Vol Life Ins App

For Employee enter Requested Amount Voluntary Coverage*

	Employee Amount
1. Enter your Current Coverage with the Orthodox HealthPlan Life Insurance. (enter zero if no current coverage)
2. Enter additional or requested Coverage Amount for you (increments of $10,000 for the Employee)

For Spouse enter Requested Amount Voluntary Coverage*

	Spouse * Amount
1. Enter your Spouse's Current Coverage with the Orthodox HealthPlan Life Insurance. (enter zero if no current coverage)
2. Enter additional or requested Coverage Amount for Spouse (increments of 5,000 for the Spouse)

Line 1 emp Amount
Line 1 SP Amount
Line 2 emp Amount
Line 2 SP Amount
Employee Amt Calculation
Spouse Amt Calculation
It appears that you are requesting an amount higher than the maximum allowable ($500,000 for Employee and $100000 for Spouse) under the Orthodox HealthPlan voluntary life insurance program. Please adjust your request accordingly.
Employee Section
Employee Name first middle last*
Gender*

MF
Date of Hire*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState

Zip
Social Security*
Birthdate*

MonthDayYear
Date
Phone*

	Employee Yes	Employee No	Spouse Yes	Spouse No
A. A heart attack or stroke?
B. Cancer (other than Nonmelanoma Skin Cancer), Hodgkin's disease, or Leukemia?
C. Emphysema or Chronic Obstructive Pulmonary Disease (COPD)?
D. HIV Infection or AIDS?
E. Diabetes, Hepatitis C or Cirrhosis of the liver?
F. Alcohol or drug abuse or dependency?
2. Within the last 5 years has the proposed insured had a Driving While Intoxicated (DWI) or a Driving Under the Influence (DUI) conviction?

Voluntary Life Insurance Application