Group Life Insurance Enrollment Form printable pdf download

GROUP LIFE INSURANCE ENROLLMENT FORM

□ INITIAL

□ CHANGE

□ TERMINATION

Employee Information:

Policyholder/ Policy #: 675751

Employee Last Name

First

M.I.

Catholic Diocese of Charlotte – GL-XXXXXX

Address:

Institution Name:

Marital Status:

Single

Married

Divorced

Widowed

S.S. #

Date of Birth

Gender:

This section for Employer to complete:

Male

Female

Wages $_________/year

Date of Hire___/___/___

Change/Termination/Reinstatement Date:______________

Basic Life insurance coverage provided by your Employer at no cost to you.

BASIC LIFE – EMPLOYEE ONLY

Basic Life coverage of $10,000 is provided and paid by your employer.

Enter the requested amount of Supplemental Life insurance coverage in the space provided. To elect coverage check the box marked “Y”. To decline

coverage check the box marked “N”.

EMPLOYEE SUPPLEMENTAL LIFE

$ _________ (In increments of $10,000 to a maximum of $100,000.)

If you enroll in or increase your Employee Supplemental Life coverage by more than 1 increment after your initial eligibility waiting period, you will be required to

provide, at your own expense, proof of good health subject to approval by Hartford Life.

SPOUSE LIFE

$ 5,000_____ (available even if you do not elect Employee Supplemental Life coverage.)

If you enroll for Spouse Life coverage after your initial eligibility waiting period, you will be required to provide, at your own expense, proof of good health subject to

approval by Hartford Life .

CHILD(REN) LIFE $ 1,000_____ (available even if you do not elect Employee Supplemental Life coverage.)

Dependent Information: (Complete only if Dependent coverage elected)

Full Name

Gender: M/F

Date of Birth: M/D/Y

Spouse:

_____________________________________________ ___________

_______________

___________________

Child:

_____________________________________________ ___________

_______________

___________________

Child:

_____________________________________________ ___________

_______________

___________________

Child:

_____________________________________________ ___________

_______________

___________________

Designate your beneficiary:

I hereby make the following beneficiary designations:

Full Name

Percentage

SS#

Relationship

Birth date

Primary Beneficiary:

______________________________________

____________

_______________

_____________

___________

Primary Beneficiary:

______________________________________

____________

_______________

_____________

___________

Contingent Beneficiary:

______________________________________

____________

_______________

_____________

___________

Contingent Beneficiary:

______________________________________

____________

_______________

_____________

___________

A beneficiary may be changed upon written request.

Please read, mark one of the boxes below, then sign and return this form to your Benefits Office:

I hereby request coverage under my employer’s Group Supplemental Term Life Insurance plan and authorize my employer to make the appropriate payroll

deductions for the coverage(s) which I have specified above. I represent that the statements above are true and complete to the best of my knowledge and belief and

are binding on any person claiming an interest in the coverage issued.

I hereby decline coverage under the Group Supplemental Term Life Insurance plan.

_______________________________________________________

______________________________

Employee’s Signature

Date