Fillable Vol Products App - VPB-APP _5-09_

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Vol Products App - VPB-APP _5-09_

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VPB-APP (5-09) Page 1 of 2
Date Received - Home Office
USAble Life
P.O. Box 1650 · Little Rock, Arkansas 72203
VOLUNTARY PRODUCTS ENROLLMENT FORM
(PLEASE PRINT)
New Enrollee Change Decline all coverages Group #:
Employer: If Evidence of Insurability (EOI) is required, please submit the Evidence of Insurability form along with this
enrollment form to us.
Employer’s Name
SECTION I. EMPLOYEE INFORMATION
Employee’s Legal Name (First, MI, Last)
Social Security No.
Home Address
City State Zip Telephone No.
Date of Birth Gender M F Salary $ ___________________ Weekly Monthly Annual
Occupation (Be Exact) Dept/Location
Hours Worked Weekly Date Employed Full-time
PLAN INFORMATION - Your non-medical group insurance program may not include all the benefits listed below. Ask
your employer for the details about the benefits available to you, your cost, if any, and whether you will be required to
complete Evidence of Insurability (EOI).
SECTION II. VOLUNTARY COVERAGE(S) – SEE INSTRUCTIONS ON REVERSE OR PAGE 2
Complete this Section if applying for these coverages.
Evidence of Insurability may be required.
Add
New
Delete
Increase
Existing
Decrease
Existing
Total Amount
of Coverage
Premium
(Completed by
Employer)
A. Voluntary Group Life:
Employee
Yes No
Spouse
Yes No
Children
Yes No
B. Voluntary AD&D:
Employee
Yes No
(EOI not required)
Spouse
Yes No
Children
Yes No
C. Voluntary STD Income Protection (VIP):
Yes No
per week
D. Voluntary Long Term Disability:
Yes No
per month
Do you presently have other disability coverage? Yes No
If yes, give monthly amount $_________
Do you intend to replace existing coverage with this
policy?
Yes No
Dependents to be covered Gender Relationship Social Security No. Date of Birth
M F
M F
M F
M F
M F
Have you or your spouse (if applying for coverage) used tobacco products in the past year? Employee Yes No
Spouse Yes No
Are you actively at work on the date of this application?
Yes No
PRE-EXISTING CONDITIONS
New Voluntary STD (VIP) plans and benefit increases: During the first year of your coverage, benefits will not be paid on
any condition for which you received medical treatment or advice within 12 months before your effective date of coverage.
New Voluntary LTD plans and benefit increases: During the first 2 years of your coverage, benefits will not be paid on any
condition for which you received medical treatment or advice within 12 months before your effective date of coverage,
unless you go 6 consecutive months treatment free.
I represent that the information provided on all pages of this enrollment form is true and correct. I understand that if I am not
actively at work on the effective date of my coverage, my insurance will not begin until the day I return to work. For those
coverages I have declined, I understand that if I choose to enroll at a later date, Evidence of Insurability may be required. If
the Plan provides that any contributions be made by me, I authorize my employer to deduct them from my pay.
Warning - It is or may be a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purposes of defrauding the company or other person. Penalties may include imprisonment, fines, and a denial of
insurance benefits in accordance with applicable state law.
Be sure to complete the Employee Beneficiary Designation on page 2/reverse side
Employee’s Signature Date
VPB-APP (5-09) Page 2 of 2
Employee’s Name (First, MI, Last)
Social Security # Employer Name
SECTION III. EMPLOYEE BENEFICIARY DESIGNATION Check if Change Only
This will revoke any existing beneficiary designations you may have for these benefits.
PRIMARY BENEFICIARY(IES) (Will receive proceeds if living at death of Employee):
Name (Last, First, MI) Address SSN Birthdate Relationship Percentage
Total must equal 100% =
CONTINGENT BENEFICIARY(IES) (Will receive proceeds if Primary Beneficiary(ies) are not living):
Name (Last, First, MI) Address SSN Birthdate Relationship Percentage
Total must equal 100% =
INSTRUCTIONS – How to Complete Section II
Initial Enrollment –Adding Coverage:
Check “Yes” by each coverage you want. Check “No” by each coverage you do not want.
If you checked “Yes” by a coverage, check the “Add New” box, and complete the “Total Amount of Coverage” for which you
are applying.
For Example, you are applying for:
• Voluntary Group Life: $50,000 on yourself, $20,000 on your spouse, and no coverage on your children
• Voluntary AD&D: $100,000 on yourself; $50,000 on your spouse, $5,000 on your children
• Voluntary LTD: $2,000 per month
SECTION II. VOLUNTARY COVERAGE(S)
Complete this Section if applying for these coverages.
Evidence of Insurability may be required.
Add
New
Delete
Increase
Existing
Decrease
Existing
Total Amount
of Coverage
Premium
(Completed by
Employer)
A. Voluntary Group Life:
Employee
Yes No
$50,000
Spouse
Yes No
$20,000
Children
Yes No
B. Voluntary AD&D:
Employee
Yes No
$100,000
(EOI not required)
Spouse
Yes No
$50,000
Children
Yes No
$5,000
C. Voluntary STD Income Protection (VIP):
Yes No
per week
D. Voluntary Long Term Disability:
Yes No
$2,000 per month
How To Change or Delete Coverage:
If you are changing any of your coverage, please complete the information for all of the coverage you have, so that we are
sure we have everything correct. Be sure to check the appropriate “Add,” “Delete,” “Increase”, or “Decrease” box.
For Example, you currently
have:
• Voluntary Group Life: $60,000 on yourself, $30,000 on your spouse, and $10,000 coverage on your children
• Voluntary STD (VIP): $300 per week
You want to change
your coverage to:
• Voluntary Group Life: $100,000 on yourself (increase), $20,000 on spouse (decrease), and no coverage for children
(delete)
• Voluntary AD&D: $100,000 on yourself only (add)
• Voluntary STD (VIP): $300 per week (no change)
SECTION II. VOLUNTARY COVERAGE(S)
Complete this Section if applying for these coverages.
Evidence of Insurability may be required.
Add
New
Delete
Increase
Existing
Decrease
Existing
Total Amount
of Coverage
Premium
(Completed by
Employer)
A. Voluntary Group Life:
Employee
Yes No
$100,000
Spouse
Yes No
$20,000
Children
Yes No
B. Voluntary AD&D:
Employee
Yes No
$100,000
(EOI not required)
Spouse
Yes No
Children
Yes No
C. Voluntary STD Income Protection (VIP):
Yes No
300 per week
D. Voluntary Long Term Disability:
Yes No
per month
0
0
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Completed 3 March 2020

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