Membership Advantages - USAble Enrollment Form
Voluntary term life, short term disability and accident enrollment.

Important notice: This form replaces all other enrollment forms on file and must be signed and dated to be valid. Group Life and Disability insurance is underwritten by USABle Life, Group # 50059083.

 

Section 1 - Member Information

 

Section 2 Term Life Insurance
(you must work at least 40 hours per month to enroll in life insurance)

Member and spouse term life benefit levels are $10,000, $20,000, $30,000, $40,000, $50,000, $60,000, $70,000, $80,000, $90,000, $100,000, $110,000, $120,000, $130,000, $140,000, $150,000, $160,000, $170,000, $180,000, $190,000 or $200,000

Open Enrollment - October 1 - 31, 2025
Benefits Effective January 1, 2026
Member Guaranteed Issue up to $100,000 
Spouse Guaranteed Issue up to $40,000
Child Guaranteed Issue up to $10,000

New Member
Member Guaranteed Issue up to $100,000
Spouse Guaranteed Issue up to $40,000
Child Guaranteed Issue up to $10,000

     

1. You cannot be enrolled as a member and as a dependent on another member's voluntary term life policy. 
2. You must be enrolled in voluntary member term life to apply for spouse/partner or child term life.
3. If you request more than the guaranteed issue you (or your spouse/partner) will be required to submit an evidence of insurability and be approved by USAble Life. Please note, that we will issue any guaranteed amount and if your Evidence of Insurability is approved your coverage will be increased. Contact Membership Advantages for the Evidence of Insurability form.
   
   

Please attach a sheet to enroll additional children. The list can be uploaded using the upload button below. The following information is required to add dependent children:

• Name 
• Date of Birth
• Relationship

 

Section 3 Short Term Disability Insurance
(you must work at least 40 hours per month to enroll in short term disability insurance)

 

 

Section 4 DUO Accident Insurance
(you must work at least 40 hours per month to enroll in accident insurance)

 

 

Section 4 Beneficiary Designation

You may choose a beneficiary(s) to receive life benefits. If no beneficiary survives, payment will be made in accordance with the terms of the policy. Unless designated otherwise, beneficiary designations for all life coverage will be the same. If multiple beneficiaries are listed you must include the percentage (%) for each beneficiary all primary beneficiaries must equal 100%. All contingent beneficiaries must equal 100%.

Additional beneficiaries can be added by uploading an additional sheet of paper. The sheet must list if primary or contingent, the name name of beneficiary, social security #, date of birth, phone number, address and relationship. The link to upload is located at the bottom of this form.

For Spouse/Partner and Child Term Life, you are the beneficiary. 

Section 5 Signature for Enrollment, Beneficiary Designation and Authorization for Payroll Deduction

I (we) request to be insured and authorize payroll deductions to cover the cost of coverage (if payroll deduction is available)*. Information in this application is given to obtain insurance, and the statements and answers are represented, to the best of my (our) knowledge and belief, to be true and complete. (we) understand that (a) the insurance applied for shall not take effect until the application is approved and will be notified of the insurance Effective Date; and (b) all insurance is subject to the eligibility provisions of the Policy; and (c) must be Actively at Work (as defined in the Group Policy) to be insured. If am not Actively at Work on the date my (our) coverage would become effective, my (our) coverage will not begin until the day return to work.

* Please read the information below.

Insurance will become effective the 1st of the month for which payroll deduction is taken. If the deduction is taken on the last day of the month, the insurance will become effective the 1st of the following month. *Payroll deduction may not be available through all employers. Contact your payroll department or the SEIU Local 503 Membership Advantages office if you have any questions. If payroll deduction is not available you will be required to self pay your premium.

Eligibility To be eligible for coverage under this plan you must maintain your membership with SEIU Local 503. You must work at least 40 hours per month in your SEIU Local 503 represented position to purchase life, short term disability or accident insurance. You must be scheduled for the minimum required hours and actively working for your insurance to take effect.

Dependents eligible for coverage include spouse/partner and all unmarried dependent children under age 26. If enrolling a domestic partner attach a completed Affidavit of Domestic Partnership form or indicate on the front of this form that you have obtained a Certificate of Registered Domestic Partnership. If you are enrolled in the member voluntary term life you cannot be covered as a dependent under another member's policy.

If a dependent cannot perform the normal activities of a person of his or her age and sex on the date of his or her coverage would begin, his or her coverage will not begin until he or she is so able.

Enrollment and Premium Change Enrollment elections can only be changed or canceled during an Open Enrollment period or with a qualified status event. You must notify SEIU Local 503 Membership Advantages office within 31 days of the qualified event to be eligible for the enrollment change. The amount of insurance and premium is subject to change as determined by the premium schedule as outlined in the benefit booklet and master policy issued by USAble Life.

Termination of Coverage Coverage under the term life plan ends when the participant fails to make the required monthly premium payment, or fails to meet the eligibility requirements and/or is no longer a member of SEIU Local 503.

Life Insurance If a plan participant retires (at any age) or if a plan participant terminates employment at age 65 or later, life insurance will be continued without cost for 31 days. Within that period, you may convert your voluntary term life Insurance to an individual guaranteed permanent policy. Application for conversion must be made within 31 days of retirement. It is your responsibility to contact the SEIU Local 503 Membership Advantages office to request an application for conversion.

If a plan participant terminates employment prior to age 65, voluntary term life Insurance benefits can be ported to an individual policy. You must apply within 31 days from the date your employment terminated. It is your responsibility to contact the SEIU Local 503 Membership Advantages office to request an application for portability.

Accident Insurance If a plan participant terminates employment prior to age 79, voluntary accident insurance benefits can be ported to an individual policy. You must apply within 31 days from the date your employment terminated. It is your responsibility to contact the SEIU Local 503 Membership Advantages office to request an application for portability.

Short Term Disability Insurance If a plan participant terminates employment or retires, short term disability insurance will terminate.

Benefit eligibility and termination provisions are detailed in the USAble Life Benefit Booklet. The booklet is located on the SEIU Local 503 website at seiu503.org click on the Membership Advantages page. You can obtain a printed copy of the booklet by contacting the SEIU Local 503 Membership Advantages office at the number below.

The plan may be amended from time to time or terminated in its entirety at any time by SEIU Local 503.

SEIU Local 503
PO Box 12159
Salem, Oregon 97309-0159

1.844.503.SEIU (7348)