Life Long Term Disability Ltd And Or Short Term Disability Std Application And Change Form printable pdf download

LIFE, LONG-TERM DISABILITY (LTD), AND/OR SHORT-TERM DISABILITY (STD)

APPLICATION AND CHANGE FORM

WELCOME TO HEALTHTRUST

Use this form to change your beneficiary(ies) as well as to enroll in or change your disability and/or life insurance coverage. Be sure to complete this entire form and retain the PINK copy. If you only need

to change your mailing address, do not complete this form; instead, call HealthTrust’s Enrollee Services Depar tment at 800.527.5001 and notify your employer.

BE SURE TO FILL OUT EACH SECTION COMPLETELY. Failure to complete each section in full could delay the star t of coverage.

HOW TO COMPLETE THIS FORM

Remove this cover sheet before you begin.

EMPLOYEE INFORMATION

Complete this section with your personal information, using your full legal name. Select the type of HealthTrust-sponsored life and/or disability coverage you are requesting. Please limit your

selection to only those coverages of fered by your employer and for which you are eligible.

STEP

Some life and disability coverages may require evidence of insurability. You will not be eligible for any amount greater than the evidence of insurability requirement if you do not submit an Evidence

of Insurabilit y form; this form may be obtained from your employer or HealthTrust. You will be added for an amount greater than the evidence of insurability requirement once approved. For more

information, refer to your cer tificate of coverage.

STEP

REASON FOR COMPLETING APPLICATION

Use this section to indicate the reason(s) for completing form.

BENEFICIARY INFORMATION

Please name your beneficiary(ies) for your life and/or disability coverages. If you wish to name a dif ferent beneficiary(ies) for your life, long-term disability (LTD), and/or shor t-term disability (STD)

coverages, at tach a separate piece of paper containing all necessary information. Otherwise, your beneficiary(ies) will be the same for all coverages.

STEP

You may name more than one beneficiary. If you specify benefit percentages, the total must equal 100 percent. If you do not specify benefit percentages, benefits will be paid in equal shares.

If you do not name a beneficiary(ies) – or if neither your primary nor contingent beneficiary(ies) survive you – benefits will be paid in order of survivorship shown in your cer tificate of coverage.

Your primary beneficiary(ies) are the person(s) you name to receive benefits. Your contingent beneficiary(ies) are the person(s) you name to receive benefits if your primary beneficiary(ies) do not

survive you.

STEP

EMPLOYEE SIGNATURE

Sign and date this form; return completed form to your employer (retain the pink copy for your records).

STEP

EMPLOYER USE ONLY

Employer must review this form and verify that steps 1-4 are completed. Employer must complete this section and forward to HealthTrust for processing at: PO Box 617, Concord, NH 03302.

Form #HT036

Questions? Please call us at 800.527.5001, Monday through Friday, 8:30 a.m. to 4:30 p.m.

Revision Date 08/13