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Additional Entities/Locations to be covered <br />Name <br />Address <br />Federal ID # Unemployment Insurance # <br />Name <br />Address <br />Federal ID # Unemployment Insurance # <br />*** If the number of additional entities exceeds space provided above, attach all additional information required on a separate piece of paper.*** <br />Paid Family and Medical Leave Benefits <br />Statutory Benefits <br />1x Benefit <br />Billing <br />Quarterly Billing in Arrears <br />Authorization <br />No one except the Chief Executive Officer, a Vice President or the Secretary of S HELTER P OINT L IFE I NSURANCE C OMPANY may make or modify <br />HELTER P OINT L IFE I NSURANCE C OMPANY. Any change or amendment to the policy shall be signed by S HELTER P OINT L IFE <br />any contract on behalf of S <br />I NSURANCE C OMPANY and the policyholder. <br />Applicant: Date ______________ Name _____________________________________ Title __________________________ <br />Signature __________________________ <br />AllanRoth <br />Producer: Date ______________ Name _____________________________________ Title __________________________ <br />A.T.Group,LLC <br />Agency Name ____________________________________________________________ Agency # __________________________ <br />Agency Address __________________________________________________________ Phone # ___________________________ <br />Policy #: Effective: Payroll Rate: <br />SPL PFML A 2 02 <br />81 <br /> <br />