THE CAPCORP PLANNING (2003) INC.
MULTI-EMPLOYER HEALTH AND WELFARE PLAN
, hereafter referred to as the "Participating Employee", desires to participate in HealthPlus, the CAPCORP Planning (2003) Inc. Multi-Employer Health and Welfare Plan ("Plan"), and
hereafter referred to as the "Participating Employer", also agrees to participate in the Plan.
ACCORDINGLY, the undersigned agree that:
The Participating Employee shall be entitled to benefits according to the schedule below.
The Participating Employee acknowledges that if he or she submits any claims
related to medical conditions that were pre-existing at the time of enrollment
in the Plan, the Participating Employer can elect not to fund such claims.
Eligible claimants in the Participant's household are (attach second page if necessary):
The Participating Employer shall make the contributions to the Plan that are
required from time to time by the Trustee.
The Administrator shall be entitled to rely exclusively on the accuracy
of any invoice submitted by a Participating Employer.
All contributions made pursuant to the Plan shall be held in a Trust
established pursuant to the Plan. Should the Participating Employer
not pay the amount required by the Trustee hereunder, the benefits
payable under the Plan to the Participating Employee shall be reduced
by the amount of the Participating Employer's obligation that is outstanding.
The Participating Employer may terminate its participation in the
Plan in respect of this Participating Employee at any time on
condition that it has paid the Trustee all amounts that have been
invoiced to the Participating Employer up to the date that the
Participating Employer's termination of participation is communicated
to the Administrator. A Participating Employer's decision to terminate
its participation in respect of this Participating Employee has no
bearing on its participation in respect of any other Participating
Employee, if any exist.
The Participating Employee is not eligible for benefits under this
Plan until the Participating Employee is accepted by the Administrator
as such. This acceptance is evidenced by the signature and date affixed
hereto by an authorized representative of the Administrator.
The Participating Employee shall cease to be covered for any or all of
the benefits set forth in this Plan on the earlier of the:
||date the Participating Employee ceases to be an Employee of a
Participating Employer, or
||date on which the Participating Employee communicates a desire to
terminate benefits under the Plan, or
||date on which the Participating Employer communicates a desire to
terminate responsibility for funding the benefits in respect of the
Participating Employee, or
||termination of the Plan.
Neither the Participating Employee nor the Participating Employer have
any other rights to the assets in the Plan other than those identified herein.
The Participating Employee and Participating Employer have each been
given an opportunity to review The CAPCORP Planning (2003) Inc.
Multi-Employer Health And Welfare Plan and each hereby consents to
all terms and conditions thereof.
IN WITNESS WHEREOF
this Participation Agreement has been executed:
By the Participating Employee:
On behalf of the Participating Employer:
On behalf of the Administrator, CAPCORP Planning (2003) Inc:
** Please note that the originals must be mailed in. **