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REPRESENTATIVE R. Poulin #44 
GROUP NO. 87378-P

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ASSOCIATED HOSPITAL SERVICE OF NEW YORK • UNITED MEDICAL SERVICE, INC
80 LEXINGTON AVENUE • NEW YORK, N.Y. 10016 • MURRAY HILL 9-2800
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GROUP ADMINISTRATOR FORM

PART 1 (FOR NEW GROUPS, CONVERSIONS, OR REOPENINGS)

GROUP NAME - Jacques Seligmann, & Co Inc.
ADDRESS NO. STREET - 5 East 57th Street
CITY STATE ZIP CODE - New York, N.Y. 10022

NUMBER ON PAYROLL(INCLUDING EXECUTIVES} - 7 

TOTAL NUMBER OF EXCLUSIONS - 4
EXPLAIN UNDER "REASON FOR EXCLUSIONS")

NET ELIGIBLE - 3
(NUMBER ON PAYROLL LESS EXCLUSIONS)

REASON FOR EXCLUSIONS (SEASONAL, PART TIME EMPLOYEES, ETC.) - Indiv contract - Over 65 - On husband's contr.

AMOUNT OF CONTRIBUTION (IF ANY) BY COMPANY TOWARD SUBSCRIPTION CHARGES:
 __ 100%   
$__ INDIVIDUAL 
$__ OTHER AMOUNT 
 _X NONE 
 __ PAYMENT TO BE MADE 
 __ MONTHLY
 __ QUARTERLY 
 __ SEMI-ANNUALLY 
 __ ANNUALLY

NEW EMPLOYEES WILL BE ELIGIBLE AS FOLLOWS: 

 _X WITHIN THE FIRST 4 MONTHS OF EMPLOYMENT 
 __ WITHIN 30 DAYS FOLLOWING __ MONTHS OF EMPLOYMENT 
 __ FOR 100% AND INDIVIDUAL CONTRIBUTION GROUPS (STRICT ADHERANCE) ONLY, NEXT MONTHLY EFFECTIVE DATE FOLLOWING ___ MONTHS OF EMPLOYMENT. 
 __ OTHER (Explain) ___________________

APPLICATIONS __ ARE __ ARE NOT... ACCEPTABLE PRIOR TO ELIGIBILITY FOR CONTRIBUTION

SIGNATURE OF GROUP ADMINISTRATOR
[[illegible]] 11/22/66
Sign Here

PART 2 (FOR NEW GROUPS ONLY)
Submitted herewith are the application of our employees to form an enrolled Blue Shield Group.

The Personnel Record furnished above is a complete statement of the total number of our employees, including full particulars relative to any to whom Blue Cross and Blue Shield have not been offered at this time.

If the applications submitted meet your requirements and appropriate contracts are issued by either AHS or UMS or both, we agree to act as Group Administrators for enrolled employees and to remit the charges payable in accordance with the terms of such contracts to you as long as they remain enrolled through our group. 

After our group is in effect, we will make enrollment available to all eligible new employees and will permit our group to be reopened (if it qualifies) periodically. The new employee eligibility rules which we wish applied to our group, are set forth above in Part 1.

We understand that this agreement may be terminated by either of us giving 30 days prior written notice.

SIGNATURE OF OFFICER ___
TITLE ___
DATE___

ORIGINAL TO BE RETURNED TO ASSOCIATED HOSPITAL SERVICE. DUPLICATE TO BE RETAINED BY GROUP ADMINISTRATOR.

ENRL-67-CHM (10-64)

Transcription Notes:
---------- Reopened for Editing 2024-03-03 13:55:20 ---------- Reopened for Editing 2024-03-03 17:54:04