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unstructuredio
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SCORE-Bench

Dataset card Data Studio Files
xet
Community
2
text
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2.18k
Zip Code
85268
Original Date of Hire
06/28/
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Annual Salary
$ , 95,000
[] Exempt
[] Non-Exempt
Occupation
REGULATORY
Date entered into an eligible class
[] Date entered into an eligible class (ex: part time to full time) or
[] Rehire Date or
[] Date of promotion to an eligible class
__/__/____
Spouse First Name (if coverage is selected)
____________
Spouse Date of Birth (mm/dd/yyyy)
__/__/____
COVERAGE ELECTIONS: Your employer will inform you of available coverage. Check yes to enroll; check no if you decline or coverage is not available.
Life/AD&D [] Yes [] No Dependent Life [] Yes [] No LTD [] Yes [] No STD [] Yes [] No
AMOUNT OF COVERAGE SELECTED FOR:
LIFE/AD&D
You: $ _,___,___ Spouse: $ _,___,___ Child: $ __,___
Note: If you have chosen coverage over the Guarantee Issue amount for you or your spouse, you will also need to complete an Evidence of Insurability form. The amount of coverage over your Guarantee Issue amount will be subject to medical underwriting and will become effective upon approval either on the first of the month coincident with or next following the date Unum approves your Evidence of Insurability form. If you DO NOT APPLY FOR coverage for you or your dependent (s) during your or their initial enrollment period, you will need to complete an Evidence of Insurability form for all amounts of coverage. You may complete and electronically submit an Evidence of Insurability form—please see your Plan Administrator.
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Beneficiary Information:
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Name (last name, first, middle initial):
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If
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t then pay:
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Relation to You:
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Benefit %: 100 100
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Request for Signature and Certification: I understand that my coverage may be subject to exclusions, limitations, delayed effective dates and benefit offsets, as described in the enrollment materials or employee booklet(s) that have been provided to me by my employer. I certify that all statements are true to the best of my knowledge and belief and I understand that a copy of this form will be made available to me at my request. I authorize my employer to make the necessary deductions from my salary or wages to
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becomes effective. I understand that my payroll deduction amount will change if my cover- ag
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Em
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Date
___
Work Phone
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Home Phone
Un rand of Unum Group and its insuring subsidiaries.
1268-03 (01/08) RETAIN A COPY OF THIS FORM FOR YOUR RECORDS AND SEND A COPY TO YOUR EMPLOYER
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CONFIDENTIAL - SUBJECT TO PROTECTIVE ORDER
CONFIDENTIAL PROTECTED HEALTH INFORMATION
INSYS-MDL-011718235
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Source: https://www.industrydocuments.ucsf.edu/docs/sydd0278
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IMPACT ON LOCAL SYSTEMS
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02
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Myth