiums, dues, fees, and administration charges.

I understand that each employee who participates in the health program under the collective bargaining agreement must

comply with the union security clause of that agreement by fulfilling employee dues obligations.

I understand that the benefit contributions are invoiced and payable in advance of the coverage period. If payment is

not received at least five (5) days prior to the next coverage period, benefits may be cancelled at the end of the period in

effect.

PLAN SPONSOR:

DATE

UNION REPRESENTATIVE:

DATE

Broker: Michael Grodsky

Aquarius Insurance Services

3834 Roxton Ave. Los Angeles, CA 90008

CA Insurance license 0F43491

phone: 323-293-6800

Delta Dental Ppo Application Form Instructions Page 3