USAble Life
Group Enrollment or Change Form
P.O. Box 1650
(Please print or type in Black ink.)
Little Rock, Arkansas 72203
New Employee
Declination
Change of Name
Group #
Beneficiary Change
Class or Salary Change
Class
Dependent Status Change (Indicate reason _______________________ )
Dept/Location
Reinstatement (Complete Date of Rehire as Employment Date)
Eff Date
SECTION 1 - APPLICANT INFORMATION
Employee Name (First, M.I., Last)
For Name Change, Give Prior Last Name
Employee’s Address (Street, City, State and Zip)
Telephone Number
(
)
Social Security #
Date of Birth
Sex
Male
Employee’s State of
Marital Status
Female
Residence
Occupation
Date Employed Full-time
Hours worked weekly
Salary
$ ________________
Weekly
Monthly
Annual
Employer’s Name
Do you have eligible dependent children?
Are you actively at work on the date of
this application?
Yes
No
Yes
No
SECTION 2
- Complete this Section if applying for Optional Coverage(s). Evidence of Insurability (EOI) may be required when applying
for these coverage(s).
Add
Delete
Add
Delete
Supp Life/AD&D
Dependent Life
STD
Indicate Date of:
Marriage/Divorce
Birth of Child
LTD
-
SECTION 3
BENEFICIARY DESIGNATION /CHANGE
Check if Change Only
This will revoke any existing beneficiary designations you may have for these benefits.
PRIMARY BENEFICIARY(IES) (Will receive proceeds if living at death of Employee):
Name (Last, First, MI)
Address
SSN
Birthdate
Relationship
Percentage
Total must equal 100%
=
CONTINGENT BENEFICIARY(IES) (Will receive proceeds if Primary Beneficiary(ies) are not living):
Name (Last, First, MI)
Address
SSN
Birthdate
Relationship
Percentage
Total must equal 100%
=
I represent that the information provided above is true and correct. I understand that if I am not actively at work on the
effective date of my coverage, my insurance will not begin until the day I return to work. I hereby designate the above
beneficiaries under this certificate and revoke the appointment of any existing beneficiary. If the Group Insurance Plan
provides that any contributions be made by me, I authorize my employer to deduct them from my pay.
Warning: Any person who commits a fraudulent act may be guilty subject to fines and confinement in prison.
Declination – I do not wish to enroll in the Group Plan at this time and I understand that I will have to furnish
evidence of insurability at my own expense if I apply at a later date.
Date
Signature of Employee
FOR HOME OFFICE USE - IF COVERAGE SUBJECT TO EOI, UNDERWRITING DECISION
Date Received Home Office
APPROVED EFFECTIVE:
DECLINED DATE:
BY:
BY:
1000-CBC (2-03)