employer_sub_agreement

UNITARIAN UNIVERSALIST ORGANIZATIONS

Subscription Agreement for Employers
Name of the Congregation*
Tax ID*
EIN
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
The Unitarian Universalist Association has established and maintains the Unitarian Universalist Association Employee Benefits Trust (the “Trust”), which provides benefits under the Unitarian Universalist Organizations Health Plan (the “Plan”). By signing this agreement, you are subscribing to and agreeing to the terms of the Plan and the Trust and you become a “Subscribing Employer.” As a Subscribing Employer you may enroll Eligible Employees, Eligible Retirees and their Dependents (as those terms are defined in the Plan and the Trust), subject to the specific elections below.
PLAN DESIGN The Subscribing Employer elects to offer (check all that apply):

Standard PPO benefits - GoldHigh deductible PPO benefits - SilverHigh deductible PPO benefits - BronzeMedicare Supplement benefitsDental/VisionLife InsuranceLong Term Disability
COVERAGE EFFECTIVE DATEThe Subscribing Employer elects to make coverage effective on (check one):

Date of hireFirst day of the month following date of hireFirst day of the month following a 30-day waiting periodFirst day of the month following a 60-day waiting period90-day waiting period
EMPLOYEE ELIGIBILITY Our congregation understands that all eligible employees must be offered coverage, though we may contribute different amounts for different employee premiums. We agree to keep records of employee elections and have them available for audit.

Agree
The Subscribing Employer elects to contribute of the monthly cost for self-only coverage (% or $)$blanks*and (% or $)blank* of the monthly cost for family coverage. If a more detailed description of your contribution policy is required, please attach an explanation on your congregation letterhead. All contributions are due on the 15th of the month and are payable to UUA Insurance Plans.
Our congregation understands that we must keep accurate records of employee contributions, report those contributions monthly to the
UUA, and have the records available for audit..
You can receive a copy of the Plan and the Trust. Please direct questions to the UUA Health Plan (617) 948-6405, or to insuranceplans@uua.org.Visit us on the web at www.uua.org/insuranceplans.
Treasurer's Name*

First NameLast Name
Congregation ID*
Signature*

Clear
Date*

MonthDayYear
Date
File upload

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UNITARIAN UNIVERSALIST ORGANIZATIONS

You can receive a copy of the Plan and the Trust. Please direct questions to the UUA Health Plan (617) 948-6405, or to insuranceplans@uua.org.Visit us on the web at www.uua.org/insuranceplans.