Benefit Election Form
See accompanying enrollment materials for coverage details
and any required outline of coverage
Employee Information - Items with ** are on file and do not need to be completed by you.
IPN:
Last Name First Name Gender Date of Birth Date of Hire Social Security Number
Home Address City State Zip Code Employee Home/Cell Phone Number
Employer Name Annual Salary Occupation
HSTA VEBA Trust $
Coverage available to all eligible employees who are actively at work for the minimum hours required by the plan.
Spouse Information -
Complete if enrolling in spouse coverage.
Last Name First Name Gender Date of Birth
Choose one Accident benefit plan. Select the Platinum Plan or Gold Plan or decline coverage.
To review the Platinum and Gold options, see the Schedule of Benefits in this packet.
Return Completed form to: HSTA VEBA, 1259 Aala St., Ste 202, Honolulu, HI 96817.
Type of Coverage All premiums displayed are Monthly
Group Accident
on/off-job
coverage
Unum Life Insurance
Company of America
PLATINUM PLAN
Class 1
GOLD PLAN
Class 2
Employee only $15.25 $10.68
Employee/spouse $24.66 $17.35
Employee/children $28.47 $18.75
Employee/spouse/children $37.88 $25.42
I decline coverage at this time
Beneficiary Information - Please name a beneficiary for any benefit payable after your death. If you have elected
any spouse or child coverage you will automatically be the beneficiary for that coverage. To update or change
beneficiaries, please contact Unum.
Primary Contingent
Name Relationship Name Relationship
I agree that:
●
All statements are true to the best of my knowledge and belief.
●
Coverage is subject to satisfying the insurer’s rules and underwriting standards. The effective date of coverage will
be determined as set forth in the policy or certificate provided to me.
●
Coverage may be subject to exclusions and limitations as described in the enrollment materials that have been
provided to me by my employer. These include any required outline of coverage.
●
For coverage to become effective, all persons I enrolled, including myself, must meet eligibility requirements.
●
I authorize HSTA VEBA Trust to make deductions, adjustments or cancellations from my salary, wages or other
compensation to pay the premium for the coverage elected. I understand that my payroll deductions will change if
my coverage or costs change.
Employee signature Date City State
THIS IS NOT AN APPLICATION FOR INSURANCE: This is an enrollment form.
AE-1200
