BML-32BBass-Vol-ENR 241-285 9/13
WHITE - EMPLOYER COPY YELLOW - BOSTON MUTUAL COPY PINK - EMPLOYEE COPY
Employer/Policyholder
Dept. ID
Employee Name (Last, First, Middle) Social Security Number
( )
Home Address (Street, City, State, Zip) Telephone #
Gender (M/F) Occupation or Job Title Date of Birth Age
Average Hours Worked Date of Hire or Date of Full Time Employment if different Effective Date
State Class
Spouse (Last, First, Middle) Gender (M/F) Date of Birth Age No. of Dependents
BOSTON MUTUAL LIFE INSURANCE COMPANY 1-800-669-2668 x700
120 Royall Street
• Canton, MA 02021
PLEASE PRINT OR TYPE
GROUP BENEFITS ENROLLMENT FORM
I apply for the insurance for which I am now eligible (or for which I may become eligible) under the provisions of the Group Policy or Group Policies issued
to my employer by the Boston Mutual Life Insurance Company and authorize deductions, if any, from my earnings of the required premium
contribution toward the cost of the insurance. I understand that if I am disabled on the date my insurance would otherwise become effective, I shall
only become insured on the date I return to active full-time work. I further understand that if I decline insurance coverage for which I am now eligible
and I desire to participate in the plan at a later date, I must furnish, at my own expense, evidence of insurability satisfactory to Boston Mutual Life
Insurance Company.
Signature of Employee Date
PAYROLL q Weekly q Bi-Weekly
TYPE:
q Monthly q Annual Earnings: $
VOLUNTARY:
Group # Div.
EMPLOYEE /FAMILY INFORMATION
LIFE
SIGNATURE
You Must Have Basic Coverage to Elect Voluntary Coverage You Must Have Voluntary Coverage to Elect Dependent Coverage
ACCEPTANCE OF INSURANCE Employee Signature Required
Please refer to your Administration Kit for enrollment and mailing instructions
REFUSAL OF INSURANCE
Employee Name Employee/Policyholder Group No.
(Last, First, Middle)
I hereby certify that I have been given an opportunity to participate in the Group Insurance Plan offered by my Employer (or the Association with whom I am
affiliated) and insured by Boston Mutual Life Insurance Company and that I have declined to do so with respect to:
q Basic Life & AD&D q Voluntary Life & AD&D q Dependent Life
I further understand that if I desire to participate in the Plan at a later date with respect to the coverage checked, I must furnish, at my own expense, evidence
of insurability satisfactory to Boston Mutual Life Insurance Company.
Signature of Employee Date
Signature of Witness Date
YES NO Insurance Amount
LIFE & AD&D q q $
YES NO Insurance Amount
LIFE & AD&D q q $
SPOUSE q q $
DEPENDENT LIFE:
CHILD(REN) q q $
BASIC:
Group # Div.
BENEFICIARY
Name of Your Beneficiary(ies) for Life and/or AD&D Benefits: Total Percentage of Benefit must equal 100%) List Additional Beneficiaries on separate sheet
Primary Beneficiary(ies): Residential Address Date of Birth Social Security # Tel. # Relationship % of Benefit
Contingent Beneficiary(ies):
If you designate more than one beneficiary, please be sure the total percentages of benefit equals 100%. If you do not designate a percentage
payable for each beneficiary, the total proceeds payable will be divided equally among each beneficiary. If an insured dependent dies, we will pay the
proceeds to you.
City of Framingham - Framingham Public Schools
