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3 <br /> CAROLINA PHYSICIANS' HEALTH PLAN <br /> EMPLOYER GROUP APPLICATION <br /> Application is hereby made to CPHP for enrollment of eligible members of <br /> the Group: <br /> Group: Orange County Local Government <br /> Address 109 Court St. Hillsborough NC 27278 <br /> (Street or P. O. Box) (City) (State) (Zip) <br /> • Billing Address: <br /> (Street or P. 0. Box) (city) (State) (Zip) <br /> Type of Ownership: Corporation ( ) Partnership ( ) Proprietorship ( ) <br /> Municipality (X) Association ( ) Other ( ) <br /> Nature of Business: Government Desired Effective Date: 7/1/89 <br /> 1. CLASSIFICATION OF PERSONS COVERED: <br /> It is agreed that applications will be 'submitted for only the <br /> following classification of persons, subject to the Special Remarks, <br /> if any, set forth in the Item 1: (check one) <br /> (A) Active, full-time employed persons on Group's payroll (X) <br /> (or) <br /> (B) Members of the Group's organization (or its affiliates) ( ) <br /> Special Remarks: <br /> 2. STIPULATIONS FOR COVERAGE: <br /> New Hire Eligibility Provisions: Same as traditional plan <br /> New Hire Pre-existing Condition Provisions: Same as <br /> traditional plan. <br /> Termination Provisions: Same as traditional plan <br /> 3. CONTRACT DATES: <br /> Initial Open Enrollment (Eligibility) Period: <br /> Desired Effective Date: 7/1/89 First Renewal Date: 1/1/90 <br /> If this contract will replace any existing group insurance plan, name <br /> the carrier and date coverage terminates: 4 <br />