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)
Kentucky Community and Technical College System
Earnings $______________ Per: Hour Wk Mo Yr
Check with your Human Resources Department about coverage options available to you and Evidence Of Insurability requirements.
Life with AD&D Employer Paid
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