Enrollment/Change Request Form Page 1 of 2 MSLIFEAPP 12/2016
STATE AND SCHOOL EMPLOYEES’ LIFE INSURANCE PLAN
ENROLLMENT/CHANGE REQUEST FORM
Underwritten by Minnesota Life Insurance Company, an affiliate of Securian Financial Group, Inc.
Pol
icy 33683-G
SECTION A: Employee/Employer Information
Employee/Retiree Last Name: First Name: MI: Social Security Number: Birthdate: (MM/DD/YYYY):
Employee/Retiree Home Address:
Email Address:
Home Phone:
Alternate Phone:
Employer Name:
Employer Phone:
Employer Address:
SECTI
ON B: Coverage
(NOTE: For more information on available coverage, contact Minnesota Life toll free at 877-348-9217)
ACTIVE FULL-TIME EMPLOYEE: Life benefits and Accidental Death and Dismemberment (AD&D) maximums are based on two times
the employee’s annual wage rounded to the next higher one thousand dollars, subject to a minimum of $30,000 and a maximum of
$100,000. The employee and employer each pay 50 percent of the monthly premium.
New EmployeeApplications made within initial 31 days of employment; coverage becomes effective on the first day of employment.
Late Enrollee ApplicantApplications made after initial 31 days of employment will be subject to medical evidence of insurability;
coverage will become effective on the first day of the month after or coincident with date of approval by Minnesota Life. (Employee
must also complete the Minnesota Life GROUP LIFE INSURANCE EVIDENCE OF INSURABILITY form.)
Date of Employment: _____________________
RETIRED EMPLOYEE: Life benefit amounts are limited to $5,000, $10,000 or $20,000. Retired employees are not eligible for AD&D
benefits. A retired employee should apply before, but no later than 31 days after the date active employee coverage terminates. A
retiree pays 100 percent of the monthly premium.
Date of Retirement: ______________________ COVERAGE AMOUNT REQUESTED: $5,000 $10,000 $20,000
DISABLED EMPLOYEE: Life benefit amounts are equal to employee’s current benefit level at the time coverage ceases as an active
employee. Disabled employees must apply no later than 31 days from the date active employee coverage terminates. Minnesota Life
is solely responsible for evaluating applications for coverage continuation. Premiums are waived after the first nine months.
(Employee must also complete the Minnesota Life NOTICE OF DISABILITY and ATTENDING PHYSICIAN’S STATEMENT forms.)
Date of Disability: ______________________
SECTI
ON C: Beneficiary Information
NOTE: You cannot designate your life insurance beneficiary on this form. To designate your life insurance beneficiary, please follow
the instructions below:
1. Log in to your myBlue site, https://myblue.bcbsms.com, and click on the My Benefits tab.
2. Scroll down to the Life Benefits section below Medical Benefits. This section will show you the effective date and amount of life
insurance coverage you have.
3. Click the link in the Life Benefits section and you will be redirected to Minnesota Life’s online beneficiary management tool. Follow
the instructions on the site to submit your beneficiary designation.
Once you submit your beneficiary information, a confirmation statement will be mailed to you. You may view or update your beneficiary
information any time by accessing Minnesota Life's website through the myBlue portal.
If you do not designate a life insurance beneficiary, any resulting life insurance benefits will be paid according to the defaults set
forth in the policy.
If you do not have Internet access, contact Minnesota Life toll free at 877-348-9217 to request a paper beneficiary designation form.
Enrollment/Change Request Form Page 2 of 2 MSLIFEAPP 12/2016
SECTI
ON D: Authorization and Certification
I am appl
ying for group term life insurance for myself through the State and School Employees’ Life Insurance Plan (Plan). I
understand that if my application is approved, coverage will become effective on the date fixed by the Plan or Minnesota Life.
I certify that all information on this form is true and complete to the best of my knowledge and belief. I understand that this
insurance is subject to all of the terms of the Plan of Insurance contained in the Minnesota Life Insurance Company, Group
Policy #33683-G, and summarized in the Certificate of Coverage provided to me. I understand that any misrepresentation by
me may result in the cancellation or rescission of coverage under the Plan.
I understand that if I am a late enrollee applicant, any insurance subject to evidence of good health or medical information will
not become effective until Minnesota Life gives its written consent. I understand that my eligibility may be affected in the event
I fail to sign this form within 31 days of the effective date of eligibility, or if for any reason my employer does not receive the
Enrollment/Change Request Form within a reasonable time following the event.
I understand and authorize that the appropriate premiums for the coverage requested will be deducted from my wages or
retirement benefits, as appropriate, and authorize release of employment and payroll information or other such eligibility
information to the Plan and/or Minnesota Life as needed to verify my eligibility, benefit amounts, or other such information
necessary in the proper administration of the Plan.
Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
______________________________________________ ___________________________________
SECTION E: Waiver/Request to Cancel Coverage (Only complete this section to waive or cancel coverage.)
Waiver of Coverage I hereby decline to apply for life insurance coverage in the State and School Employees’ Life
Insurance Plan. I understand that an active employee who waives coverage in the Plan may apply for coverage at a later
date so long as he continues to qualify as an active employee. I further understand that late enrollee applicants are subject
to medical evidence of insurability that may result in coverage being denied. I understand that a service retired employee
or totally disabled employee who declines to apply for continuation of coverage in the Plan within 31 days of the date his
coverage ceases as an active employee, forfeits his right to participate in the State and School Employees’ Life Insurance
Plan and will not be allowed to apply at a later date.
Cancellation of Coverage I hereby request that my life insurance coverage in the State and School Employees’ Life
Insurance Plan be cancelled. I understand that an active employee who cancels his coverage in the Plan may apply for
coverage at a later date so long as he continues to qualify as an active employee. I further understand that late enrollee
applicants are subject to medical evidence of insurability that may result in coverage being denied. I understand that a
service retired employee or totally disabled employee who cancels his coverage in the Plan forfeits his right to participate
in the State and School Employees’ Life Insurance Plan and will not be allowed to apply at a later date.
SIGN BELOW ONLY IF YOU DO NOT WANT LIFE INSURANCE COVERAGE.
______________________________________________ ___________________________________
Employee/Retiree Signature Date
FOR QUESTIONS REGARDING THE STATE AND SCHOOL EMPLOYEES’ LIFE INSURANCE PLAN, VISIT THE PLAN’S WEBSITE AT
http://KnowYourBenefits.dfa.ms.gov/
OR CONTACT THE DFA-OFFICE OF INSURANCE AT 866-586-2781.
COVERAGE AMOUNT:
REQUESTED EFFECTIVE DATE:
GROUP NUMBER:
INFORMATION VERIFIED: (INITIAL AND DATE)
Employee/Retiree Last Name
First Name
MI
Social Security Number
Daytime Phone
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