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.
______________________________________________ ___________________________________
Employee/Retiree Signature (Required) Date
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.
FOR PERSONNEL/PAYROLL USE ONLY
REQUESTED EFFECTIVE DATE:
INFORMATION VERIFIED: (INITIAL AND DATE)
Employee/Retiree Last Name
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