COVERAGE ELECTIONS: Your employer will inform you of available coverage. Check yes to enroll; check no if you decline or
coverage is not available.
Life/AD&D Yes No Dependent Life Yes No LTD Yes No STD Yes No
AMOUNT OF COVERAGE SELECTED FOR:
LIFE/AD&D You: Spouse: Child:
Note: If you have chosen coverage over the Guarantee Issue amount for you or your spouse, you will also need to complete
an Evidence of Insurability form. The amount of coverage over your Guarantee Issue amount will be subject to medical
underwriting and will become effective on the rst of the month coincident with or next following the date Unum approves
your Evidence of Insurability form. If you DO NOT APPLY FOR coverage for you or your dependent (s) during your or their
initial enrollment period, you will need to complete an Evidence of Insurability form for all amounts of coverage. You may
complete and electronically submit an Evidence of Insurability form—please see your Plan Administrator.
Beneficiary Information:
Name (last name, first, middle initial): Relation to You: Benefit %:
If the beneficiary(ies) named above are not living, then pay:
Request for Signature and Certification: I understand that my coverage may be subject to exclusions, limitations, delayed effec-
tive dates and benet offsets, as described in the enrollment materials or employee booklet(s) that have been provided to me by
my employer. I certify that all statements are true to the best of my knowledge and belief and I understand that a copy of this form
will be made available to me at my request. I authorize my employer to make the necessary deductions from my salary or wages
to pay the premium when my insurance becomes effective. I understand that my payroll deduction amount will change if my cover-
age or costs change.
_______________________________________ _______________ __________________ __________________
Employee Signature Date Work Phone Home Phone
AE-1107 RETAIN A COPY OF THIS FORM FOR YOUR RECORDS AND SEND A COPY TO YOUR EMPLOYER
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
GROUP INSURANCE ENROLLMENT FORM
Unum Life Insurance Company of America
2211 Congress Street, Portland, ME 04122
Employee Social Security Number Gender Date of Birth
(mm/dd/yyyy) Hours Worked Per Week
M F
/ /
Employee First Name M.I. Last Name
Employee Street Address City State Zip Code
Original Date of Hire Annual Salary Occupation
/ /
Exempt Non-Exempt
Date entered into an eligible class (ex: part time to full time) or
Rehire Date or
Date of promotion to an eligible class Spouse First Name (if coverage is selected) Spouse Date of Birth (mm/dd/yyyy)
/ / / /
Policyholder Name Policy No. Division No.
Please print legibly and complete this form in its entirety. Blank fields will cause significant delays in processing.
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