I REQUEST COVERAGE under the Long Term Disability Insurance Plan through my employer’s group
insurance contract, as now or hereafter applicable to me, and authorize the appropriate deductions from my
wages. PLEASE CHOOSE AN OPTION BELOW: Options 1 through 3 pay a maximum benefit of $6000
less deductible sources of income
Option 1 – 50% with 6– month elimination period
Option 2 – 60% with 4– month elimination period
Option 3 – 60% with 3– month elimination period
I DECLINE COVERAGE under the Long Term Disability Insurance Plan. I understand that if I desire to apply at
a later date for the benefits that I have declined, I will have to furnish evidence of insurability and be approved by
Prudential.
FLORIDA RESIDENTS – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
NEW YORK RESIDENTS – Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or 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 five thousand dollars
and the stated value of the claim for each such violation.
I have read and understand the terms and requirements of the fraud warnings included as part of this form.
__________________________________________ ____________________
Employee Signature Date
Effective Date of Coverage: ___________ Benefit Administrator’s Signature: _______________________
Important: If a change is due to reclassification and the employee wishes to remain in his or her original plan, he or
she must complete Reclassification Form B indicating his or her intent not to change plans.
