Form 48495md4 - Life And Disability Income Insurance Enrollment Form - Reliastar Life Insurance Company Page 2
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1
2Spouse Life
If you are covered for Supplemental Life you can elect Dependent Spouse coverage.
When you are initially eligible for Dependent Spouse coverage you can elect up to the Guaranteed Issue (GI) Limit of $30,000
without Evidence of Insurability on your spouse.
Total Dependent Spouse Life coverage up to $250,000 in $10,000 increments is available if your spouse completes an
Evidence of Insurability form subject to approval by ReliaStar Life. Spouse coverage is limited to 100% of the employee’s
Supplemental Life coverage amount. Minimum coverage amount is $10,000.
Spouse Name and
Spouse Name ___________________________________________
Spouse Date of Birth ___________________
Date of Birth
Spouse Life Election
_______________
Elect: $
($10,000 increments)
Waive
Note: The employee is the beneficiary for any Dependent Spouse insurance coverage.
Dependent Child(ren) Life Insurance
Child(ren) Life
If you are covered for Supplemental Life you can elect Dependent Child(ren) coverage.
When you are initially eligible for Dependent Child(ren) Life coverage you can elect from $1,000 to $25,000 in $1,000
increments on your children from birth to less than 26 years without Evidence of Insurability. Child(ren) coverage is limited to
100% of the employee’s Supplemental Life coverage amount. Minimum coverage amount is $1,000.
Child(ren) Life
_______________
Elect: $
($1,000 increments)
Election
Waive
Note: The employee is the beneficiary for any Dependent Child(ren) insurance coverage.
READ THIS INFORMATION CAREFULLY AND THEN SIGN AND DATE BELOW
I authorize my employer to deduct from my wages the premium, if any, for the elected coverage.
To the best of my knowledge and belief, the information I have provided on this form is correct.
I understand my coverage begins on the effective date assigned by ReliaStar Life, provided I am actively at work.
I also understand that evidence of insurability may be required for coverage to become effective.
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Employee's Signature
Date Signed (mm/dd/yyyy)
THIS IS NOT AN APPLICATION FOR INSURANCE.
It is an enrollment form for coverage under a group plan sponsored by your employer.
48495MD4
ReliaStar Life Insurance Company P.O. Box 20 Minneapolis, MN 55440
DIS/GATGI (04/10)
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