Fillable Pm 65 Pr1 (Louisiana State University)

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Pm 65 Pr1 (Louisiana State University)

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Louisiana State University
Office of Accounting Services
Payroll
204 Thomas Boyd Hall
Application Employee Payroll Deduction Authorization LSU-PR1
R
equest: ______________ Initial ______________ Renewal
Plan Name: ___________________________________________________________________________
Organization as registered with the LA Secretary of State:
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
City/State/Zip: ________________________________________________________________________
Organized: _______________________________ Chartered: ______________________________
EIN: _________________________________________________________________________________
Registered to do business in state of Louisiana: ☐ Yes ☐ No
Rated _______________ in 20_______ issue of A.M. Best Life and Health Insurance Report
Principal Officers of organization:
Name: ______________________________________________________________________________
Title: _______________________________________________________________________________
Address: ____________________________________________________________________________
City/State/Zip: _______________________________________________________________________
Email Address: _______________________________________________________________________
Phone Number: (______) _______________________________________________________________
Designated Coordinator:
Name: ______________________________________________________________________________
Title: ________________________________________________________________________________
Address: _____________________________________________________________________________
City/State/Zip: ________________________________________________________________________
Email Address: ________________________________________________________________________
Phone Number: (______) ________________________________________________________________
Plan Information:
Type of Insurance: _____________________________________________________________________
_____________________________________________________________________________________
Description of Benefits and/or Service:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Will the employee have the option to retain coverage:
At separation: ☐ Yes ☐ No At Retirement: ☐ Yes ☐ No
Describe plan requirements or restrictions:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Statutory authority, if applicable: R.S. ______________________ Other: ________________________
Is organization regulated by the Department of Insurance: ☐ Yes ☐ No
Is the organization regulated by the Office of Financial Institutions: ☐ Yes ☐ No
Sponsoring Campus/Agency: _____________________________________________________________
Area of solicitation authorized: ___________________________________________________________
I hereby certify that I have read and understand the requirements as currently published by
Louisiana State University governing miscellaneous payroll deductions which requirements must
be met to obtain and continue payroll deduction authorization and do further pledge compliance
with same. I further attest that the above and foregoing statements are true and correct to the
best of my knowledge and belief.
Date and Corporate Seal
Signature Principal Organization
Title
Date and Corporate Seal
Signature Principal Organization
Title
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Pm 65 Pr1 (Louisiana State University)

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Completed 23 July 2020

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