Fillable Form Usic-2020ee - Employee Enrollment Form For Group Disability printable pdf download

ASSURANT EMPLOYEE BENEFITS

UNION SECURITY INSURANCE COMPANY (the “Company”)

Administrative Office: One Riverfront Plaza, Westbrook, ME 04092-9700

EMPLOYEE ENROLLMENT FORM FOR GROUP DISABILITY

This Area for Agent or Plan Administrator Use Only

Group Number:

Requested effective date of coverage: The first day of

__________________, ___________

Month

Year

To enroll, please type or print in dark ink and return to your Agent or Employer. Keep a copy for your records. Any changes must be

Failure to sign and date the application and to accurately complete the questions on this application may

initialed by the Applicant.

affect the existence or amount of coverage.

Last Name

First Name

Middle

Birth Date

Gender

Social Security No.

Initial

(MM/DD/YY)

Home Address

Number/Street

City

State

Zip

Home Phone Number

Employer Name

Your Work Location/Site

(

)

Date of Hire

Occupation

Annual Income $

Your scheduled work hours per week

Will the coverage applied for with this enrollment application:

a. replace any existing disability income coverage?

Yes

b. be in addition to any existing disability income coverage?

Yes

All applicants review the following guidelines and complete this section to request coverage.

Amounts must be elected according to the Rate Schedule provided.

Depending on the amount of coverage you elect, you may be required to complete the Health Questions.

Consult your agent for details concerning maximum amounts of insurance and Evidence of Insurability requirements.

(N)ew

Coverage

(I)ncrease

Monthly Benefit

If (I) Or (D), My

Monthly

(D)ecrease

Amount

Prior Coverage

Premium / Rate

(C)ancel

Was

Short-Term Disability

Yes

Elimination Period________________

Max. Period of Payment___________

Long-Term Disability

Yes

Elimination Period__________________

Max. Period of Payment_____________

Number of Salary Deductions/Year ________

MY SIGNATURE ON THIS APPLICATION REPRESENTS THAT:

I authorize the Payroll Department to deduct the required premium from my salary for the insurance coverage for which I am applying. These

authorized deductions may be made at intervals mutually agreed upon by my employer and the Company, and are to be paid to the Company when

due. I understand I am responsible for paying any premium due for which the Payroll Department cannot make a regularly scheduled deduction. I

understand that in order to revoke this authorization, I must notify my Payroll Department in writing to cancel the premium deductions and abide by any

rules specified by the employer's benefit plan and/or by law. I apply for the coverages designated for which I am eligible under my employer’s

plan with Union Security Insurance Company. I understand that I must be actively at work on the effective date, or coverage will be

deferred until I return to work and that dependent coverage (if applicable) will not become effective while the dependent is in a hospital

or similar facility.

NOTICE: For this group insurance plan to become effective, a minimum number of employees must apply. Your coverage will not go

into effect unless the minimum requirement is met.

The insurance applied for shall be in force as of the date described in the certificate provided the Company approves my application without any

modifications as to the plan amount or premium. If the application is approved with any such modification, the insurance shall not take effect until the

certificate has been delivered to and accepted by me and furthermore shall not take effect if there has been a change in the health of any person to be

insured as stated since the date of application.

All of the information on this application is complete, correct and true to the best of my knowledge and belief.

Dated at: _____________________________________ On: ___________________________________

City

State

Month

Day

Year

___________________________________

_________________________________

Signature of Employee

Printed Name of Employee