UNUM Disability Plan Self-Enrollment (2026)
  • UNUM Disability Plan Self-Enrollment (2026)

    Complete this form to enroll in Jackson Hinds General Staff and Nurse Practitioners' UNUM Short-Term and Long-Term Disability plans for 2026.
  • Auto Calculation Short Term

    Max Salary Entry is $100,000 & Max STD weekly is $1000/week
  • Auto Calculation Long Term

    Max Salary Entry is $100,000 & Max STD weekly is $1000/week
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  • Acknowledgment and Authorization

  • I understand the UNUM plan provides me a weekly disability benefit of 60% of my salary, after I have been disabled for 7 days due to either an illness of accident, and that my benefits will be paid for up to 13 weeks per short term disability. I understand that a long term disability claim will extend to a period of 5 years.


    I understand that I may enroll during Open Enrollment and that I may be subject to evidence of good health if I do not enroll when I am eligible. I understand I may be subject to a pre-existing limitation if I am a new hire/enrollee. I understand that any salary increase will automatically change my benefit and deduction and I authorize my payroll department to automatically make any necessary deduction changes to reflect any payroll changes. My signature is binding either as a "wet" signature or as a digitial signauture using my private PIN Code.

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  • *PLEASE NOTE: A copy of this form will be emailed to you. Please print and give a copy to service rep and HR Office. 

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