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This is an enrollment option for you to select additional long term disability insurance for you. If you would like to complete a hardcopy of the enrollment form, or you have questions or concerns, contact Human Resources.

Long Term Disability Coverage 2010 Enrollment

*Your Email Address:

If you do not have an email address to insert in the previous question, please insert the following email address: employee@cicl.com

To accurately process your decision, it is necessary for you to complete this form in its entirety and do not leave any questions unanswered. If a question does not apply to your decision, place the letters "NA" for your answer and proceed to the next question until completed.

Would you like to select long term disability coverage (Y/N):

   * SS#:

   * Gender (M/F):

   * Date of Birth (month/date/year):

   *

Hours scheduled to work per week:

   * First Name:

   * Middle Initial:

   * Last Name:

   * Street Address:

   * City:

   * State:

   * Zip:

   * Date of Hire with CICL (month/date/year):

   * Annual Compensation: (To determine this figure, take the scheduled number of hours you are scheduled to work per week and multiple that times 52 week. This will give you the total number of scheduled hours for the year. The next step is to take the total number of scheduled hours for the year and multiple that times your hourly rate. This figure will represent your annual compensation for the purpose of this coverage. This figure does not take into account any overtime or increased hours that you pick up during the year.)

   * Are you a Residential Specialist or Program Coordinator (non-exempt) Y/N:

   * Are you a Program Administration, Program Manager, or Program Director (exempt) Y/N:

   * If you have selected this coverage option, you will be contacted by Human Resources to complete the calculation for the annual cost of the coverage with you. What is the best time of the day to by contacted: (please place an "a" for AM and a "p" for PM)

   *

Authorization of Participation

Yes, I would like to participate. I authorize CICL to deduct from my compensation the necessary premium for this coverage. I understand that the effective date of my coverage will be delayed if I am not in active employment status because of injury, sickness, temporary lay-off, or leave of absence of the date this insurance would otherwise become effective.

My electronic signature at the end of this form verifies the accuracy of the information provided above. (Y/N):

   * I would like to have a copy of the Plan Highlights, including all statements regarding exclusions and benefit amounts and offsets.

   *

Decline Participation

No, I do not wish to participate. I understand that evidence of insurability will be required, at my own expense, if i decide to elect this coverage inthe future. Place a "Y" for your answer if you want to decline coverage.:

Employee Electronic Signature:

I certify that all statements are true to the best of my knowledge and belief and I understand that a copy of this form will be made available to me at my request. I authorize CICL to make the necessary deductions from my compensation to pay the premium when my insurance becomes effective. I undertstand that my payroll deduction amount will change if my coveage or costs change.

My employee number and the last four digits of my SS# are: (111111/2222)