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Forms To Complete (Tennessee Technological University)

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Section 4: Forms
In this section you will find forms that were previously mentioned.
If you do not know an effective date, plan numbers, codes, etc., leave
them blank as we will assist with the
se entries.
The following forms REQUIRE your completion:
1. Basic Life Insurance Beneficiary Designation Application
2.
LTD Exempt Enrollment Form
3.
Designation of Beneficiary
Do not sign this form until you meet with us, as we will need to notarize
this form.
4.
PayFlex Flexible Spending Accounts Enrollment Form
5.
Dependent Information Sheet
The following OPTIONAL forms are completed only if the benefit is
selected:
1.
2.
Optional Accidental Death Enrollment Application
Optional Group Term Life Insurance Enrollment
STATE OF TENNESSEE GROUP INSURANCE PROGRAM
BASIC LIFE INSURANCE BENEFICIARY DESIGNATION APPLICATION
State of Tennessee • Department of Finance and Administration • Benefits Administration
19th Floor, 312 Rosa L. Parks Avenue • Nashville, Tennessee 37243 • 615.741.3590 or 800.253.9981
EMPLOYEE INFORMATION
Name Social Security Number Edison ID (if known)
Employing Department/Agency Dept ID Date of Hire Date of Birth
Work Address City State Zip Code
Home Address City State Zip Code
Marital Status
q
Single
q
Married
q
Divorced
q
Widowed
Gender
q
Male
q
Female
Daytime Phone Number
AUTHORIZATION
I understand that this enrollment is NOT for health insurance coverage and is for basic term life and basic accident coverage only. Unless I enroll
in family health insurance, coverage is provided to the employee only (not spouse or child). If I enroll in family health insurance coverage, my
covered dependents will also be enrolled in basic life coverage; however dependents do not elect a beneficiary as the benefit will automatically
default to me as the employee. I further understand that a new application must be completed and returned to my agency benefits coordinator
any time I want to designate a new beneficiary. Failure to designate a beneficiary will result in the proceeds being paid to my spouse, children,
parents or estate according to applicable contract provisions in the event of my death.
I authorize the state group insurance program to release information to their life insurance contractor on behalf of myself and all family members
(name, address, social security number, age, gender, salary, enrollment effective/termination date) required to establish eligibility and coverage
levels for the purpose of obtaining life insurance coverage. This authorization shall be in force for the time period I have a pending application or
am enrolled with this life insurance company. The state group insurance program will not condition treatment, payment or enrollment eligibility
on the signature of this authorization and may not have the right to control further disclosures of this information.
Upon termination of employment, I may convert my basic term life coverage to an individual policy with the insurance company. Payment of
monthly premiums directly to the insurance company will be my responsibility.
I confirm that all information that I have provided on this application is accurate. I understand that providing false and/or misleading information
may subject me to disciplinary and/or legal action. I authorize my employer to deduct the required premium from my salary/wages.
Employee Signature Date
TYPE OF REQUEST
q
New Enrollment
q
Beneficiary Add/Change
Effective date of beneficiary designation:
Enrolled in health coverage:
q
Yes
q
No
If yes, type of health coverage:
q
Employee only
q
Employee + dependents
This application is to be used to designate a beneficiary for basic life insurance coverages. Individuals who
elect NOT to enroll in health insurance will be provided with basic term life and basic accident coverage
with the premium being provided by the State of Tennessee. These amounts of coverage CANNOT be
increased.
Individuals who
DO elect health coverage will also receive the same state support; however, the amount
of coverage will increase as your salary increases, with additional premiums deducted from your
paycheck. If enrolling in health coverage, covered dependents will also receive life insurance benefits;
however, the amount of coverage is different from that of an employee.
Please refer to the eligibility and enrollment guide for further information.
FA-1005 (rev 10/13)
Complete beneficiary designation on back of this application and return to your agency benefits coordinator
RDA SW20
RESET
✔
Tennessee Tech University
9001700000
PRIMARY BENEFICIARY DESIGNATION
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Total for Primary Beneficiary (must be 100%) Total
CONTINGENT BENEFICIARY DESIGNATION
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Total for Contingent Beneficiary (must be 100%) Total
NOTE: Contingent beneficiary will only receive benefits if all primary beneficiaries are deceased.
Name Edison ID
OR
SSN
GLAD 4 01/12 (TN)
The Lincoln National Life Insurance Company
P.O. Box 2616, Omaha, NE 68103-2616
Phone: (800) 423-2765 Fax: (877) 573-6177
Please Use Ink or Type
GROUP ID:
TENNBOR
GROUP POLICY #:
1023334000000
Billing Division or Location:
A. Employee Information (Complete for ALL Enrollments)
Employer Name/Company Name (Please Print)
County
Employer ZIP
State
Employee Last Name First Name Middle Initial
Social Security Number
Date of Birth
Street Address City State Zip
Gender: Male Female
Marital Status: Married Single
Home Phone
( )
Work Phone
( )
Completed By Employer
Average Hours Worked Per Week:
Occupation:
Earnings: Hourly Monthly Weekly Yearly
$
Date of Full-Time Employment:
Rehire Date:
Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for.
