Participant Change
for CTA-Endorsed Plans
SI 13365-CTAvol (8/17)
Standard Insurance Company
CTA Benets and Services
PO Box 4744 Portland OR 97208
Tel & TTY 800.522.0406 Fax 888.414.0393
Use this form only when you wish to make a change after insurance becomes effective. If you have had a qualifying family
status change in the last 60 days and would like to apply for additional coverage, please also complete and submit an
enrollment form. Changes will not be retroactive. Mark all boxes that are applicable and complete all sections that apply.
Please return completed form to The Standard at the address above.
Name Change - Former Name _____________________________________________________________________________________
Address Change
Salary Change New Gross Annual Salary $ ____________________________
Reinstatement Date Returning to Work _______________________________
Select coverage(s) to reinstate: ALL COVERAGES Disability Life Dependents Life
You must inform The Standard within 120 days of returning to work to reinstate your coverage without proof of good health.
Other _________________________________________________________________________________________________________
SIC
USE
ONLY
POLICY NO.
MAILING ADDRESS
*
PRIMARY PHONE SECONDARY PHONE
SCHOOL DISTRICT
*
Please do not abbreviate.
FIRST NAME
*
MIDDLE INITIAL LAST NAME
*
PARTICIPANT ID
CITY
*
STATE
*
ZIP
*
HOME EMAIL ADDRESS
I wish to make the choices indicated on this form. If electing coverage, I authorize my employer to deduct premiums from my wages to cover my cost
of insurance sponsored by California Teachers Association. I understand that my employer may provide updated payroll information to The Standard
either periodically or at The Standard’s request to ensure proper premium deductions are being made for my coverage. I understand that a copy of
this form will be provided to my employer to facilitate payroll deduction for the coverages that I have elected. I understand that my premium deduction
amount will change if my coverage or costs change. This authorization will remain in effect until cancelled by me or by The Standard. I certify that I
am a member of California Teachers Association and understand that termination of CTA membership will cancel my coverage and deductions.
Participant Signature ___________________________________________________________Date __________________________________
Signature Required
Changes
Employee Information * Required elds.
For additional information and forms go to: www.CTAMemberBenefits.org/TheStandard
