GUARDIAN
The Guardian Life Insurance Company of America
Benefits Effective:
-
Month
-
Day
Year
Date
Please check appropriate option
Initial Enrolment
Re-Enrollment
Add Employee/Dependents
Drop/Refuse Coverage
Information Change
Increase Amount
Family Status Change
Please obtain this from your Employer
Class? Division? Subtotal Code?
Class
Division
Subtotal Code
About you
Name
First Name
Middle Name
Last Name
Social Security Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Please Select
M
F
Date of Birth (mm-dd-yyyy)
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Are you married or do you have a spouse?
Please Select
Yes
No
Do you have children or other dependents?
Please Select
Yes
No
Date of marriage/union
-
Month
-
Day
Year
Date
Placement date of adopted child:
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Month
-
Day
Year
Date
About Your Job
Hours worked per week
Job Title
Work Status
Active
Retired
Cobra/State Continuation
Date of full time hire:
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Month
-
Day
Year
Date
About Your Family
Please include the names of the dependents you wish to enroll for coverage. A dependent is a person that you,as a taxpayer, claim; who relies on you for financial support; and for whom you qualify for a dependency tax exception. Dependencytax exemptions are subject to IRS rules and regulations. Additional information may be required for non-standard dependents suchas a grandchild, a niece or a nephew.
Spouse (First, MI, Last Name)
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Gender
Please Select
Female
Male
Social Security Number
Date of Birth (mm-dd-yyyy)
-
Month
-
Day
Year
Date
Child/Dependent 1 (First, MI, Last Name)
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Add or Drop
Please Select
Gender
Please Select
Female
Male
Social Security Number
Date of Birth (mm-dd-yyyy)
-
Month
-
Day
Year
Date
Status (check all that apply)
Please Select
Student (post high school)
Disabled
Non standard dependent
Child/Dependent 2 (First, MI, Last Name)
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Add or Drop
Please Select
Gender
Please Select
Female
Male
Social Security Number
Date of Birth (mm-dd-yyyy)
-
Month
-
Day
Year
Date
Status (check all that apply)
Please Select
Student (post high school)
Disabled
Non standard dependent
Child/Dependent 3 (First, MI, Last Name)
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Add or Drop
Please Select
Gender
Please Select
Female
Male
Social Security Number
Date of Birth (mm-dd-yyyy)
-
Month
-
Day
Year
Date
Status (check all that apply)
Please Select
Student (post high school)
Disabled
Non standard dependent
Child/Dependent 4 (First, MI, Last Name)
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Add or Drop
Please Select
Gender
Please Select
Female
Male
Social Security Number
Date of Birth (mm-dd-yyyy)
-
Month
-
Day
Year
Date
Status (check all that apply)
Please Select
Student (post high school)
Disabled
Non standard dependent
Drop Coverage
Drop Employee
Drop Dependents
The date of withdrawal cannot be prior to the date this form is completedand signed. "Last Day of Coverage"
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Month
-
Day
Year
Date
Termination of Employment Retirement. "Last Day Worked"
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Month
-
Day
Year
Date
Other Event
Date of Event
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Month
-
Day
Year
Date
Coverage Being Dropped
Please Select
Dental
Employee
Spouse
Child(ren)
Loss Of Other Coverage:I and/or my dependents were previously covered under another insuranceplan. Loss of coverage was due to:
Please Select
Termination of Employment
Divorce
Death of Spouse
Termination/Expiration of Coverage
Date
-
Month
-
Day
Year
Date
I have been offered the above coverage(s) and wish to drop enrollment for the following reasons:
Please Select
Covered under another insurance plan
Other
If Other (additional information may be required)
PPO - Dental Coverage: You must be enrolled to cover your dependents. Pick only one
Please Select
Employee Only
Employee and 1 Dependent
EE, Spouse & Dependent/Child(ren)
I do not want this coverage. If you do not want this Dental Coverage, please mark all that apply
Please Select
I am covered under another Dental plan
My spouse is covered under another Dental plan
My dependents are covered under another Dental plan
Signature
Preview PDF
Submit
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