Office Overhead Plan - The Trust

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Office Overhead Plan - The Trust

Application for Group Office Overhead Expense InsurancePlease PrintMember NameAPA Membership NumberSocial Security No.Category of Membership: Full Member q Associate Member qHome AddressStreet City State Zip CodeMailing AddressStreet City State Zip CodeHome Telephone No. Business Telephone No. EmailMale q Female q Date of BirthMonth Day YearFirst year you became a full/associate member of the American Psychological Association.Have you ever been enrolled in any APA Insurance Programs with Liberty Mutual? Yes q No qIf yes, what type of coverage and is coverage still in effect?EmployerOccupationAre you actively engaged in your occupation on a full-time basis? Yes q No q If so, how many hours do you work?Do you now carry or have an application pending for other group or individual Office Overhead Insurance? Yes q No qIf yes, please indicate below.Insuring Company Amount of Monthly Benefit How Long Are Benefits Payable?AccidentSicknessDetach and send backWhat was the average monthly office expense incurred by you duringthe preceding 6 months in the conduct and operation of your office?You may select a monthly benefit from $500 to $5,000 in increments of $100.Monthly Benefit Desired:Note: Include only your share of expenses if office expenses are shared.(Please complete other side)


Notes


Monthly Expense WorksheetRent or mortgage interestEmployee’s salaries and payrolltaxesBusiness automobile leasing costs(within IRS limits)TelephoneElectricityWaterHeatAdministrationThis plan is underwritten and administered by Liberty Life AssuranceCompany of Boston, a member of the Liberty Mutual Group. It is theonly Office Overhead program endorsed by the American PsychologicalAssociation Insurance Trust. The Trust and Liberty have been workingtogether for over 55 years. A group Office Overhead policy has beenissued to the Trustees of the APA Insurance Trust. Each participatingmember receives a certificate outlining the benefits to which one isentitled under the policy.The descriptions in this brochure are necessarily brief and are subjectto provisions that can only be expressed exactly in the certificates ofinsurance. Have any questions? Call Liberty Mutual at 1-888-287-8494.Please detach and complete the attached application as soon as possibleand mail to:Administrator, APA Group Insurance PlansLiberty Mutual Insurance CompanyPO Box 1525Dover, NH 03821-1525Office cleaning servicesTelephone answering servicesTotal fixed monthly expensesMonthly Prorated ExpensesAccountant’s servicesProperty, state and localbusiness taxesBusiness Insurance(office, auto, professional liability)Interest charges on business loansDues to professional associationsMiscellaneousTotal monthly prorated expensesGrand Total of MonthlyOverhead Expense

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