SMALL GROUP EMPLOYER APPLICATION
Wage-Based Benefit: 50% 60% 66 2/3% of Basic Weekly Wages to a Benefit Maximum of $ Flat Benefit: $50 $100 $150 $200 $250 not to exceed 66 2/3% of Basic Weekly Wages Class Defined Plan: Complete STD amount in Section I Benefits Begin: Due to an Accident: (select one) Due to Sickness: (select one) 1st day 8th day 15th day 31st day 8th day 15th ... ................
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