Fillable Form 110: H71129 State of Idaho male Mailing (Boise State University)

Fill Online, Printable, Fillable, Blank Form 110: H71129 State of Idaho male Mailing (Boise State University) Form

Use Fill to complete blank online BOISE STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 110: H71129 State of Idaho male Mailing (Boise State University)

On average this form takes 24 minutes to complete

The Form 110: H71129 State of Idaho male Mailing (Boise State University) form is 2 pages long and contains:

  • 0 signatures
  • 4 check-boxes
  • 93 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Boise State University

BROWSE BOISE STATE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
110
Return this form to:
Voluntary Term Life
Your Human Resources Principal Life
Employee Enrollment
Office Insurance Company
& Waiver - ID
Company name
Agency
Account number/unit number
State of Idaho
H71129
Employee Information
Name
Social security number
Mailing address (street)
Birth date
male
female
(city) (state) (ZIP code) Do you have an eligible spouse or child(ren)?
Yes No
Date of Hire
Voluntary Term Life
Employee Benefit
Election
1 x salary 2 x salary 3 x salary
Minimum:$ 20,000
Maximum:$500,000
Monthly Premium
Benefit Election –
Check Box
Spouse Benefit
Election*
$10,000 $20,000 $30,000 $40,000 $50,000
Minimum: $10,000
Maximum:$50,000
Monthly Premium
Benefit Election –
Check Box
Child(ren) Benefit
$10,000
Election*
Monthly Premium $2.00
Benefit Election –
Check Box
*Spouse or Child benefits cannot exceed 100% of Employee’s coverage.
G
P60275 Page 1 of 3 06/2012
male
female
Name(s) of child(ren) Birth date Social security number
male disabled or
female handicapped child *
male
disabled or
female
handicapped child *
male
disabled or
female
handicapped child *
* When your child, who is developmentally disabled or physically handicapped, reaches/exceeds the maximum age, an
Application to Continue Handicapped Child form must be completed and reviewed to determine eligibility.
Is your spouse employed by The State of Idaho? Yes No
110
Voluntary Term Life Beneficiary Designation
All primary and contingent beneficiaries, whether adults or minors, should be included in the beneficiary
designation below.
Primary Beneficiaries:
Name Percentage Relationship
Address Social security number
Name Percentage Relationship
Address Social security number
Name Percentage Relationship
Address Social security number
Contingent Beneficiaries:
Name Percentage Relationship
Address Social security number
Name Percentage Relationship
Address Social security number
The right to make future changes is reserved. If two or more beneficiaries are named, the proceeds shall be paid to the
named beneficiaries, or to the survivor or survivors, in equal shares, unless specified otherwise.
If any beneficiary is designated as trustee, it is understood and agreed that Principal Life Insurance Company shall not be
a party to nor bound by the conditions of any trust and payment of the net proceeds of said policy on the death of the
insured to the then designated beneficiary shall be a complete discharge as to Principal Life.
If you have designated a minor child(ren) as your beneficiary, you must complete the Uniform Transfers to Minors Act
form.
Eligible Dependent Information (Complete if you have elected benefits for your spouse or children)
Spouse’s name
Birth date
Social security number
GP60275 Page 2 of 3 06/2012
110
Employee Agreement (Read and sign)
I understand and agree with the following statements:
•
My dependents are not eligible for coverages I don’t have. My dependents, including step children and any over the
maximum age, are eligible based on plan provisions but those over the maximum age will be verified when a claim is
filed.
•
If I refuse life coverage, I may apply later but I must show proof of good health and coverage will be subject to
approval by Principal Life Insurance Company.
•
I authorize my employer to deduct contributions from my pay.
•
I represent all information on this form and attachments
are complete and tr
ue to the best of my knowledge. They are
part of this request for coverage. I agree Principal Life is not liable for a claim before the effective date of coverage
and all policy provisions apply. I have read, or had read to me, the information and my answers on this form. During
the first two years coverage is in force,
fraud or intentional
misrepresentations can cause changes in my coverage,
including cancellation back to the effective date.
•
Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement, may be guilty of insurance fraud.
•
I authorize Principal Life to release data as required by law. If signed in connection with an application, reinstatement
or a change in benefits, this form will be valid two years from the date below. I may revoke authorization for
information not yet obtained. I understand data obtained will be used by Principal Life for claims administration and
determining eligibility for life coverage. Information will not be used for any purposes prohibited by law.
•
I understand that as the employee, the insurance I and my dependents have applied for will begin on the effective
date of coverage provided I am at work on that date. If I am not actively at work on such date, subject to the terms of
the group policy, coverage may not go into effect until after my return to work. Furthermore, I understand that no
insurance may become effective for any member of my family while he/she is in a period of limited activity.
A copy of this form will be as valid as the original.
I declare that the information I have completed on this enrollment form is complete and true. I understand an agent or
broker cannot guarantee coverage, revise rates, benefits or provisions without written approval from Principal Life.
Your signature
X_____________________________________________ Date Signed _______________
Instructions
After this form is completed and signed, please make a copy of it.
Send the original form to your Human Resources Office
Keep the copy for your records
GP60275 Page 3 of 3 06/2012
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 110: H71129 State of Idaho male Mailing (Boise State University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document