Agency Agreement Template For Sick Pay Aetna Page 2
Download a blank fillable Agency Agreement Template For Sick Pay Aetna in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Agency Agreement Template For Sick Pay Aetna with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Plan Sponsor Information:
Plan Sponsor Name:
Employer Name (if different):
Contact Name: _________________________________Phone Number: ________________
Plan Sponsor Address: ________________________________________________________
Employer Identification Number (EIN): __________________________________________
Plan Sponsor
Aetna Life Insurance Company
Signature of Authorized
Signature of Authorized
Representative:
Representative:
_____________________________________
_______________________________________
Title: ________________________________ Title: _________________________________
Date: ________________________________ Date: _________________________________
Please return completed agreement to:
Aetna Life Insurance Company
Attn: Disability Financial Unit, RT32
151 Farmington Avenue
Hartford, CT 06156
Any questions can be directed to the Aetna Tax Reporting Unit toll free at 877-262-3862 (877-26-Aetna)
Substitute Form 2678
- 2 -
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business