Saif Corporation Form F3135 – Fill Out and Use This PDF

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N on d isa b lin g Cla im s Re im b u r se m e n t Pr og r a m

En r ollm e n t For m

Em ploy er s m ay choose t o r eim bur se SAI F Cor porat ion for m edical ex penses on accept ed nondisabling claim s up t o t he m ax im um r eim bur sem ent am ount set by t he Or egon Depar t m ent of Consum er and Business Ser v ices. Reim bur sem ent of claim s is gener ally not r ecom m ended w her e t he em ploy er 's annual pr em ium is less t han $ 15,000, since t he

r eim bur sem ent claim cost s m ay ex ceed any pr em ium sav ings. For addit ional det ails about t his pr ogr am go t o sa if . com and click " I am an em ploy er . "

I f y ou choose t o enr oll in t his pr ogr am , y ou m ust com plet e t his for m and r et ur n it t o SAI F.

This r eim bur sem ent elect ion w ill r em ain in effect unt il SAI F r eceiv es y our w r it t en r equest t o end it or unt il y our cov er age is cancelled.

I f y ou hav e any quest ions or need assist ance, please cont act y our agent or SAI F r epr esent at iv e.

We elect t o par t icipat e in t he Nondisabling Claim s Reim bur sem ent pr ogr am effect iv e

_______________ and under st and t hat r eim bur sem ent is opt ional under t his pr ogr am .

The ev aluat ion fr equency for policies w it h a cash flow r et r ospect iv e r at ing plan w ill be quar t er ly . Policies w it h a guar ant eed cost or r egular r et rospect iv e r at ing plan m ust select a r eim bur sem ent fr equency .

Ev aluat ion fr equency for guar ant eed cost and r egular r et r ospect iv e r at ing plans:

Annual Quar t er ly

F3135

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