Blue Star Benefits Enrollment Form

Blue Star Benefits Enrollment Form

2026 Enrollment
I Am Currently EnrolledI'm A New Enrollee
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number (Employee)*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Blue Star Location of Employment*
Hire Date*
Hours worked per week*

Term Life Insurance

Coverage is available to you, your spouse, and any dependents. Please complete all required fields.
Face Value
Estimated Premium
Beneficiary Name

First NameLast Name
Beneficiary Relationship
Beneficiary Social Security Number
Relationship Not Listed (Write Here)

Coverages Selected & Notes
This form acknowledges the enrollment and acceptance of the listed benefits selected (and who is covered) for 2025. You will have another opportunity to review your selections and update any information as needed. Please sign below to acknowledge your enrollment and acceptance of these benefits. Thank you for your time.
Signature

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