2026 LEGAL ENROLLMENT FORM

MEMBERSHIP ADVANTAGES
Legal Insurance Enrollment Form

Important notice: This form replaces all other legal insurance enrollment forms on file and must be signed and dated to be valid. Legal insurance is underwritten by ARAG Legal.

Section 1 - Member Information

This enrollment is for:*

New MemberOpen EnrollmentCancelEnrollment Change (indicate reason for change below)

Reason for Change

MarriageDeathDivorceOther

Date of change

Date

Name*

Date of Birth*

Date

Gender

MaleFemaleNon-Binary

Email*

example@example.com

Agency Employed*

Address*

Mailing Address

Street Address Line 2

City and State

Zip

Home/Cell Phone*

Work Phone

Marital Status*

SingleMarriedWidowedDivorcedDomestic Partnership (per Affidavit of Domestic Partnership)Domestic Partner (if enrolling a domestic partner you must complete a SEIU Local 503 Affidavit of Domestic Partnership Form)

Section 2 - Coverage Requested

Coverage Election*

Individual ($18.04 per month)Family ($23.74 per month)

Spouse/Domestic Partner Name

Child 1 - Name and Date of Birth

Child 2 - Name and Date of Birth

Child 3 - Name and Date of Birth

If any of the dependent children listed above is a child with a disability, please indicate so below.

See eligibility information on the bottom of this form for a dependent child with a disability who is age 26 and over. New members enrolling a dependent child over the age of 26 with a disability must include a copy of the Guardianship papers with their completed enrollment form.

Dependent child with a disability?*

Check if dependent child 1 is a child with a disability.Check if dependent child 2 is a child with a disability.Check if dependent child 3 is a child with a disability.Check if dependent child 4 is a child with a disability.

*Disability guardianship papers can be uploaded here.

Signature for Enrollment and Authorization for Payroll Deduction/Change (if payroll deduction is available).

I hereby apply for benefits under the SEIU Local 503 group insurance plan issued by ARAG Insurance Company and agree to pay the required monthly premium. The amount of insurance and the premium is subject to change as determined by the master policy agreement between SEIU Local 503 and ARAG® Insurance Company. See below for termination of coverage information.

Member Signature

Date

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.

New Member - members are eligible to enroll within 90 days of new SEIU Local 503 membership. Members who are enrolled can enroll their spouse/domestic partner and all unmarried dependent children of you or your spouse/ partner, under the age of 26. New members can also enroll their unmarried dependent children with a disability, who are age 26 or over, if the member or the members spouse/domestic partner is their court-appointed legal guardian. Legal guardianship papers must be submitted with enrollment form.

Open Enrollment - members are eligible to enroll during an annual open enrollment period. Members who are enrolled can enroll their spouse/domestic partner and all unmarried dependent children of you or your spouse/partner, under the age of 26.

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. To continue coverage of an unmarried dependent child with a disability who reaches age 26, you or your spouse/partner must be their court-appointed legal guardian before the child reaches age 26. Guardianship papers must be submitted to SEIU Local 503 Membership Advantages no later than 31 days after your child's 26th birthday.

Coverage under the legal plan ends when the participant fails to make the required monthly premium payment and/or is no longer a member of SEIU Local 503. If a plan participant retires, the participant may continue coverage under the plan as a retiree provided the retiree maintains membership in SEIU Local 503 and makes the required monthly premium payments. The plan may be amended from time to time or terminated in its entirety at any time by SEIU Local 503.

Pre-Existing Conditions and Continued Coverage

Any legal matter which occurs or is initiated prior to the effective date of the policy will be considered excluded and no benefit will apply. ARAG® defines "initiated" as the date when the written notice of the legal dispute is sent or filed by you or received by you; or a ticket or citation is issued; or an attorney is hired. Any legal matter for which coverage has already been confirmed will continue to be covered under the plan until that particular matter is completed. Please remember that only the insurance policy can give the actual terms, coverages, amounts, conditions and exclusions.

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