Fillable LifeEnrollment2010final - EP Generic

Fill Online, Printable, Fillable, Blank LifeEnrollment2010final - EP Generic Form

Use Fill to complete blank online SOUTHERN COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

LifeEnrollment2010final - EP Generic

On average this form takes 33 minutes to complete

The LifeEnrollment2010final - EP Generic form is 4 pages long and contains:

  • 0 signatures
  • 2 check-boxes
  • 131 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Southern College

BROWSE SOUTHERN COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Underwritten by Hartford Life And Accident Insurance Company. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including
issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by
Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in
force or discontinued.
North American Division of Seventh-day Adventists
Enrollment Period
9/22/09
Income Protection Benefits
Information About You
Name:
Social Security Number:
Employer (Conference, School, etc.):
Title:
Effective Date: 6/1/2010 Date of Birth: Date of Hire:
Instructions
Please enter all required information clearly so that there will be no question as to your meaning.
• Step 1: Please enter and/or check your coverage elections and details. You may only elect – and will be covered for – levels of
coverage included in your employer’s contract.
• Step 2: Your costs should be calculated based on your age and Salary as of your effective date.
• Step 3: Please sign, date and return this form to your Human Resource representative by 4/15/10.
Supplemental Life Insurance
You can purchase Supplemental Life Insurance in increments of $10,000. The maximum amount you can purchase cannot be more than 7
times your annual Salary or $750,000. If you are currently participating in this coverage and currently have an amount more than or equal to
3 times your Salary or $250,000, whichever is less, you may increase your coverage by $10,000 without providing evidence of insurability.
Additional coverage amounts will require evidence of insurability that is satisfactory to The Hartford before the excess can become effective.
If you are newly eligible and electing for the first time or are currently enrolled with an amount less than 3 times your Salary or $250,000,
whichever is less, you may elect an amount up to the guaranteed issue amount of the lesser of 3 times your annual Salary or $250,000
without providing evidence of insurability. Additional coverage amounts will require evidence of insurability that is satisfactory to The
Hartford before the excess can become effective.
Salary calculations for figuring guaranteed issue: Your salary plus tuition assistance and other taxable income. (Include parsonage
allowance or voluntary pre-tax contributions such as 403b retirement contributions, education IRA's, or section 125 benefits.)
$__________________ x 3 = $_____________________.
Salary Guaranteed Issue Maximum**
**Your Guaranteed Issue Maximum should be rounded down to the next lower $10,000 if not an even multiple thereof.
Current Coverage
(including GI amount) if
applicable
Additional (or new)
Coverage Requested
*Total Coverage /Life
Benefit amount
Employee Supplemental Life
Spouse Supplemental Life
Dependent Child Supplemental
Life
Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+
Rate $0.55 $0.55 $0.61 $0.67 $0.92 $1.39 $2.26 $3.91 $4.19 $7.33 $13.05 $20.77 $29.51 $46.42 $77.57
To calculate your Monthly cost, please use the following formula(s):
÷ $10,000 = x = $
*Life Benefit Amount Rate Above My Monthly Cost *
I elect to purchase the total amount of $________________ in Life coverage.
North American Division of Seventh-day Adventists
Supplemental Life Benefits Enrollment Form
Clear Form
0
$0
$0
$0
$0
0
0.00
0
Name: _______________________________________________________________________________
Underwritten by Hartford Life And Accident Insurance Company. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including
issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by
Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in
force or discontinued.
North American Division of Seventh-day Adventists
Enrollment Period
9/22/09
Spouse Supplemental Life Insurance
If you elect Supplemental Life Insurance for yourself, you may elect Spouse Supplemental Life Insurance in increments of $10,000. The
maximum amount you can purchase cannot be more than the lesser of $250,000 or 100% of your elected and approved Supplemental Life
Insurance. If you are currently participating in this coverage and currently have an amount more than or equal to $30,000 you may increase
your coverage by $10,000 without providing evidence of insurability. Additional coverage amounts will require evidence of insurability that is
satisfactory to The Hartford before the excess can become effective.
If you are newly eligible and electing for the first time or are currently enrolled with an amount less than $30,000 you may elect an amount up
to the guaranteed issue amount $30,000 without providing evidence of insurability. Additional coverage amounts will require evidence of
insurability that is satisfactory to The Hartford before the excess can become effective.
Costs are based on your Spouse’s age.
Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+
Rate $0.55 $0.55 $0.61 $0.67 $0.92 $1.39 $2.26 $3.91 $4.19 $7.33 $13.05 $20.77 $29.51 $46.42 $77.57
To calculate your Monthly cost, please use the following formula(s):
÷ $10,000 = x = $
Life Benefit Amount Rate Above My Monthly Cost*
I elect to purchase the total amount of $________________ in Life coverage for my Spouse.
SPOUSE:
First Name Last Name Gender Date of Birth Date of Marriage
Child(ren) Supplemental Life Insurance
If you purchase Supplemental Life Insurance for yourself, you may purchase Child(ren) Supplemental Life Insurance for your Dependent
Child(ren) between the ages of Live Birth and 19 years (26 years if a full time student) in increments of $1,000. The maximum amount you
