Fillable INSTRUCTIONS FOR COMPLETING THE ACCIDENT PLAN APPLICATION Please (University of Wisconsin)

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INSTRUCTIONS FOR COMPLETING THE ACCIDENT PLAN APPLICATION Please (University of Wisconsin)

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Securian Financial is the marketing name for Securian Financial Group, Inc. and its affiliates. Insurance products are issued by its
affiliated insurance companies.
INSTRUCTIONS FOR COMPLETING THE ACCIDENT PLAN APPLICATION
Please complete the application form to enroll for accident insurance. Premiums for this plan will be
deducted through a payroll deduction.
If you are enrolling in Employee coverage only, complete all fields in the employee information
section.
If you are enrolling in Employee + Spouse coverage, complete all fields in the Employee and
Spouse sections.
If you are enrolling in Employee + Child coverage, complete all fields in the Employee and
Children sections.
If you are enrolling in Employee + Family coverage, complete all fields in the Employee, Spouse
and Children sections.
Sign and date the application.
RETURN the application to your HR/Payroll Specialist.
Your election to enroll for coverage must be made within 30 days of your enrollment period.
If you are not enrolling for the Accident Plan an application does not need to be submitted.
QUESTIONS: Contact your HR/Payroll specialist
CHILDREN INFORMATION
(only complete if you want coverage)
17-32520
Group Accident Insurance Enrollment
Securian Life Insurance Company
Group Customer Service
400 Robert Street North • St. Paul, Minnesota 55101-2098
Return to your Payroll Center received
SPOUSE INFORMATION
(only complete if you want coverage)
EMPLOYEE INFORMATION
(always complete for coverage)
First name
First name
Street address
Email address
Phone number
Phone number
Zip code
Last 4 digits of SSN or EE ID
Email address
Date of birth
Date of birth
City State
Amount of insurance elected
Supplemental Plan
Middle initial
Middle initial
Last name
Last name
Date of employment
EMPLOYER NAME: State of Wisconsin POLICY NUMBER: 76038
AUTHORIZATION
I understand that Securian Life Insurance Company shall incur no liability until the first premium is paid, and that
premiums for the contributory insurance will be deducted from my pay. The information submitted is true and complete
to the best of my knowledge and belief. I have reviewed all applicable eligibility requirements for the coverage(s) I have
elected and certify all such requirements have been met.
Date of birth Date of birthChild nameChild name
Employee signature
X
Employee name (please print) Date signed
x
EdF94069 9-2019
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INSTRUCTIONS FOR COMPLETING THE ACCIDENT PLAN APPLICATION Please (University of Wisconsin)

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Completed 10 October 2020

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