Enrollment Form
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1
2Enrollment Form
Underwritten by:
United of Omaha Life Insurance Company
Employer Section
(To be completed by the employer/plan administrator. Required fields are marked with an asterisk (*).)
*Employer's Name:
*Effective Date:
Group ID:
Radnor Township School District
G000AXCN
Sub Group ID:
Location Code:
Class:
*Occupation:
*Salary:
Hourly
Weekly
Bi-Weekly
*Date of Hire:
Hours Worked Per Week:
$
Monthly
Semi-Monthly
Annually
Employee Section
Enrollment ID: 21553
(Please print clearly. Required fields are marked with an asterisk(*).)
*Last Name:
*First Name:
MI:
*Social Security Number:
*Birth Date (MM/DD/YYYY):
*Gender:
Male
*Marital Status:
Single
Married
Female
Divorced
Widowed
*Street Address:
E-Mail Address:
*City:
*State:
*Zip Code:
Telephone:
Voluntary Short-Term Disability Coverage Election
Premium Amount
Employee Coverage Only
Enroll
Decline
Benefit Amount
(Per Paycheck = 0/Year)
Short-Term Disability
$____________
$____________
Voluntary Life Coverage Election
Benefit Amount -
Premium Amount
Employee Only Coverage
Select One Option
(Per Paycheck = 0/Year)
Voluntary Life - Employee
$20,000
$____________
$50,000
$____________
$100,000
$____________
$150,000
$____________
Other
$______________
$____________
Decline
If you are enrolling for Voluntary Term Life coverage in excess of the Guarantee Issue Amount of 5 times your annual salary or $150,000 (whichever is less), you
must complete and submit an Evidence of Insurability form. The form is available from your employer, or complete online at
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ID: B-56430, FORM CONTINUES ON PAGE 2
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