STATE OF TENNESSEE GROUP INSURANCE PROGRAM
BASIC LIFE INSURANCE BENEFICIARY DESIGNATION APPLICATION
State of Tennessee • Department of Finance and Administration • Benefi ts Administration
26th Floor, 312 Rosa L. Parks Avenue • Nashville, Tennessee 37243 • 615.741.3590 or 1.800.253.9981
EMPLOYEE INFORMATION
Name Social Security Number Edison ID (if known)
Employing Department/Agency Dept ID Date of Hire Date of Birth
Work Address City State Zip Code
Home Address City State Zip Code
Marital Status
Single
Married
Divorced
Widowed
Gender
Male
Female
Daytime Phone Number
AUTHORIZATION
I understand that this enrollment is NOT for health insurance coverage and is for basic term life and basic special accident coverage only. Unless
I enroll in family health insurance, coverage is provided to the employee only (not spouse or child). If I enroll in family health insurance coverage,
my covered dependents will also be enrolled in basic life coverage; however dependents do not elect a benefi ciary as the benefi t will automatically
default to me as the employee. I further understand that a new applicatoin must be completed and returned to my agency benefi ts coordinator
any time I want to designate a new benefi ciary. Failure to designate a benefi ciary will result in the proceeds being paid to my estate in the event
of my death.
I authorize the state group insurance program to release to Dearborn National on behalf of myself and all family members information (name,
address, social security number, age, gender, salary, enrollment effective/termination date) required to establish eligibility and coverage levels
for the purpose of obtaining life insurance coverage. This authorization shall be in force for the time period I have a pending application or am
enrolled with this life insurance company. The state group insurance program will not condition treatment, payment or enrollment eligibility on
the signature of this authorization and may not have the right to control further disclosures of this information.
Upon termination of employment, I may continue this coverage on a direct pay basis to the insurance company; however, payment of monthly
premiums is my responsibility.
I confi rm that all information that I have provided on this application is accurate. I understand that providing false and/or misleading information
may subject me to disciplinary and/or legal action. I authorize my employer to deduct the required premium from my salary/wages.
Employee Signature Date
TYPE OF REQUEST
New Enrollment
Benefi ciary Change
Enrolled in health coverage:
Yes
No
If yes, type of health coverage:
Employee only
Employee + dependents
This application is to be used to designate a benefi ciary for basic life insurance coverages. Individuals who
elect NOT to enroll in health insurance will be provided with basic term life and basic special accident
coverage with the premium being provided by the State of Tennessee. These amount of coverage CANNOT
be increased.
Individuals who DO elect health coverage will also receive the same state support; however, the amount of
coverage will increase as your salary increases, with additional premiums deducted from your paycheck.
If enrolling in health coverage, covered dependents will also receive life insurance benefi ts; however, the
amount of coverage is different from that of an employee.
Please refer to the eligibility and enrollment guide for further information.
FA-1005 (rev 3/11) Coverage administered by Dearborn National Life Insurance Company
Complete benefi ciary designation on back of this application and return to your agency benefi ts coordinator
