As an employee of ___________________________ (name of firm), I do wish to participate in the Company’s Medical Plan.

____________________________ (name of firm) is hereby authorized to make the necessary deductions from my earnings or any disability benefit paid to me by the company, for the amount specified in the Group Insurance Schedule.

It is my understanding that I will be eligible to participate in the Company Medical Plan as of ________________ (date) and that the monthly deductions referred to herein will begin on _________________ (date).

I further understand that the acceptance of my application for participation in the Company Medical Plan is contingent upon my ability to meet the medical requirements determined by ___________________________ (name of insurance company).

Date: _________________

Signature: ___________________________