All coverage amounts are subject to the limitations and exclusions as stated in the policy.
TYPE OF COVERAGE
AMOUNT OF COVERAGE
TOTAL
PREMIUM
Voluntary Long Term Disability
Yes No*
Level 1 Plan – 50% to $2,000 max
Level 2 Plan – 60% to $4,000 max
Level 3 Plan – 60% to $7,000 max
$
E. Request for Coverages
This coverage has been offered to me and after careful consideration of the benefits, I have decided to:
REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National
Life Insurance Company. I hereby enroll for group insurance, for which I am eligible or may become eligible. If contributions are
required, I authorize my employer to deduct premiums from my salary.
NOT ENROLL myself in the Program. I understand that if I enroll for coverage at a later date, and if a physical examination or
further medical information is required, it will be at my own expense.
NOTE: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.
The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The
Lincoln National Life Insurance Company, or its insurance partners, and the initial premium is paid to The Lincoln National Life
Insurance Company. A delayed effective date will apply if the employee is not Actively at Work or an Active Member, or a dependent
is in a period of limited activity on the date insurance would otherwise take effect.
Employee Full Name: Employee Signature: Date:
TENNESSEETECHNOLOGICALUNIVERSITY
DESIGNATIONOFBENEFICIARY
EmployeeName T#:
InaccordancewiththeTTUproceduretodisbursefinalcompensationofwagesandbenefitsinthe
eventofemployeedeath,Iherebydesignatethebeneficiary(ies)listedbelow:
CompleteSection sIandIIIorSectionsIIandIII
SectionI
Idesignatepaymentofallwagesandbenefitstothesamebeneficiary(ies)designatedforretirementbenefits.
BeneficiaryName:
SectionII
Wages:(TCA830‐2‐103)
LastName FirstName Middle Soc.Sec.No. DateofBirth Sex Relationship
AnnualLeave(TCA88‐50‐808,SectionIII.E.)
LastName FirstName Middle Soc.Sec.No. DateofBirth Sex Relationship
SickLeave(TCA88‐50‐808,SectionVII)
LastName FirstName Middle Soc.Sec.No. DateofBirth Sex Relationship
CompensationTime(TCA88‐50‐808)
LastName FirstName Middle Soc.Sec.No. DateofBirth Sex Relationship
EstateAddress:
SectionIII
I,theemployee,revokeanypreviousbeneficiarynominationsanddirectthattheforgoingdesignations
supersedeanypreviouslyfiled.
EmployeeSignature: Date:
S
TATEOFTENNESSEE
(NOTARYSEAL)
Notary Public _________________________________
My Commission Expires: __________________________
_________________________ personally appeared before me this the _______ day of
_________________, ___________, who makes oath that (they) executed the foregoing instrument.
COUNTY OF PUTNAM
Dependent Information Sheet
Employee T# Effective date of coverage:
First Name MI Last Name
Date of Birth
Gender ○ M ○ F
Marital Status ○ S ○ M ○ D ○ W
Social Security Number
Home Address City ST ZIP
County a separate sheet if necessary
DEPENDENT INFORMATION
First Name MI Last Name
Date of Birth Social Security Number
Relationship Gender ○ M ○ F
Acquire date * Has this dependent ever employed/student of TTU?
Covered: ○ Medical ○ Dental ○Vision
First Name MI Last Name
Date of Birth Social Security Number
Relationship Gender ○ M ○ F
Acquire date * Has this dependent ever employed/student of TTU?
Covered: ○ Medical ○ Dental ○Vision
First Name MI Last Name
Date of Birth Social Security Number
Relationship Gender ○ M ○ F
Acquire date * Has this dependent ever employed/student of TTU?
Covered: ○ Medical ○ Dental ○Vision
First Name MI Last Name
Date of Birth Social Security Number
Relationship Gender ○ M ○ F
Acquire date * Has this dependent ever employed/student of TTU?
Covered: ○ Medical ○ Dental ○Vision
First Name MI Last Name
Date of Birth Social Security Number
Relationship Gender ○ M ○ F
Acquire date * Has this dependent ever employed/student of TTU?
Covered: ○ Medical ○ Dental ○Vision
* The acquire date is the date of marriage, birth, adoption or guardianship.
