COMPANION LIFE INSURANCE
New Employee
Change Address
Change Beneficiary
Terminate Coverage
Name of Employer (Use Name from Group Billing Notice or Master Application)
Group No. (10 digit #)
Group No. (3 digit #)
Social Security Number
Effective
Full Time
Date of Birth (M/D/Y)
/
Month
/
Day
Year
Sex
Female
Male
First Name
Middle Name
Last Name
Hours Worked Per Week
Weekly
Weekly Earnings
Occupation
Street
Apt/Suite No.
City
State
ZIP Code
COVERAGE REQUESTED
Basic Life
Marital Status
Single
Married
Spouse First Name
Spouse Middle Name
Spouse Last Name
Spouse Birthdate (M/D/Y)
/
Month
/
Day
Year
Spouse Social Security Number
Beneficiary First
Beneficiary Middle
Beneficiary Last
Relationship to Insured
Date
/
Month
/
Day
Year
Your Signature
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Continue (Retirement)
Should be Empty: