• ENROLLMENT FOR LIFE INSURANCE

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  • BENEFICIARY DESIGNATION

  • (Please Indicate a Primary and Contingent Beneficiary)

  • PRIMARY

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  • CONTINGENT

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  • I understand that this coverage shall become effective only if this application is accepted by the Amalgamated Life Insurance Company.

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  • NON-PARTICIPATION OPTION

  • I have been given an opportunity to apply for life insurance offered by Amalgamated Life Insurance Company. I understand this plan has been made possible for me through my Employer and I have had its benefits thoroughly explained to me. I choose not to apply at this time, and understand that a later application may require the submission of evidence of insurability. The Insurance Company will have the right to accept or reject my application.

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  • A member of the Amalgamated Family of Companies

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  • Should be Empty: