Group Term Life Insurance Form

Group Term Life Insurance Form
Employee/Applicant Data
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Social Security Number
Martial Status
Group Term Life Insurance Coverage Amount
Complete all blocks. If your current Optional Term plan does not include some of the options below (e.g. Accidental Death and Dismemberment (AD&D) or Dependent Term Life), or the employee is not enrolled in the option or the option is not eligible for portability based on your contract, please indicate ‘not applicable’ (NA).
Coverage Termination Date

DayMonthYear
Date
Date of Termination of Employment

MonthDayYear
Date
Explain reason of Termination of Employment
Salary and Date of Last Day Actively at Work
Group Contract Number
Current Optional Term Life Coverage Amount – Employee
Current Optional AD&D Coverage Amount – Employee
Current Dependent Term Life Coverage Amount – Spouse
Current Optional AD&D Coverage Amount – Spouse
Current Dependent Term Life Coverage Amount – Children
Current Optional AD&D Coverage Amount – Children
I certify that, to the best of my knowledge and belief, the information provided in Section 2 is correct and the employee who is named on this form is eligible for portability according to the terms specified in the Prudential group contract. Signature of Employer Representative (employer certification for portability eligibility)
Assignment Data
Last Name of Assignee or Trustee
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Social Security Number/Tax Identification Number
I certify that, to the best of my knowledge and belief, the assignment information provided above is correct. Signature of Employer Representative (employer certification of assignment information)
Group Term Life Insurance Coverage Amount(s) (to be completed by employee/applicant)
Please note: If you are eligible for AD&D coverage, any amounts elected must be equal to or less than the group term life amount. All insurance amounts will be rounded down to the nearest $1,000. Coverage amounts will be reduced by any accelerated benefits paid under the Accelerated Benefit Option.
Optional Term Life and Dependent Term Life Coverage
Employee (Optional Term Life Insurance):

Retain current face amountElect lower amount
Amount
Spouse (Dependent Term Life Insurance):

Retain current face amountElect lower amount
Amount
Children (Dependent Term Life Insurance):

Retain current face amountElect lower amount
Amount
Optional AD&D Coverage
Employee

Retain current face amountElect lower amount
Amount
Spouse

Retain current face amountElect lower amount
Amount
Children

Retain current face amountElect lower amount
Amount
Employee/Applicant Beneficiary Designations (to be completed by employee/applicant or assignee, if assigned)
Name

First NameLast Name
Phone Number

Area CodePhone Number
Social Security Number
Date of Birth

MonthDayYear
Date
Relationship
Percentage
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check one, if applicable:

TrustEstateCorporation
Name
Tax ID Number/Tax Exempt ID Number
Creation/Incorporation/Formation Date
Phone Number

Area CodePhone Number
Percentage
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONTINGENT BENEFICIARIES: Death benefits will be paid to the contingent beneficiaries if the primary beneficiary(ies) is not alive. Use a separate sheet if you want to name additional beneficiaries. If designating a Trust, Estate, or Corporation, please complete the corresponding fields.
How many employees would avail of this insurance policy
*At a later stage we will ask for a detailed employee records
Dependent Term Life Insurance Coverage - Spouse (to be completed by employee)
This section should only be completed if you previously had dependent coverage with Prudential for your spouse and you wish to continue this dependent coverage. Note: With the exception of death and divorce, you must elect portability in order for your spouse to have portable coverage. The employee is the beneficiary for Dependent Term Life Insurance.
Is spousal coverage being ported due to the death of the employee or divorce?

YesNo
Is spouse confined for medical care or treatment at home or elsewhere?

YesNo
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
I represent that supplied above is true and correct. I have thoroughly reviewed, understand and accurately responded to all questions on this form.
Should be Empty:

Group Term Life Insurance Form

Employee/Applicant Data

Group Term Life Insurance Coverage Amount

Assignment Data

Group Term Life Insurance Coverage Amount(s) (to be completed by employee/applicant)

Employee/Applicant Beneficiary Designations (to be completed by employee/applicant or assignee, if assigned)

Dependent Term Life Insurance Coverage - Spouse (to be completed by employee)