HR Dept. – Complete this section. Retain form for your records.
DENTAL
BENEFICIARY
SIGNATURE
Enrollment and Change Form
Standard Life Insurance Company of New York
SNY 10789-B 1 of 2 (5/04)
COVERAGE SECTION
APPLICANT
CHANGE
Your Name (Last, First, Middle) Group Name Group Number(s)
Your Address City State Zip
Your Soc. Sec. No. Date of Birth
Male
Female
Job Title/Occupation
Mark all boxes and complete all sections that apply. Return completed form to your Human Resources Department (HR Dept.).
For questions about the coverage options available to you, and any Evidence Of Insurability requirements, ask your HR Dept.
1. Life Insurance
Life
Life with AD&D Employer paid amount $
Additional/Optional Life
Additional/Optional Life with AD&D Your requested amount $
2. Voluntary Life Insurance
Voluntary Life
Voluntary Life with AD&D Your requested amount $
3. Dependents Life Insurance
Life
Life with AD&D Employer paid amount $
Spouse requested amount $ Spouse Name Date of Birth
Children requested amount $
4. Supplemental Life Insurance
Supplemental Life Your requested amount $ Spouse requested amount $
5. Short Term Disability
Employer Paid
Enhanced (Buy-up)
Voluntary STD
6. Long Term Disability
Employer Paid
Enhanced (Buy-up)
Voluntary LTD
MAPB
7. Dental (See below)
Employer Paid
High Plan
Voluntary Dental
Marital Status
Single
Married
Divorced
Coverage requested for
You, your Spouse and Children
You and your Spouse
You only
You and your Children (no Spouse)
Are you covered for dental insurance under another plan?
Yes
No Are one or more Dependents?
Yes
No
Spouse Child 2
Child 1 Child 3
List Dependents to enroll or delete.
(Last name if different, First, Middle Initial)
List Dependents to enroll or delete.
(Attach sheet for additional Dependents if needed)
M F
Sex
Date of
Birth
M F
Sex
Date of
Birth
Dental Insurance Waiver: Contributory Dental Insurance
The Dental Insurance coverage available to me and my Dependents has been explained to me and I do not want to enroll at this time.
I understand that if I elect to enroll in the future, the Dental Insurance coverage may be subject to a Late Enrollment Penalty.
I decline Dental Insurance for myself
I decline Dental Insurance for one or more Dependents
This designation applies to coverage available through your Employer, if any, under Coverage Section 1 or 2 above. Unless specified otherwise on
a separate sheet, this designation will also apply to coverage available through your Employer, if any, under Coverage Section 4 above.
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.
Add Dependent
Delete Dependent
Name Change
Beneficiary Change
Date of add/delete Former name
Other
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 change.
Fraud Notice – Only applies to Accident and Health Insurance (AD&D/Disability/Dental): Any person who knowingly and with intent
to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially
false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the
claim for each such violation.
Member/Employee Signature Required Date (Mo/Day/Yr)
Dvsn ID
Billing Cat. Date of Hire/Rehire Hrs Worked Per Wk
Earnings $ Per:
Hour
Wk
Mo
Yr
