Participation Statement for HIP

HIP Low-cost Health Insurance                HIP ULtra Value Plus (10/500/50)

Company Name:   _________________________________

I confirm the above-named company is complying with MHL Business Group, Ltd. Participation requirements. The following employees are regularly employed on a full-time basis working at least 20 hours per week.

       

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I hereby represent and agree that all answers and statements in this statement are full, complete and true, to the best of my knowledge and belief. I understand that the said answers and statements form the basis upon which insurance will be effective. I understand that omissions, misrepresentations or misstatements about employment history could result in an otherwise valid and voiding of insurance.

   __________________________________________                 ________________________________________
   Signature of Owner, Partner or Officer                                               Print Name

   __________________________________________                 ________________________________________
   Title                                                                                                        Date

   __________________________________________                 ________________________________________
   Witness                                                                                                 Print Witness Name