3.540 RCUH Group Life Insurance
RCUH Life Insurance Change Form (75-100% FTE) (B-5L)
Employee Name:______________________________________ RCUH Employee ID#:_______________
SECTION I: Life Insurance Change Request or Waiver of Coverage Acknowledgement
The RCUH provides Group Life Insurance benefits to regular employees working 75% FTE or more. Eligible employees will receive
a life insurance benefit of two (2) times their annual salary rounded upward to the next higher $1,000, if not a multiple thereof, not to
exceed $600,000 (default option). For more information, see RCUH Policy No. 3.540.
Imputed Income
The Internal Revenue Service (IRS) Code states that any life insurance coverage in excess of $50,000 provided by an employer,
regardless of who pays the premium, is subjected to taxation in accordance with its imputed income tax table. Therefore,
coverage values in excess of $50,000 will be subject to the imputed income tax withholding.
I have elected not to take advantage of the full life insurance benefit and instead elect (Please note, by reducing your full life insurance
benefit, you will need to go through Medical Underwriting if you wish to buy back up to the full life insurance benefit at a later time):
Employee Life Insurance benefit of two (2) times my annual salary rounded upward to the next higher $1,000 to a maximum of $200,000.
Employee Life Insurance benefit of two (2) times my annual salary rounded upward to the next higher $1,000 to a maximum of $100,000.
Employee Life Insurance benefit of two (2) times my annual salary rounded upward to the next higher $1,000 to a maximum of $50,000.
Decline any Group Life Insurance benefits/coverage in its entirety.
SECTION II: Life Insurance Beneficiary Designation
The Beneficiary(ies) of my RCUH Life Insurance Plan provided through RCUH’s Group Life Insurance Carrier is/are as follows:
Percent of Benefit (totals must equal 100%):
Beneficiary Name: Relationship: Primary Contingent _____%
Phone Number: Email:_________________________
Mailing Address:________________________________________________________
Beneficiary Name: Relationship: Primary Contingent _____%
Phone Number: Email:_________________________
Mailing Address:________________________________________________________
Life Insurance companies generally will not disburse payments directly to minor beneficiaries. Payment will normally be made to the legally recognized guardian of
the minor beneficiary, executor of the estate, or RCUH’s Group Life Insurance Carrier.
SECTION III: Employee Certification
• I understand that RCUH has provided me the opportunity to enroll in the Group Life Insurance plan (default option: two (2)
times my annual salary not to exceed $600,000) for myself.
• I further understand that if I wish to switch my election in the future or apply for Group Life Insurance benefits at a later date, I will
be required by RCUH Life Insurance Carrier to provide evidence of insurability and be approved prior to any additional coverage
taking effect.
• I certify the designation of the beneficiary(ies) listed above.
Employee Signature: Date:
RCUH will only accept WET SIGNATURES
RCUH is committed to protecting the security of your personal information.
Please submit via encrypted email to: rcuh_benefits@rcuh.com or FAX: 808-956-5022
RCUH USE ONLY Authorized By:
RCUH Form B-5L rev 03/20/19, 04/30/2019, 03/12/2020, 05/03/2020, 05/08/2020
