Pacific Guardian Life
Basic
HSTA Voluntary Employees Beneficiary Association Trust
Group Life Insurance Enrollment Application
New Change Cancel
Social Security #
Name (last, first, mi)
HSTA-VEBA Trust ID#
Street Address
Male
Female
City
State
Zip Code
Date of Birth
/ /
Home Telephone
( )
School/Work Telephone
( )
Name of School
Date Employed Date of Membership Membership Type:
Active
Retired
It is important that your beneficiary designation be clear so that there will be no question as to your meaning. The beneficiary designation may be
changed at any time. The designation takes effect as of the date the completed form is received and accepted by HSTA Voluntary Employees Beneficiary
Association Trust.
Beneficiary Information
Name (last, first, mi):
Relationship:
Primary
Address:
SSN: DOB:
Name (last, first, mi):
Relationship:
Primary
Contingent
Address:
SSN: DOB:
Name (last, first, mi):
Relationship:
Primary
Contingent
Address:
SSN: DOB:
Name (last, first, mi):
Relationship:
Primary
Contingent
Address:
SSN: DOB:
Name (last, first, mi):
Relationship:
Primary
Contingent
Address:
SSN: DOB:
I certify that the information provided is true and complete. I authorize HSTA-VEBA Trust to set the effective date of coverage and to make the
deductions, adjustments or cancellations from my salary, wages, pension or other compensation for the monthly premium.
Employee Signature: ___________________________________Date:__________________
HSTA-VEBA
Trust use
Effective/Change Date: Termination Date:
This life insurance plan is underwritten by:
Pacific Guardian Life Insurance Company, Limited
