Fillable Standard Long Term Disability Insurance Enrollment Form and (West Virginia Northern Community College)

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Standard Long Term Disability Insurance Enrollment Form and (West Virginia Northern Community College)

On average this form takes 6 minutes to complete

The Standard Long Term Disability Insurance Enrollment Form and (West Virginia Northern Community College) form is 1 page long and contains:

  • 1 signature
  • 11 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

U.S.A. forms for West Virginia Northern Community College

BROWSE WEST VIRGINIA NORTHERN COMMUNITY COLLEGE FORMS

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Standard Long Term Disability Insurance
Enrollment Form
and
Calculation Worksheet
Employee Name:
Social Security
Number:
Telephone
Number:
Street Address:
City, State, Zip:
I wish to enroll in the voluntary Long Term Disability.
I wish to decline enrollment in the voluntary Long Term Disability.
Human Resource Office/Payroll Use Only
Effective Payroll Date: Completed by:
Employee Signature Date
Monthly Salary:
65 & Over
55-59
60-64
Under 30
50-54
35-39
30-35
45-49
40-44
Age Income Percent Annuity Percent
0.00034
0.00038
0.00081
0.00163
0.00017
0.00149
0.00060
0.00123
0.00075
0.00135
0.00151
0.00227
0.00306
0.00450
0.00690
0.00167
0.00515
0.00547
Locate your age on the chart, record Income Percent = , then multiply by your monthly salary to equal
Income Premium =
Locate your age on the chart, record Annuity Percent = , then multiply by your monthly salary to equal
Annuity Premium =
Income Premium and Annuity Premium added together equal your Total Monthly LTD Premium =
Date:
Hire Date:
(Complete worksheet below)
Instructions
In order to complete the
calculation, you must tab through
after you record your
percentages.
Print, sign, and return form to the Human Resource Office.
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Standard Long Term Disability Insurance Enrollment Form and (West Virginia Northern Community College)

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Completed 27 July 2020

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