SI 7533D-101770
3/11
1of 2
10/09
Standard Insurance Company Enrollment and Change
CSU Benefits Team, 920 SW 6
th
Ave., Portland, OR 97204 Vol. Trust Life-VT 101770-A/ Vol. AD&D-648371-A/ Vol. LTD-648379-A
Check with your plan administrator, or call The Standard at 800.378.5745, if you have any questions concerning the coverage options
that apply to your group. Please mail completed form to the address above.
To Be Completed By Member Check all boxes and complete all sections that apply.
Your Name (Last, First, Middle) Your Social Security Number
Birth Date
Male Female
Your Address
City
State ZIP Phone Number
Employer Name
The California State University
Job Title/Bargaining Unit Campus
Date of Hire Hours Worked Per Week
Earnings $________________ Per: Hour Week Month Year
Change Use this section only when you wish to make a change after insurance becomes effective.
Beneficiary Change (Use Beneficiary Section Below) Name Change Former name _______________________________________
Add or Delete Dependent Date of marriage _______ Date of domestic partnership filing _______ Date of birth/adoption _______
Coverage Check with your plan administrator or call The Standard at 800.378.5745 about Evidence Of Insurability requirements.
Voluntary Life Insurance VT-101770-A See brochure for increments and amounts available.
Employee Requested amount $________________ Spouse/Domestic Partner Requested Amount $ _______________________
Spouse Name, Date of Birth and SSN _______________________________________________________________________________
Child(ren) $5,000 $10,000 $20,000
Child(ren) Name(s) and Date(s) of Birth______________________________________________________________________________
Voluntary Accidental Death and Dismemberment (AD&D) Insurance Group No. 648371-A See brochure for amounts available.
Employee only Requested amount $_______________ Employee and Dependents Requested amount $ _______________
Spouse/Domestic Partner Name, Date of Birth and SSN ________________________________________________________________
Child(ren) Name(s) and Date(s) of Birth _____________________________________________________________________________
Voluntary Long Term Disability See brochure for amounts available.
Requested amount $_______________ Check one of the following, if eligible: Benefit Waiting Period
30-days 90-days
Beneficiary Designations are not valid unless signed, dated, and received by The Standard during your lifetime. See page 2 for further
information. This designation applies to Voluntary Life Insurance- VT 101770-A available through your Employer, if any.
Primary - Full Name Address Soc. Sec. No. Relationship % of Benefit
Contingent - Full Name Address Soc. Sec. No. Relationship % of Benefit
This designation applies to Voluntary AD&D Insurance Policy No. 648371-A available through your Employer, if any.
Primary - Full Name Address Soc. Sec. No. Relationship % of Benefit
Contingent - Full Name Address Soc. Sec. No. Relationship % of Benefit
Signature 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.
Member/Employee Signature Required __________________________________________ Date (Mo/Day/Yr) ____________________
