GROUP LIFE
ENROLLMENT/CHANGE CARD
The Prudential Insurance Company of America
751 Broad Street, Newark, New Jersey 07102
Please refer to the description of your plan for coverage options and amounts available to you.
Employee’s Last Name
First Name
MI
Name of Employer
Group Contract
Claim Branch
No.
43272
RIO HONDO COLLEGE
Employee’s Address
Occupation
Employee’s Annual Salary
$
Social Security No.
Date of Birth
Date Employed
Married
Widowed
Male
-
-
/
/
/
/
Single
Divorced
Female
Please mark the appropriate box according to your plan.
Type of Coverage
Amount
Effective Date
Type of Coverage
Amount
Effective Date
50,000.00
x
Basic Term Life (Non Contrib.)
Optional AD&D – Employee
Basic Dependent – Spouse
Optional AD&D – Employee
and Family
Basic Dependent – Children
Optional AD&D – Spouse
Employee Optional Term Life
Optional AD&D – Children
Optional Term Life – Spouse
Optional Term Life – Children
x
AD&D (Non Contrib.)
50,000.00
MY BENEFICIARY’S NAME (PLEASE PRINT) Example: Mary A. Doe, not Mrs. J. Doe
Primary Beneficiaries
First Name
MI
Last Name
Address
Relationship
Percentage
Product
BASIC LIFE
AD&D
Contingent Beneficiaries
First Name
MI
Last Name
Address
Relationship
Percentage
Product
BASIC LIFE
AD&D
If more than one primary beneficiary is designated, settlement will be made in equal shares to the designated beneficiaries
(or beneficiary) who are then still living, unless their shares are specified. If there is no named beneficiary, or no beneficiary survives
the insured, settlement will be made in accordance with the terms of your Group Contract.
FLORIDA RESIDENTS – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
NEW YORK RESIDENTS - Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a
civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. This notice ONLY applies
to accident and disability income coverage.
EMPLOYEE’S SIGNATURE
I am enrolling for coverage and I authorize my employer to deduct from my earnings until further notice my contributions for
insurance under a contract issued by The Prudential Insurance Company of America. I understand that if I desire to increase the
amount of my insurance or add dependent coverage hereafter, I may be required to furnish evidence of insurability for myself
and/or my dependents. I declare the statement above is true and understand it is the basis for determining the monthly
GL.2010.068
Ed 4.2010