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10/01/1987 Agreement APPLICATION for Group Insurance to SUN LIFE RANCE CONgpreNY OF CANADA U.S. Headq rtes, Wellesley Hills, Ma. 02181 (1 FULL LEGAL NAME Y ❑ Corporation Board of County Commissioners, "-'Monroe County ❑ Partnership ❑ Proprietorship Location Key West, Florida `33040 ® Municipality ❑ School Board Nature of Business Municipal Entity ❑ specify 2 SUBSIDIARIES OR AFFILIATES to be included Full Legal Name Relationship Location Nature of Business No. of Ees 3 EMPLOYEES to be insured — Persons employed on a permanent full -time basis (minimum workweek of 30 hours) Specify any categories to be excluded from insurance • On this basis, how many employees would be eligible to enroll for the insurance? 900 4 WAITING PERIOD (before an employee can become insured) 60 days month(sl•of continuous employment. Is the same waiting period applicable, for all benefits requested, to those employees eligible on the effective date? ❑ No ® Yes (if "no" is checked, complete details must be supplied by Yie:applicant) 5 EFFECTIVE DATE Subject to 8 below, insurance on those benefits to which the employees are not required, to contribute takes effect on the effective date. Subject to 8 below, insurance on those benefits to which the employees are required to contribute takes effect on the effective date provided notice in writing, of the names of the employees who have agreed to participate, is received by Sun: Life within one month after such date and the number of participating employees is at least % of those eligible at the effective date. The effective date is October 1 19 8 7 6 OTHER INSURANCE Will any of the benefits under this plan for any class of employees: (a) replace similar benefits under another plan? Et No ❑ Yes cancelled 19 (show last day benefits in effect) (b) supplement similar benefits under another plan? [t No ❑ Yes Benefits Name of other carrier in (a) in (b) 7 INSURANCE BENEFITS REQUESTED For Employees For Dependents ❑ Life ❑ Weekly Indemnity ❑ Life ❑ A.D. &D. ❑ Long Term Disability • © Dental ® Dental ❑ ❑ Are any benefits union negotiated? ® No ❑ Yes (Supply copy of agreement) 8 CONDITIONS OF COVER The Applicant hereby agrees that no insurance shall be considered in effect under this Application unless he agrees (a) to forward immediately to Sun Life on forms supplied by Sun Life all particulars required for the issuance of the policy or policies and to accept such policy or policies when issued by Sun Life, (b) to pay the balance (if any) of the first premium thereon, and (c) that any insurance granted in consideration of the amount paid with this application shall be in accordance with the terms and conditions of the policy or policies which may be issued, and shall cease at the expiration of one month from the effective date, or upon notice by Sun Life of the prior rejection of the application. The Applicant represents that all the companies included under the policy issued pursuant to this application have agreed to be included. AM UNTPAIDWITHTHISAPPLICATION$ -12,468.76 Board o County Co l«issioners, Monroe r A &las F7 0 17 ( ul •al Name) Coun / i ( • and • of S • n Oa. �! s (Authorized Signature) 4 Countersigned by not re • - . / 41, / CMA,&4.4 a f �' (Licensed Resident Agent when required by law) (Title) GR 77 P-A (3M- 12 -86) 47717