Group Life Enrollment Form

Group Enrollment or Change Form

For Group Life Benefit
Please select one (1) of the applicable reasons you are completing this form:

New HireBeneficiary ChangeChange of Name

Beneficiary Information

Who will receive proceeds upon your death
Are you changing your beneficiary designations?

YesNo
Primary Beneficiary(ies)

Will receive proceeds if living at death of Employee
Beneficiary Name (Last, First, MI)*
Beneficiary Address (include City, State and Zip)*
Beneficiary Social Security Number*
Beneficiary Date of Birth*

MonthDayYear
Date
Beneficiary Relationship to You*
Ex: Mother, Father, Sister, Brother, Friend, Spouse, Child
Benefit Percentage*
You can split proceeds by percentages. Must equal 100

Primary Beneficiary(ies)

Will receive proceeds if living at death of Employee
Beneficiary Name (Last, First, MI)
Beneficiary Address (include City, State and Zip)
Beneficiary Social Security Number
Beneficiary Date of Birth

MonthDayYear
Date
Beneficiary Relationship to You
Ex: Mother, Father, Sister, Brother, Friend, Spouse, Child
Benefit Percentage
You can split proceeds by percentages. Must equal 100

Contingent Beneficiary(ies)
You can designate contingent beneficiaries and in the event that your primary beneficiaries die, your contingent beneficiaries will receive the proceeds of this benefit.
Would you like to designate contingent beneficiaries?

YesNo

Contingent Beneficiary(ies)

Will receive proceeds if living at death of Employee
Beneficiary Name (Last, First, MI)
Beneficiary Address (include City, State and Zip)
Beneficiary Social Security Number
Beneficiary Date of Birth

MonthDayYear
Date
Beneficiary Relationship to You
Ex: Mother, Father, Sister, Brother, Friend, Spouse, Child
Benefit Percentage
You can split proceeds by percentages. Must equal 100

Contingent Beneficiary(ies)

Will receive proceeds if living at death of Employee
Beneficiary Name (Last, First, MI)
Beneficiary Address (include City, State and Zip)
Beneficiary Social Security Number
Beneficiary Date of Birth

MonthDayYear
Date
Beneficiary Relationship to You
Ex: Mother, Father, Sister, Brother, Friend, Spouse, Child
Benefit Percentage
You can split proceeds by percentages. Must equal 100

Authorization
I represent that the information provided above 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 maybe 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.
Signature

Clear
Please enter the date you are signing this form

MonthDayYear
Date
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Group Enrollment or Change Form