MHL BUSINESS GROUP, LTD
GROUP APPLICATION FOR HIP

     Guidelines For All Plans

1. The employer must be a member in good standing of MHL Business Group Ltd.
2. All applications that you submit with a personal check must be accompanied with proof of business (i.e. Schedule C, WT4B, Certificate of Business etc.).
3. All member groups must be self-employed or have employer/employees relationships.
4. We cannot except enrollment if they are not properly completed and accompanied by the premium payment.
5. Your premium must be received before the first of the month of coverage, to avoid termination of coverage.

All premiums must be made payable to MHL Business Group Ltd. as administrators for HIP or your check will be returned.

The information provided above is true and correct to the best of my knowledge. I understand that coverage and benefits may be effected by failure to provide complete and accurate information. I understand all current employees have the option of joining HIP now or on my groups annual anniversary date.

_____________________________	___________________
Signature of Owner/Partner	Representative
____________________	_________________________
Date	Representative's Phone Number