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<br />tMPLOYEES At,D OWNERS NOT ..3,CCOUNTED FOR m. QUARTERLY \^,1AGE ;'.JC CETAIL. R~PORT
<br />
<br />Please use 1IIi5 space to aanmt for Ef11lIovees awl 0IIlners NOT irdJded on lie Mnnesota SfaIe E.mpklyer's 0u00erly Wage ;;md DefaD Report
<br />(Form WES-1O). Adcitional dowmentcmn may be required reganing OYlOOlS. ,
<br />
<br />EMPlOYEE I OWNE~ NAriIE
<br />
<br />SOGI,'" fECUi~l1Y NI.JI.eER
<br />
<br />HIRE DAn:
<br />
<br />TERMlNAllQN DATE
<br />
<br />#- OF HOURS WORKED
<br />
<br />--~'-'~ . - I
<br />,.\)0 i;\G
<br /> , -- ---~
<br /> ~- -,~-
<br /> -
<br />" .. .....~~~-
<br />
<br />FOR~,ER EtlPl..O'r'::ES E,'JROL.LED \VITH C06~':: COVERAGE
<br />
<br />Please use Ulis space to accooot for JonMr ~Ioyees 00Vlmld by COBRA conlinuaion. Indicala eIher 1he notification dale If the Individuol is cwrenIIy
<br />UJ1der COBRA or the ca'lCeIIation date if SI indiIrict.Ia's COBRA ~ is \'lrminatitg. EmpIopers must.. cornpIelc the SolaR Employer
<br />VerIk:atIon of Tennlnated Employees fonn (1*400016).
<br />
<br />"",
<br />
<br />FORMER EMPIOVf:E. NAME
<br />
<br />SOClfo.L SECURITY NlMlER
<br />
<br />NOilFlCATION DAlE
<br />
<br />COBRA. TERMINA110N DATE
<br />
<br /> '-.-
<br /> f )/'l'.'U:'.
<br /> I"' .- .-'.--
<br />~----..'" -- ---- '-. _.__~~_~~_L
<br />.---- ...-...--
<br />
<br />
<br />CUlrent MEDlCA.L Insurance Carrier ~ ~'fP
<br />PIeasa Ii!lt AlL medi31 mnieJs forlhe pevilus 5 years {If ~ a/l8dJ ackJI/i:JnrJ Jl89f'.s):
<br />NMIE OF~ RBEl."-'lDATE DATES OF CllVERAGE
<br />---, -_--(""', I. /' - /-' .-.-);..)7. E-= - -~".o-~::
<br />~t:."~~.__' ..' ,- -= -- .,--
<br />
<br />Ral6WaI Rates: ___._.~Slnglo FaMIly ReneWBI Plan (product) Name:.
<br />ClI'mIlt DENTAllnsunnce CalTler Renewal Dme
<br />
<br />INDJVQJAL
<br />
<br />~'lON FCR TBWINA110N
<br />
<br />AGE'-JT J 8ROKn NFORr.1ATION
<br />
<br />Agent Name i~ jf ti.ri T. f~ c,'-I/\
<br />
<br />._~, ~- .-)... ; ~ 9" "~UJ :'\
<br />Addr J.- (I I"") ,. ,. ...~ . ~ I. ......_;,
<br />ess r'.... '., ~. 1'.. I "_ IV .,,1
<br />,; ," . ." ...... ._ ~.- t. ~- .,..~. -.-r- It"' f,
<br />C"dy, Stale, ZIP _ tv; 1,:1; ;..f!~:'i';I'.\ .1"l: ~ ~.) '-l'T .r
<br />
<br />email Mfmss/'lt f. l' {).-tj jji: :.1.--' ,~(,'({1:1'{p-.,.-t''k?''_~
<br />-",/,.' /:, _0"-- /f"-:...:..,/..." --f' //.'. ~J
<br />~_..,..<;""1-:?7',I . _~---'-". ._---L!5://:..;/~_ '1-0...
<br />~ iiJ'Reiltr.iI signature~- /.:=..... PiWed Nalr.e liRd
<br />(if appIil:aIJI.~)
<br />
<br />Phone "",1 ,,~~ . 7';-~-j .. f:Jtl.f
<br />I.'" -'r2' ? U' ,
<br />Fax ~\!."(:J. -0. J --' '.f - "-Nl'~:- ..,.~.)
<br />G .-, '"K
<br />Broker Number .._0, .... {;/, . , _
<br />
<br />A. ,r" .-1
<br />~__:;;:'L._t-?ro.J.lp._ ..
<br />
<br />.)t Il ;.~-:
<br />/ tie"\. 'f.t..
<br />o*'
<br />
<br />EMPL8Y:R SIGNATURE
<br />
<br />I hereby certify that Ihe information provided In this document, and any additional information submitted b support this application, is
<br />accurate and complete.
<br />
<br />I understand that errors or omissions regarding this information may resaJt in premium adjustments and/or terminatioR of the OOIltract
<br />as permit AY Minnesota law. \ i ( .. ,L" ~'l ,
<br />. ----JCJ\.V- '--'U - v-\.~ <'V' 0 \, o=z
<br />.' -- - ~G- Jtaoo 0"._"-- ~
<br />r.~~~ ~ .
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