SI 7533D-134892 (4/17) 1 of 2 (8/03)
Standard Insurance Company Enrollment and Change Form
Mark all boxes and complete all sections that apply. Return completed form to your Human Resources Department.
Your Name (Last, First, Middle)
Group Name
Kentucky Community and Technical College System
Group Number(s)
Your Address
Your Soc. Sec. No.
Male Female
Job Title/Occupation
Employee ID No.
Earnings $______________ Per: Hour Wk Mo Yr
Check with your Human Resources Department about coverage options available to you and Evidence Of Insurability requirements.
Life Insurance
Life with AD&D Employer Paid
Additional/Optional Life
Additional/Optional Life with AD&D Your requested amount 1x Annual Earnings 4x Annual Earnings
2x Annual Earnings 5x Annual Earnings
3x Annual Earnings
Dependents Life Insurance
Spouse / Children Requested Amounts
Option 1: Spouse $10,000 / Child $5,000 Option 2: Spouse $5,000 / Child $3,000
Option 3: Spouse $5,000 / No Child Coverage Option 4: Spouse $10,000 / No Child Coverage
Option 5: No Spouse Coverage / Child $5,000
Spouse Name______________________________ Date of Birth______________________________
This designation applies to Life/Life with AD&D Insurance available through your Employer, if any. Designations are not valid unless signed,
dated, and delivered to the Employer during your lifetime. See page 2 for further information.
Primary - Full Name Address Soc. Sec. No. Relationship % of Benefit
Contingent - Full Name Address Soc. Sec. No. Relationship % of Benefit
Use this section only when you wish to make a change after insurance becomes effective. Complete all boxes and sections that apply.
Beneficiary Change Complete Beneficiary Section above.
Add/Change Additional/Optional Coverage Date _______________
Add/Change Dependent Coverage Date __________________
Address Change Name Change Former Name ____________________________________ Other _______________________
Use this section only when you wish to terminate coverage after insurance becomes effective. Complete all boxes and sections that apply.
Terminate Additional/Optional Coverage Date ___________________
Terminate Dependent Coverage Date ___________________
I wish to make the choices indicated on this form. If electing coverage, I authorize deductions from my wages to cover my
contribution, if required, toward the cost of insurance. I understand that my deduction amount will change if my coverage or costs
Member/Employee Signature Required
Date (Mo/Day/Yr)
SI 7533D 2 of 2 (8/03)
Beneficiary Information
Your designation revokes all prior designations.
Benefits are only payable to a contingent Beneficiary if you are not survived by one or more primary
If you name two or more Beneficiaries in a class:
1. Two or more surviving Beneficiaries will share equally, unless you provide for unequal shares.
2. If you provide for unequal shares in a class, and two or more Beneficiaries in that class survive, we will pay
each surviving Beneficiary his or her designated share. Unless you provide otherwise, we will then pay the
share(s) otherwise due to any deceased Beneficiary(ies) to the surviving Beneficiaries pro rata based on the
relationship that the designated percentage or fractional share of each surviving Beneficiary bears to the
total shares of all surviving Beneficiaries.
3. If only one Beneficiary in a class survives, we will pay the total death benefits to that Beneficiary.
If a minor (a person not of legal age), or your estate, is the Beneficiary, it may be necessary to have a guardian
or a legal representative appointed by the court before any death benefit can be paid. If the Beneficiary is a trust
or trustee, the written trust must be identified in the Beneficiary designation. For example, “Dorothy Q. Smith,
Trustee under the trust agreement dated .”
A power of attorney must grant specific authority, by the terms of the document or applicable law, to make or
change a Beneficiary designation. If you have any questions, consult your legal advisor.
Dependents Insurance, if any, is payable to you, if living, or as provided under your Employer’s coverage under
the Group Policy.