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GGFM-ER-8514 Maxwell Health Employer Information Form 02/24 <br /> Life insurance, continued <br />C.Actively at Work: <br />Are all employees Actively at Work (as defined in the applicable Certificate) on the policy effective date that are <br />normally insured? ..................................................................................................................................... Yes No <br />Identifying employees who are not at work on the eligibility date helps us prevent any coverage issues before they <br />occur. <br />Please advise if there are any special agreements or amendments to the prior carrier contract and if any <br />employees are: <br />•On workers’ compensation •Eligible to convert <br />•Partially disabled •Grandfathered or retired <br />Please use the space provided to list those employees who are not at work on the eligibility date. This is for life <br />insurance only. Note: Group life benefit in-force amount includes basic and optional/voluntary life coverage amounts. <br />Employee <br />name <br />Date of <br />birth <br />Last <br />day <br />worked <br />Reason (ie. <br />Disability, <br />FMLA, Leave of <br />Absence, <br />Maternity <br />Leave, etc.) <br />Group <br />life <br />benefit <br />in force <br />Voluntary <br />life <br />benefit <br />in force <br />Expected <br />return-to- <br />work date <br />On <br />continuation <br />with premium <br />Waiver claim <br />filed? <br /> Yes No Yes No <br /> Yes No Yes No <br /> Yes No Yes No <br /> Yes No Yes No <br />If you selected yes to any of the above, please complete the questions below for each employee affected. If you require <br />more space you may provide a spreadsheet with the information for each employee. <br />If a waiver claim was filed, please indicate the name of the employee and the prior carrier’s decision. <br />If no waiver claim was filed, please indicate the name of the employee and what the Waiting Period is for filing a Waiver <br />of Premium claim. <br />Please note: Employees who are not Actively at Work on the effective date can be covered only under the Continuity of <br />Coverage provision. Continuity of Coverage is not available to employees who are eligible for or receiving benefits <br />(including Waiver of Premium) under another group insurance provision in the policy. The prior carrier contract also helps <br />determine coverage intent when transitioning to your new group policy. FAILURE TO IDENTIFY THESE EMPLOYEES <br />AND TO FILE FOR WAIVER OF PREMIUM WITH THE PRIOR CARRIER MAY RESULT IN A LOSS OF COVERAGE <br />FOR THEM. <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />X