Basic Life /AD&D Insurance
Enrollment Form
EMPLOYEE SECTION (Please print clearly. Required fields are marked with an asterisk (*).)
SOCIAL SECURITY NO.
LAST NAME (PRINT) FIRST NAME (PRINT) MI GENDER
□ MALE
□FEMALE
DATE OF BIRTH
STREET ADDRESS
CITY
STATE ZIP
□ FULL-TIME
□ PART-TIME
BENEFICIARY FOR DEATH BENEFITS (Right to change beneficiary is reserved to the insured.)
If more than one beneficiary is named, the beneficiaries shall share benefit equally unless otherwise stated below. If indicating benefit percentages, the
percentages must total 100% for Primary Beneficiaries and 100% for Secondary Beneficiaries. Some states have laws regarding beneficiary designation.
Please consult your employer/benefits administrator for additional information.
Primary Beneficiary Designation
LAST NAME FIRST NAME RELATIONSHIP
(Spouse, Child, etc.)
DATE OF BIRTH
(MM/DD/YYYY)
ADDRESS OF BENEFICIARY
(Address, City, State, Zip)
BENEFIT
PERCENTAGE
Percentage Total: 100%
Secondary Beneficiary Designation
LAST NAME FIRST NAME RELATIONSHIP
(Spouse, Child, etc.)
DATE OF BIRTH
(MM/DD/YYYY)
ADDRESS OF BENEFICIARY
(Address, City, State, Zip)
BENEFIT
PERCENTAGE
Percentage Total: 100%
ENROLLMENT INFORMATION
Enrollment must occur within 31 days from the date the employee becomes eligible (or as otherwise stated in the policy). If you are required to pay premiums
for any coverage, the enrollment form must be signed and dated to authorize payroll deductions. The premium amounts indicated on this form are estimates,
and are subject to change based on the final terms and conditions of the policy as well as your salary and age on the effective date of the policy.
AGREEMENT AND SIGNATURE
I represent that the information I have provided in this enrollment form is complete, true and accurate to the best of my knowledge. I understand that payment of
premium does not ensure my eligibility for coverage. I understand and agree that I must satisfy all active work and/or active employment requirements that
pertain to the policy to be eligible for coverage. I understand and agree that life insurance coverage for my eligible dependents may be delayed if they are
confined (at home, in a hospital, or in any other institution or facility) or disabled on the date insurance would otherwise begin, in accordance with the terms of
the policy. Should I decline coverage(s), I understand and accept the Waiver of Group Insurance provisions that follow.
By signing below, I acknowledge that I understand and agree to the above statements, and that I have read and understand the benefit summaries provided to
me for each line of coverage. I understand that payment of premium does not ensure eligibility for coverage.
SIGNATURE OF EMPLOYEE ____________________________________________ DATE ______/______/______
WAIVER OF GROUP INSURANCE
Should I apply for waived coverage(s) in the future (either for myself or my eligible dependent(s)), I understand that evidence of insurability may be required,
acceptable to the Insurance Company, at my own expense.
The above requirements will apply unless otherwise stated in the policy, or unless prohibited by any applicable state or federal law.
DISTRICT USE ONLY
DISTRICT NAME:
DISTRICT ID #:
HIRE DATE: EFFECTIVE DATE:
HOURS WORKED PER WEEK: OCCUPATION: AMOUNT OF COVERAGE:
Original/District Copy/SISC Copy/Employee
click to sign
signature
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