Fillable Here is your Enrollment Form. (Daemen College)

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Here is your Enrollment Form. (Daemen College)

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Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
ENROLL 18 NY Continue on Next Page. . .
1
Lincoln Life & Annuity
Company of New York
Home Office: 100 Madison St., Ste 1860, Syracuse, NY 13202
All Group Insurance questions and correspondences sent to:
Group Insurance Service Office
P.O. Box 2616, Omaha, NE 68103-2616
Phone (800) 423-2765 Fax (877) 573-6177
Here is your Enrollment Form.
Group ID: DAEMEN2
1. Your Personal Information
Group/Employer/Participating Organization Name
Daemen College
County
Zip
State
Your First Name MI Last Name
Employee ID No.
Date of Birth
/ /
Street Address (Include Apt. or Suite No.)
City
State
Zip
Home Phone
( ) -
Cell Phone
( ) -
Work Phone
( ) -
Email Address
Gender: Male Female
Marital Status: Married Single
2. Personal Information on Dependents — Complete if you are enrolling dependents.
Spouse
First Name Middle Name/MI Last Name
Provide contact information if different than Your information above.
Home Phone
( ) -
Cell Phone
( ) -
Work Phone
( ) -
Email Address
Dependent Children – List all children you are enrolling (attach a separate sheet, if needed).
First Name Middle Name/MI Last Name
Gender
Male Female
DOB
/ /
Full-time Student
Yes No
Male Female
/ /
Yes No
Male Female
/ /
Yes No
Employer Completes this Section.
Billing Division or Location:
Sort Group/Code: Payroll Cycle:
Policy #(s):
Average Hours Worked Per Week:
Full-time Part-time
Occupation:
Earnings: Hourly Weekly Monthly Yearly $
Date of Employment: / /
Actively at Work? Yes No
Date of Rehire: / /
Follow these steps to complete the form.
Print clearly in ink.
Step 1: Fill in or confirm your personal information.
Step 2: Fill in dependent information, if any.
Step 3: Select your benefits.
Step 4: Assign beneficiaries.
Step 5: Confirm enrollment.
Step 6: Sign, date & return the form.
ENROLL 18 NY Continue on Next Page. . .
2
3. Benefit Selection - Choose your benefits.
Employer Completes
this section.
Type of Insurance
Amount of
Insurance
Total Premium
(Weekly)
Class
Effective Date
/ /
Voluntary Life Only Yes No*
$
$
/ /
Voluntary Dependent (Spouse Only)
Life Only Yes No*
You must be enrolled for Life insurance in order to add
spouse and/or child insurance.
$
$
/ /
Voluntary Dependent (Child Only)
Life Only Yes No*
You must be enrolled for Life insurance in order to add
spouse and/or child insurance.
$
$
*By selecting “No,” application for insurance at a later date may require further medical information and/or a physical exam, which
will be at my own expense.
--Actual deductions may vary slightly from above illustrations due to rounding--
ENROLL 18 NY Continue on Next Page. . .
3
4. Select Your Beneficiaries — Choose who receives your insurance benefits.
Primary Beneficiary(ies)
The Primary Beneficiary is the person(s) you identify to receive insurance benefits upon your death.
If more than three Primary Beneficiaries, please attach a separate sheet of paper.
If multiple Primary Beneficiaries, total percentage of all combined must equal 100%.
First Name Middle Initial Last Name
Street Address
City
State
Zip
Social Security Number
- -
Date of Birth
/ /
Relationship to You
Percentage
%
Phone Number
( ) -
First Name Middle Initial Last Name
Street Address
City
State
Zip
Social Security Number
- -
Date of Birth
/ /
Relationship to You
Percentage
%
Phone Number
( ) -
First Name Middle Initial Last Name
Street Address
City
State
Zip
Social Security Number
- -
Date of Birth
/ /
Relationship to You
Percentage
%
Phone Number
( ) -
Contingent Beneficiary(ies) and Other Beneficiary Designations
A Contingent Beneficiary will receive benefits only if the Primary Beneficiary(ies) does not survive you. Please attach a separate
sheet to identify a Contingent Beneficiary. If multiple Contingent Beneficiaries, total percentage of all combined must equal 100%.
To name a Beneficiary(ies) by product, attach a separate sheet identifying product and beneficiary.
ENROLL 18 NY
4
5. Confirm Enrollment
This group insurance has been offered to me and after careful consideration of the benefits, I have decided to:
ENROLL FOR INSURANCE for which I am or may become eligible under the group policies issued by Lincoln Life & Annuity
Company of New York, or its insurance partners. If contributions are required, I authorize my Employer to deduct premium
from my pay.
NOT ENROLL myself in the group insurance offered. I understand if I enroll for insurance at a later date, and if a physical
examination or further medical information is required, it will be at my own expense.
NOT ENROLL my dependents in the group insurance offered. I understand if I enroll my dependents for insurance at a later
date, and if a physical examination or further medical information is required, it will be at my own expense.
Fraud Warning/State Disclosure(s)
THIS WARNING DOES NOT APPLY TO APPLICATION FOR LIFE INSURANCE:
ACCIDENT AND HEALTH INSURANCE FRAUD. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF CLAIM CONTAINING ANY
MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT
MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL
PENALTY NOT TO EXCEED $5000 AND THE STATED VALUE OF THE CLAIM FOR EACH VIOLATION.
ACCELERATED DEATH BENEFIT INFORMATION. THIS BENEFIT IS INCLUDED WITH EMPLOYEE LIFE INSURANCE, AT NO ADDITIONAL
PREMIUM CHARGE OR COST OF INSURANCE CHARGE. NO LIEN, DISCOUNT, OR ADMINISTRATIVE CHARGE IS ASSOCIATED WITH
THIS BENEFIT. RECEIPT OF ACCELERATED DEATH BENEFITS MAY AFFECT ELIGIBILITY FOR PUBLIC ASSISTANCE PROGRAMS AND
MAY BE TAXABLE. FOR THIS REASON, EMPLOYEES SHOULD CONSULT THEIR PERSONAL TAX ADVISORS BEFORE CLAIMING THIS
BENEFIT.
FOR CRITICAL ILLNESS AND ACCIDENT INSURANCE: THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE
FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY
RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.
INSURANCE FOR SHORT TERM DISABILITY, LONG TERM DISABILITY, AND/OR CRITICAL ILLNESS MAY CONTAIN A PRE-EXISTING
CONDITION EXCLUSION. PLEASE SEE YOUR CERTIFICATE FOR MORE INFORMATION.
6. Sign and Return
I understand the group insurance requested will not be effective until approved by the Group Insurance Service Office of Lincoln
Life & Annuity Company of New York, or its insurance partners. A delayed effective date will apply if you are not Actively at Work/an
Active Member. A delayed effective date may apply to your dependent, if he or she is confined in a hospital or health care facility
or is in a period of limited activity on the date insurance would otherwise take effect.
I understand the information provided is for enrollment in group insurance as offered by my Employer and will not be used for
underwriting purposes.
By signing below, you agree that all statements made above are to the best of your knowledge and belief.
THIS WARNING DOES NOT APPLY TO APPLICATION FOR LIFE INSURANCE:
ACCIDENT AND HEALTH INSURANCE FRAUD. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY
FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL
THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT
TO EXCEED $5000 AND THE STATED VALUE OF THE CLAIM FOR EACH VIOLATION.
Your Full Name (Print):
Your Signature: X Date / /
Complete and return this form.
(Be sure to sign and date the form to start your insurance.)
Questions? Call 800-423-2765
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Completed 29 January 2021

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