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Employee Last Name First Name Fee
Albers Peggy $175.00
* * * * * * *
Add fee amounts to calculate your total annual fee
for AgriPlan or BizPlan Total Fee 175.00
(4) AVAILABLE BENEFITS (Check the benefits available to
the eligible employee)
Employee and Family
: Medical or Medical Related Health Insurance
9 Dental Insurance
: Medical or Medical Related Expense
Reimbursement (Please indicate amount below.
This does not include premiums.)
$ 5000 Maximum amount of medical reimbursement
available per eligible employee for Plan year.
Employee Only
9 Term Life Insurance - $50,000.00 max. death
benefit
9 Disability Insurance
(5) Authorization
The undersigned employer [Darwin Albers] hereby
executes this agreement on the 21st day of Dec
1995, and the plan start shall be January 1st of
this year. [Reproduced literally.]
During 2001, pursuant to the authorization that he signed to
provide a medical reimbursement plan under AgriPlan through
AgriBiz, Mr. Albers provided such a plan (AgriPlan/AgriBiz
medical reimbursement plan) for the benefit of Ms. Albers and her
family.
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Last modified: November 10, 2007