Aaron Castro TX ASSURITY MASTER APPLICATION 5/01/2023

ASSURITY MASTER APPLICATION TEXAS

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Company/Group Name*
Tax ID or EIN*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Group Contact - Name*
Group Contact - Title*
Contact Phone Number*
Contact email address*
What is the group's industry?*
How many eligible employees are there?*
Minimum of 3 needed on this form
Requested Effective Date of Insurance*

MonthDayYear
Date
Beginning of this year's enrollment period*

MonthDayYear
Date
End of this year's enrollment period*

MonthDayYear
Date
What is the payroll deduction frequency for benefits?

Weekly (52)BiWeekly (26)Semi-Monthly (24)Monthly (12)
Today's Date*

MonthDayYear
Date
GroupCompany Representative's Title*
Group/Company Representative's Signature*

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ASSURITY MASTER APPLICATION TEXAS