Group Insurance Enrollment Form - Sagicor

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GROUP INSURANCE ENROLLMENT FORM
Group Policy No.
Certificate No.
Occupation:
Male
Female
Mr. Mrs. Ms.
First Name
Middle Name
Last Name
Address:
Telephone No:
Date of Birth:
Coverage:
No. of Dependents including
Spouse?
Home:
Life
Health
Work:
I
I
Day
Month
Year
Marital Status:
Do you wish to
Beneficiary:
Relationship:
Single
Divorced
cover your
Dependents?
Married
Maiden Name
________________________________
Yes
No
Separated
Widow (er)
Common Law
WITNESSES – (Required if Beneficiaries are listed)
1.
Name:
Signature
___________________________________________________________________________________
__________________________________________________________
2.
Name:
Signature
___________________________________________________________________________________
__________________________________________________________
I reserve the right to change the beneficiary appointed above subject to any statutory reasons. If the Group Insurance Plan provides that any contributions
be made by me, I authorize my employer to deduct them from my pay.
__________________________________________________________
_________________________________________________________________________
Date
Signature
TO BE COMPLETED BY EMPLOYER – SHOULD BE THOROUGHLY COMPLETED
EARNINGS
This employee has been continuously employed by
First Employed
us since the date of his/her employment shown and
I
I
Day
Month
Year
is at present working a minimum of 30 hours per
Weekly
week for full pay.
Monthly
Date Appointed
I
I
Day
Month
Year
Annually
End of Waiting Period
I
I
Day
Month
Year
______________________________________________________
Salary
________________________________
Company Stamp & Administrator Signature
Effective Date of Insurance
I
I
Day
Month
Year
DEPENDENTS TO BE INSURED
1 = Spouse
2 = Common Law Spouse
3 = Son
4 = Daughter
5 = Stepson
6 = Stepdaughter
Name
Date of Birth
Relationship
Address
I
I
Day
Month
Year
I
I
Day
Month
Year
I
I
Day
Month
Year
I
I
Day
Month
Year
I
I
Day
Month
Year
I
I
Day
Month
Year
AUTHORIZATION: I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance
company or other organization, institution, person or medical information bureau that has or may hereafter have any records or knowledge of me or my
health, to give such information to SAGICOR LIFE INC.
………………………………………
………………………………………….
………………………………….………………………
Date
Employee
Witness
GI40010 – February 2015

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