Form 48495md4 - Life And Disability Income Insurance Enrollment Form - Reliastar Life Insurance Company
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Life and Disability Income Insurance Enrollment Form
NSTRUCTIONS: Top box to be completed by the Employer/Plan Sponsor. Remainder to be completed by the Employee.
I
Name of Employer/Plan Sponsor
Group/Plan Number
Account Number/Location
North American Division of Seventh-day Adventists
67807-4
Class/Occupation
Date of Hire
Annual Salary
Employment
Active Full-Time
(mm/dd/yyyy)
Status:
Active Part-Time
Effective Date of Coverage
This change is due to: (check all that apply)
Late Entrant*
Initial Eligibility Following Hire
or Change:
Other: ___________________________________________
Change in Coverage Amount
*A late entrant is an individual who is first enrolling for supplemental or dependent life income coverage after the first available opportunity.
Employee Information
Employee Name (last, first, middle initial)
Date of Birth (mm/dd/yyyy)
Social Security #
Employee I.D. #
Employee Address (street address, city, state, zip code)
Work Phone Number
Home Phone Number
Female
Male
Disability Income Coverage
Monthly Income
Elect Coverage – (Only Full-Time Employees are eligible for coverage)
Benefits (LTD)
(Note: LTD coverage is
employer provided.)
Employee Life Insurance (Subject to a combined basic and supplemental plan maximum of $850,000.)
Basic Life (
Standard Plan – Employee ($100,000), Spouse ($50,000), and Child(ren) ($10,000)
Note: Basic
Life insurance is
Waive – I waive the Standard Plan and elect Plan A or B (Employee please see your Human Resources Representative for
employer provided and
Plan A or Plan B enrollment form)
only available to Full-time
Employees.)
Supplemental Life
When you are initially eligible for Supplemental Life Insurance you can elect the Guaranteed Issue (GI) Limit of $250,000
without Evidence of Insurability.
Total Supplemental Life coverage up to $750,000 in $10,000 increments is available if you complete an Evidence of Insurability
form subject to approval by ReliaStar Life. Minimum coverage amount is $10,000.
Supplemental Life
_______________
Elect: $
($10,000 increments)
Election
Waive
Designate your beneficiary(ies) below.
Beneficiary Information
Relationship to Employee
Benefit %
Name of Beneficiary (last name, first, middle initial)
Primary
Address
Date of Birth
Social Security Number
Phone Number
Name of Beneficiary (last name, first, middle initial)
Primary
Contingent
Relationship to Employee
Benefit %
Address
Date of Birth
Social Security Number
Phone Number
Name of Beneficiary (last name, first, middle initial)
Primary
Contingent
Relationship to Employee
Benefit %
Address
Date of Birth
Social Security Number
Phone Number
Dependent Spouse Life Insurance
48495MD4
ReliaStar Life Insurance Company P.O. Box 20 Minneapolis, MN 55440
DIS/GATGI (04/10)
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