Multiple Companies Form
Employers with 100 or fewer eligible employees
(To be used when one individual does not have controlling interest of the companies)
The standard guidelines generally require that groups with multiple Tax I.D. numbers will be considered
as one group as long as:
 One owner controls the majority of each separate business.
o A copy of current 1120 S (Schedule K-1 Form) must be provided for each owner; and
o A copy of most recent Quarterly Wage and Tax Statement must be provided for each
company; and
 The two or more groups may have different Standard Industrial Classification Codes (SIC),
however rates will be based on the SIC code with the majority of employees (in states where an
SIC code factor is allowed).
Groups that do not meet the above guidelines may be considered if the owners of the company designate
one individual to act on behalf of all the groups.
DESIGNATION
The owners of the businesses listed below hereby authorize the individual named below to act on behalf
of the entire group. This individual has administrative authority for the decision making in relation to this
insurance contract.
Name of individual with
administrative authority
As an owner of one or more of the listed businesses I authorize the above named individual to have total
administrative authority for the decision making of this insurance contract.
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance,
and civil damages.
I understand Innovation Health/Aetna will rely on the information I provide in determining eligibility for coverage,
setting premium rates, compliance with applicable laws, and other purposes, and that any misrepresentation or
fraudulent statement may result in rescission of the group policy, termination of coverage, increase in premiums, or
other consequences. Innovation Health/Aetna reserves the right to audit and to request documentation as evidence
of business activity at any time and from time to time in order to validate my compliance with eligibility and
underwriting guidelines as well as validate the applicability of State and Federal laws. I understand that my failure to
comply with any such request may also result in termination of coverage, increase in premiums, or other
consequences.
Business Name
Owner’s Name (print)
Percentage
of
Ownership
Signature
Date
10/13