New Customer Agreement

ALL portions of this New Account Agreement must be complete and accurate or your Agreement will not be accepted by the issuing company

New Customer Agreement

Antik LLC will use this General New Account Agreement with its appointed and affiliated insurance providers

1) Account Profile

* Indicates required field

Company Legal Name *

Situs State *

SIC Code *

Federal Tax ID *

Nature of Business *

Years in Business *

Responsible Office *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Administrative Contact *

First

Last

Phone Number *

Email *

2) Proposed Insureds

# of employees eligible for coverage *

Any employee class EXCLUDED from eligibility? *

New Hire Waiting Period *

0 Days 30 Days 90 Days

Eligible Employees Are: *

Full Time Benefit Eligible Part Time Employee (Over 30hr/week) Part Time Employee (Over 20hr/week)

Allow to apply? *

Spouse/Domestic Partner Dependants over 18

My Sales Representative *

3) Employer Agreement and Disclosure

-Upon approval, the account holder (your company) agrees to establish a voluntary insurance program for the benefit of it's employees/members. For each employee/member who executes a payroll deduction request, we will withhold the amount authorized. We will forward this money to the issuing provider upon notice of the premium due from each employee/member.
-We may, upon written notice, discontinue our participation in this month-to-month insurance program. In such event, the continued payment of premiums will be a matter directly between each employee/member and the issuing provider.
-We assume no responsibility for forwarding premiums from anyone other than current employees/members.
-We understand that the provider does not disclose personal information about the employees/members to companies/organizations not affiliated with the insurance provider.
-For group insurance coverage, we may receive paper versions of the certificates and accompanying notices. However, we instead request that we receive electronic delivery, where applicable.

I agree to the above *

Agree

Authorized Representative (Name) *

Date - mm/dd/yyyy *

Submit

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New Customer Agreement

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