Employee Signature Date
Definitions and Required Documents
Definition Required Document(s) for Verification
Spouse: A person to whom the participant is legally married
** You will need to provide a document proving marital relationship AND a document proving joint ownership.
Proof of Marital Relationship
Government issued marriage certificate or license
Naturalization papers indicating marital status
Proof of Joint Ownership
Bank Statement issued within the last six months with both names; or
Mortgage Statement issued within the last six months with both names; or
Residential Lease Agreement within the current terms with both names; or
Credit Card Statement issued within the last six months with both names; or
Property Tax Statement issued within the last 12 months with both names; or
The first page of most recent Federal Tax Return filed showing “married filing jointly” (if married filing
separately, submit page 1 of both returns) or form 8879 (electronic filing)
** If just married in the current calendar year, a marriage certificate only is acceptable proof of eligibility
Natural (biological) child under age 26: A natural (biological) child
The child’s birth certificate; or
Certificate of Report of Birth (DS-1350); or
Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240); or
Certification of Birth Abroad (FS-545)
Adopted child under age 26: A child the participant has adopted or is in the process of legally adopting
Court documents signed by a judge showing that the participant has adopted the child; or
International adoption papers from country of adoption; or
Papers from the adoption agency showing intent to adopt
Child for whom the participant is legal guardian: A child for whom the participant is the legal guardian
Any legal document that establishes guardianship
Stepchild under age 26: A stepchild
Verification of marriage between employee and spouse (as outlined above) and birth certificate
of the child showing the relationship to the spouse; or
Any legal document that establishes relationship between the stepchild and the spouse or the
member
Child for whom the plan has received a qualified medical child support order: A child who is named as
an alternate recipient with respect to the participant under a qualified medical child support order (QMCSO)
Court documents signed by a judge; or
Medical support orders issued by a state agency
Disabled dependent: A dependent of any age (who falls under one of the categories previously listed) and
due to a mental or physical disability, is unable to earn a living. The dependent’s disability must have begun
before age 26 and while covered under a state sponsored plan.
Documentation will be provided by the insurance carrier at the time incapacitation is determined
STATE OF TENNESSEE GROUP INSURANCE PROGRAM
OPTIONAL ACCIDENTAL DEATH ENROLLMENT APPLICATION
State of Tennessee • Department of Finance and Administration • Benefits Administration
19th Floor, 312 Rosa L. Parks Avenue • Nashville, Tennessee 37243 • 615.741.3590 or 800.253.9981
AUTHORIZATION
I confirm that all the above information is accurate. I understand that providing false and/or misleading information may subject me to
disciplinary and/or legal action. I authorize my employer to deduct the required premium from my salary/wages.
I authorize the state group insurance program to release information to their life insurance contractor on behalf of myself and all family members
(name, address, social security number, age, gender, salary, enrollment effective/termination date) required to establish eligibility and coverage
levels for the purpose of obtaining life insurance coverage. This authorization shall be in force for the time period I have a pending application or
am enrolled with this life insurance company. The state group insurance program will not condition treatment, payment or enrollment eligibility
on the signature of this authorization and may not have the right to control further disclosures of this information.
I understand that a new application must be completed and returned to my agency benefits coordinator any time I want to designate a new
beneficiary. Failure to designate a beneficiary will result in the proceeds being paid to my spouse, children, parents or estate according to
applicable contract provisions in the event of my death. Dependents do not elect a beneficiary as the benefit will automatically default to me as
the employee.
Employee Signature Date
TYPE OF REQUEST ACTION FOR ENROLLMENT CHANGE
q
New Enrollment
q
Employee only
q
Employee + dependents
q
Enrollment Change
q
Add Dependent
q
Terminate Dependent
q
Update Dependent Eligibility
Effective Date of Change:
q
Terminate Coverage
q
Add/Change Beneficiary
q
Change Coverage Type to:
q
Single
q
Family
FA-0831 (rev 10/13)
EMPLOYEE INFORMATION
First Name MI Last Name Date of Birth Gender
q M q F
Marital Status
q S q M q D q W
Social Security Number Employing Agency Daytime Phone Number Edison ID
Home Address City ST ZIP Code
DEPENDENT INFORMATION
Name (First, MI, Last) Date of Birth Relationship Gender Acquire date * Social Security Number
q M q F
q M q F
q M q F
q M q F
* The acquire date is the date of marriage, birth, adoption or guardianship.
Proof of a dependent’s eligibility must be submitted with this application for all new dependents.
Complete beneficiary designation on back of this application and return to your agency benefits coordinator
RDA SW20
RESET
✔
PRIMARY BENEFICIARY DESIGNATION
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Total for Primary Beneficiary (must be 100%) Total
CONTINGENT BENEFICIARY DESIGNATION
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Name Social Security Number Relationship Percent of Benefit
Home Address City State Zip Code
Total for Contingent Beneficiary (must be 100%) Total
NOTE: Contingent beneficiary will only receive benefits if all primary beneficiaries are deceased.
Name Edison ID
OR
SSN
✔
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Forms To Complete (Tennessee Technological University)

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Completed 19 July 2020

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