Submit completed form to your employer and retain a copy for your records.
Group insurance products and services described herein are issued by Liberty Life Assurance Company of Boston, a Lincoln Financial Group company. Home Office:
Boston, MA. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial
and contractual obligations. ©2018 Lincoln National Corporation. All rights reserved.
Roger Williams University Enrollment Form
Please return completed form to your benefits department
Roger Williams University
Employer Address (City, State, ZIP Code)
Employee Name (Last, First, Middle)
Address (City, State, ZIP Code)
Male
Female
Single
Married
Divorced
Widowed
Hire Date (MM/DD/YY)
Annual Salary
Type of Enrollment
$
New Employee
Qualified Life Event
Rehire Rehire Date:
Coverage Elections
Please indicate your coverage elections below. The Employee must enroll in Optional Life and Accidental Death & Dismemberment
(AD&D) coverage to elect Optional Dependent Life and AD&D coverage. The Optional Spouse Benefit cannot be greater than the
Employee Optional Benefit. Evidence of Insurability may be required. Please see your plan booklet for additional information.
Employee Optional Life and AD&D
Yes
No
$
Spouse Optional Life and AD&D
Yes
No
$
Child(ren) Optional Life and AD&D
If electing for Dependent coverage (Spouse and Child), please complete the following:
Spouse Name: Date of Birth:
Child Name: Date of Birth:
Child Name: Date of Birth:
Child Name: Date of Birth:
Dependent Child(ren) coverage is available to eligible dependent child(ren) under 26 years of age.
Employee Signature and Authorization
ACCEPT: I declare that all information given in this enrollment form is true and complete to the best of my knowledge and belief. I request
coverage under my employer’s plan of benefits as indicated above. I authorize my employer to deduct from my earnings my contributions for
the coverage(s) selected. I understand that with respect to coverages I have declined, Lincoln Financial Group has the right to require
Evidence of Insurability in order to consider any later request to change this decision and that my request may be denied. I am an employee
in active employment working at the employer’s regular place of business.
DECLINE: I hereby decline all optional coverage as offered by my employer. I certify that I have been given the opportunity by my employer to
enroll for coverage. I understand that Lincoln Financial Group has the right to require Evidence of Insurability in order to consider any later
request to change this decision and that my request may be denied. I am an employee in active employment working at the employer’s
regular place of business.
Employee Signature: Date:
Completion of this enrollment form does not guarantee coverage. Evidence of Insurability may be required. Please see your plan
booklet for additional information.
1 Old Ferry Road, Bristol, RI 02809
