Group Dental / Vision Application (Page 2 of 2) in pdf

Please send Membership Materials and Enrollment Materials to (CHECK ONE):



Group Attn: _________________________________________________________Phone: (______)______________________



Broker or Agent

Under ERISA (Employee Retirement Income Security Act of 1974), it is required that there be a named fiduciary for each employee

benefit plan. It is understood that the undersigned Employer is the named fiduciary for each employee benefit plan.] [I understand and

agree if, on the effective date, an employee is not in permanent full-time active work or unable to perform usual and customary duties,

coverage will not be effective until the employee returns to an active eligible status]. I hereby certify that the information provided herein

is true and complete to the best of my knowledge and that I have read and understand this form.

The information contained herein describes the essential provisions of the elected coverage(s) discussed between the above client and

an authorized National Guardian Life Insurance Co. representative. By signing this form, both parties agree that these are the essential

provisions the client is purchasing. The details of this form may be changed by either party with mutual agreement.

WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Signed: __________________________________________________________________________________ _____/______/______

Name

Title

Date

National Guardian Representative __________________________________ FL Lic. No. _________________ _____/______/______

Date

[

Agent (if applicable)

Tax I.D. Number

Firm Name (if applicable)

National Guardian Life Insurance Company appointment on file

Address

National Guardian Life Insurance Company application

attached

City/State/Zip

Phone

Fax

Email Address

TO BE COMPLETED BY NATIONAL GUARDIAN LIFE INSURANCE COMPANY

Group Set Up Information

Account Management Approval

Account Manager:____________________

Signature____________________________

Date ______/_______/_______

Notes:

NVI/NDN GRP APP 04/06 FL

20060807

See reverse side

Group Dental / Vision Application Page 2