AUTHORIZATION TO PARTICIPATE IN MEDICAL PLAN

As an employee of [name of firm] , I do (do not) wish
to participate in the Company’s Medical Plan.

[name of firm] is hereby authorized to make the
necessary deductions from my earnings or any disability
benefit paid to me by the company, for the amount specified
in the Group Insurance Schedule.

It is my understanding that I will be eligible to participate
in the Company Medical Plan as of [date] and that the
monthly deductions referred to herein will begin on [date]

I further understand that the acceptance of my application
for participation in the Company Medical Plan is contingent
upon my ability to meet the medical requirements determined
by [name of insurance company]

Date:_________________ Signature:___________________________