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024 <br />Reliance Standard Life <br />Insurance Company <br />PRELIMINARY APPLICATION FOR GROUP INSURANCE <br />1. Prospective Policyholder: Lee County Government <br />(Exact Legal Name) <br />2. Federal Employer Identification Number: 56- 6000313 <br />3. Complete address: 408 Summit Drive Santord NC Eee <br />(Street Address) (City and State) (County) (Zip Code) <br />Executive Correspondent Toyse McGehee Title Hr Director Phone 919- 718 -4615 <br />Routine Correspondent Amanda Hart Title Personnel Assistant Phone q j q 7Ig -4615 <br />Mailing Address (If different) PO Box <br />4. Nature of business: (If Association: purpose, when formed) Local Government <br />5. The prospective policyholder is a _ corporation, _ partnership, _ proprietorship, _ union, <br />_association, _other (specify) Government <br />6. INDICATE AFFILIATES OR SUBSIDIARIES TO BE COVERED, IF ANY: <br />(Include divisions only if all are not to be included) <br />Name and Location <br />Nature of <br />Relationship <br />Nature of <br />Business <br />No. of Employees <br />by Coverage <br />Life <br />AD &D <br />WI <br />LTD <br />VAR <br />STOP <br />LOSS <br />Other <br />7. POLICY TO BE ISSUED IN THE STATE OF: NC 8. Requested Effective Date: _ u ,gt 1, 2015 <br />(If other than state of Applicant's main office, explain in REMARKS) (Month) (Day) (Year) <br />9. COVERAGES APPLIED FOR: X Life, XAD &D, _Wl, _LTD, _VAR, _STOP LOSS, Other Life <br />10. Is any group insurance now in force or currently being applied for on the Proposed Insureds ? no <br />If yes, (A) Indicate in Remarks: name of carrier; type of coverage; effective date; brief benefit description; <br />eligibility; etc. <br />(B) Provide prior experience, including premiums and incurred claims(or paid claims and claim reserves at <br />start and end of period.) <br />11. Is it proposed to terminate or change any existing group insurance coverage? —X y es _no <br />If yes, indicate in REMARKS: name of carrier; type of coverage, and date of termination, or date and type of change. <br />[12. Are all Proposed Insureds actively at work? _ yes _no If not, please list the following for employees not <br />actively at work: <br />NAME DATE OF BIRTH LAST DAY WORKED FACE AMOUNT REASON FOR ABSENCE 1 <br />REMARKS: <br />This Preliminary Application is subject to the acceptance and approval in writing by Reliance Standard Life Insurance <br />Company at the Administrative Offices in Philadelphia, Pennsylvania; and nothing contained herein shall be binding upon <br />said Company until this Preliminary Application is so approved. $ been paid herewith. It will be applied toward <br />the first premium due on the policy or policies if any be issued. Such issuance is subject to the: terms; conditions; <br />limitations; and exceptions of the policy or policies if any be issued. <br />Name of Agent or Broker of Record (print or type) Share <br />Mark Rrnwder 1 nn % <br />Print or type name of Broker's firm, if applicable <br />Mark III Brok erage, Inc. <br />by <br />(authorized signature) (Title) <br />LRS- 8209 -1088 <br />by <br />(authorized signature) <br />Chair, Lee Board of County Co mmissioners <br />(title or position with Applicant) <br />Dated at <br />Date <br />Group <br />Agency Office <br />