INSURANCE QUESTIONNAIRE - CARANCI, JOHN C.

• Document Type: FOIA
• Keywords: CARANCI JOHN C
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001496349
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 1
• Document Creation Date: June 22, 2015
• Document Release Date: December 31, 2008
• Case Number: F-2007-00327
• Publication Date: March 15, 1957

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FOLL ING AGENCY SPONSORED INSURANCE RO GRAMS HAVE BEEN EXPLAINED TO M
W A R A G E N C I E S E M P L O Y E E S P V ASSOCIATION (WAEPA) DREAD DI SEASES
R UP H 0 S1 I T AL I Z AT I ON IN
CORPORATED (0HZ)
NCO- E REPLACEMENT
I/ X M I I T U A L B E N E F I T O F O M A H A
H O S P I T AL IZ AT 10N
CASH PAYMENT OF PREMIUMS AT THE TIME
UNITED LIFE INSURANCE (U
BLIC) "~/'~~
~?
EMPLOYEE APPLIES FOR INSURANCE MUST
COVER E PERIOD OF TIME HE WILL BE
AWAV FR HEADQUARTER ~
R T R I P INSURANCE
4. ITINERARY To be ca let ed only
G
f r in ividuals making 'application
for Air Trip Insurance)
y
APPROVED FOR RELEASE^DATE:
12-Nov-2008
'' I AM NOW PARTICIPATING,
PARTICIPATE IN THE INSURANCE
OR WOULD LIKE TO
PROGRAMS LISTED BELOW.
SIGNATURE OF EMPLOYEE
TYPE OF POLICY
OESI R E 0
NOW HAVE
POLICY NUMBER
DEDUCT ONS AUTHORIZED
EA P A Y P ERIOD
CASH PAID
9
6.
SIGNATU
RE OF EMPLOYEE
I DO NOT ELECT TO P
ARTICIPATE IN
ANY OF THE STATED INS
URANCE PROGRAMS
7 . P (Signature)
BCD (Signature)
EMPLOYEE
INTERVIEWED BY
8. PAYROLL DEDUCTIONS AUTHORIZED
INSURANCE PROGRAM
INITIAL DEDUCTION TO BEGIN
ON AMOUNT OF DEDUCTION EACH
PAY PERIOD ENDING
SUBSEQUENT PAY PERIOD
WAEPA LIFE
UNITED LIFE
:e .... _
I
GHI HOSPITALIZATION
-:-
MUTUAL HOSPITALIZATION
9. REMARKS
PC
DISTRIBUTION
INSURANCE QUESTIONNAIRE
4
ORIGINAL -FINANCE DIVISION,
DUPLCATE -RETAIN IN BCD; DES
IF DEDUCTIONS ARE AUTHORIZED
TROY AFTER PROCESSING
TRIPLICATE-RETAIN IN CPB DURI
NG PROCESSING, THEN TRANSMIT TO OFFICIAL
PERSONNEL OLDER
FORMLNO 797 OBSOLEIEIPREVIOUS
I JU 56 ON
CONFI NTIAL
(When Tiled In)