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EMPLOYER NAME: KITTITAS COUNTY <br />Name (used for payment purposes): <br />Producer Physical Address (No PO Box or PMB) ... <br />Secondary Producer Name: Phone11 : Fax: <br />PRODUCER SIGNATURE: <br />DATE: <br />Producer must submit a Commission Rate Template to WCIF with this application. <br />..... ..... <br />DEFINITIONS <br />WCIF CLASS DEFINITION <br />Group of employees (affiliates, subsidiaries, or office locations within the same employer) within the same employer <br />with the same benefit options as the main group. Classes have the same BSI Account Number as the main group, and are <br />included on the same bill, but are assigned class codes and will have separate class premium totals on the bill. <br />WCIF ELIGIBLE EMPLOYEES DEFINITION <br />WCIF requires that employees work a minimum of 20 hours per week or 80 hours per month (whichever is less) to be eligible <br />for benefits. An Employer may require an employee to work more than 20 hours per week or 80 hours per month based on <br />employer policy or contractual requirements, and WCIF will honor the organization's minimum threshold. (Note: A covered <br />employee will remain covered during any unpaid furlough so long as the covered employee does not exceed 30 unpaid <br />furlough days in a single calendar year. Furlough days DO NOT include FMLA qualified absences, whether paid or unpaid). <br />Elected officials of participating employers are eligible for coverage and are exempt from the minimum hour requirement. <br />WCIF EFFECTIVE DATE DEFINITION <br />WCIF defines an employee's coverage effective date as follows. Employees hired: <br />• On the first of the month are eligible for coverage effective the date of hire. (If the first of the month falls on a weekend <br />or holiday and the employee reports for work on the first business day following, coverage is retroactive to the first.) <br />. On the 2nd to the 31st of the month are eligible for coverage effective on the first day of the month following the date of <br />hire. <br />Employers may impose their own waiting periods. If an employer chooses to do so, the effective dates as listed above will <br />apply after the employee completes the employer's waiting period and becomes eligible for benefits. Note: Special eligibility <br />provisions are in place for firefighters. <br />WCIF ELIGIBLE DEPENDENT DEFINITION <br />Dependents who are eligible for WCIF coverage include: <br />• A lawful spouse or domestic partner, <br />• Children to age 26 including biological, step, foster, adopted children from the date of assumption of legal <br />obligation for total or partial support, children required by court order or qualified medical child support order <br />(QMCSO) to be covered by a participant. <br />All other dependents are not eligible without evidence of legal guardianship. <br />2017LMGMA2 Page 2 of 9 (092116JM) <br />