California OneAmerica Employer Implementation Package

Today's Date*

MonthDayYear
Date
Legal Business Name*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your Mailing address the same as you Physical Address?*

YesNo
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Nature of your business*
Date your Business was formed*

MonthDayYear
Date
Business Tax ID/EIN*
Is your business a (mark one):*

CorporationPartnershipLLCUnionOther
Has Applicant ever filed for bankruptcy, or will bankruptcy be filed within the next year?*

YesNo
Will Applicant cease or materially reduce active business operation within the next two (2) years?*

YesNo
Is Applicant's revenue dependent upon government contracts or private grants?*

YesNo
Please Explain*
Effective date of coverage requested (must be the first of the month selected)*

MonthDayYear
Date
Choose all that apply. Please choose plans selected:*

Employer Sponsored Short Term DisabilityEmployer Sponsored Long Term DisabilityEmployer Sponsored Lump Sum Long Term DisabilityEmployer Paid Life with AD&D
International Employees: Will ALL eligible Employees be working or residing inside the United States?*

YesNo
Are there any Eligible Employees working and/or residing in CA, HI, NJ, NY, RI, or PR?*

YesNo
If YES, Please indicate below the state, number of Eligible Employees in that state, and number currently insured under the state mandated disability plan: *
Life Insurance New Hire Waiting Period*

0 Calendar Days30 Calendar Days60 Calendar Days90 Calendar Days
Disability New Hire Waiting Period*

0 Calendar Days30 Calendar Days60 Calendar Days90 Calendar Days
Your Agent's Name:*
Name of Person Filling out this Form*
Title of Person Filling out this Form*
Email Address:*
Signature*

Clear