can purchase is $25,000.
Please
your election.
I Elect Life
in the total
amount of
and My
Benefit
Will Be:
My total
Monthly
Cost for all
my
Covered
Child(ren)
Will Be:
I Elect Life in
the total
amount of
and My
Benefit Will
Be:
My total
Monthly
Cost for
all my
Covered
Child(ren)
Will Be:
I Elect Life in
the total
amount of
and My
Benefit Will
Be:
My total
Monthly
Cost for
all my
Covered
Child(ren)
Will Be:
I Elect Life
in the total
amount of
and My
Benefit Will
Be:
My total
Monthly
Cost for
all my
Covered
Child(ren)
Will Be:
I Elect Life in the
total amount of
and My Benefit
Will Be:
My total
Monthly
Cost for
all my
Covered
Child(ren)
Will Be:
$1,000 $0.19 $6,000 $1.15 $11,000 $2.11 $16,000 $3.07 $21,000 $4.03
$2,000 $0.38 $7,000 $1.34 $12,000 $2.30 $17,000 $3.26 $22,000 $4.22
$3,000 $0.58 $8,000 $1.54 $13,000 $2.50 $18,000 $3.46 $23,000 $4.42
$4,000 $0.77 $9,000 $1.73 $14,000 $2.69 $19,000 $3.65 $24,000 $4.61
$5,000 $0.96 $10,000 $1.92 $15,000 $2.88 $20,000 $3.84 $25,000 $4.80
$0
0
0
Name: _______________________________________________________________________________
Underwritten by Hartford Life And Accident Insurance Company. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including
issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by
Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in
force or discontinued.
North American Division of Seventh-day Adventists
Enrollment Period
9/22/09
CHILD(REN):
First Name Last Name Date of Birth Gender
Beneficiary Designation
You must select your beneficiary – the person (or more than one person) or legal entity (or more than one entity) who receives a benefit
payment if you die while covered by the plans. This beneficiary designation will be for ALL group life insurance coverage issued by
The Hartford for you, unless specifically named otherwise. Please make sure that you also name a contingent beneficiary – who would
receive your benefit if your primary beneficiary dies first.
Please make sure your beneficiary designation is clear so that there will be no question as to your meaning. If you name more than one
primary or contingent beneficiary, show the percentage of your benefit to be paid to each beneficiary. Please provide all of the information
requested below. If your beneficiary is not related either by blood or by marriage, insert the words, “Not Related” as their stated relationship.
If you need assistance, contact your benefits administrator or your own legal advisor.
Full Name Address
Social
Security #
Relationship
Date of
Birth
Percent-
age
Primary
Beneficiary
Contingent
Beneficiary
The beneficiary for insurance on the lives of your spouse and children will automatically be you, if surviving. Otherwise, the beneficiary will
be the estate of the spouse and children, subject to policy provisions. A beneficiary for employee Life Insurance may be changed upon
written request.
Spousal Consent For Community Property States Only: If you live in a community property state – Arizona, California, Idaho, Louisiana,
Nevada, New Mexico, Texas, Washington, or Wisconsin – you may complete the Spousal Consent section, which allows your spouse to
waive his or her rights to any community property interest in the benefit. Disclaimer: Spousal consent does not apply to ERISA plans.
This will certify that, as spouse of the Employee named above, I hereby consent to my spouse designating the person(s) listed above as
beneficiaries of group life insurance under the above policy and waive any rights I may have to the proceeds of such insurance under
applicable community property laws. I understand that this consent and waiver supersede any prior spousal consent or waiver under this
plan.
Signature of Employee’s Spouse: ________________________________ Date: ______________________________
%
%
%
%
Name: _______________________________________________________________________________
Underwritten by Hartford Life And Accident Insurance Company. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including
issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by
Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in
force or discontinued.
North American Division of Seventh-day Adventists
Enrollment Period
9/22/09
Confirmation
I acknowledge that I have been given the opportunity to enroll in the Life insurance coverage described in the Benefit Highlight Sheets and
offered through North American Division of Seventh-day Adventists.
I understand and agree that if I decline coverage now, but later decide to enroll, I will be required to provide evidence of insurability that is
satisfactory to The Hartford and be approved for such coverage before it becomes effective. I understand my request for coverage may be
denied by The Hartford.
I understand and agree that insurance will go into effect and remain in effect only in accordance with the provisions, terms and conditions of
the insurance policy. I understand and agree that only the insurance policy issued to the policyholder (your employer) can fully describe the
provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the enrollment
form and the insurance policy, I agree to be bound by the insurance policy.
If I have life insurance coverage with The Hartford, I understand and agree that my life insurance benefit is reduced at a specified age stated
in the policy.
I authorize my employer to make the appropriate payroll deductions from my earnings.
I understand that no insurance will be valid or in force if I am not eligible in accordance with the terms of the group policy as issued to my
employer. I acknowledge and agree that if group participation requirements are not met, this policy will not be implemented and the
coverage I have elected will not be in force.
Signed Date
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

LifeEnrollment2010final - EP Generic

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document