Voluntary Group Long Term Disability Employee Application Nj

ADVERTISEMENT

Voluntary Group Long Term Disability
Employee Application—New Jersey
Group no.
Account no.
Cert no.
(Please print or type.)
Proposed effective date
Name of employer
Employee Information—Failure to accurately complete the questions on this application may affect the existence or amount
of coverage requested.
Name
Social Security no.
LAST
FIRST
MI
/
/
Date of birth
Sex:
Male
Female
Basic earnings $
Hourly
Weekly
Monthly
Yearly (Check one.)
Hours worked per week
Hire date
Job title
Work location
CITY
STATE
ACCEPTANCE
Your plan offers disability insurance in $100 units. You may select an amount from $500 to $5,000, in even $100 units, not to
exceed 60% of basic monthly earnings. Refer to the Payroll Deduction Chart to determine your approximate cost per pay-
check. Please indicate your benefit level:
I hereby apply for a monthly benefit in the amount of $
subject to the terms of the group policy issued by Union
Security Insurance Company.
Yes, I would like to participate in the Union Security Insurance Company Voluntary Group Long Term Disability Insurance
plan. I understand that by signing and submitting this form to elect coverage, I am authorizing payroll deductions from my
salary. I further certify that any information disclosed on this application is accurate and that my answers to any questions
are true, accurate and complete, to the best of my knowledge and belief. I understand that I must be actively at work on the
effective date or coverage will be deferred until I return to work.
REFUSAL
No, I do not wish to participate. I understand that I will not be entitled to any benefits under this coverage and will not be able
to apply at a later date without providing proof of good health satisfactory to Union Security Insurance Company and that I can
be turned down for coverage on the basis of my health. Coverages not elected will be assumed refused, even if not
specifically refused.
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. Payroll deductions may begin prior to the effective date of your
insurance.
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
EMPLOYEE SIGNATURE
DATE
Insurance Company use only (Do not complete.)
Age
Premium
Effective date
Coverage amount $
Union Security Insurance Company
Mail to: Assurant Administrative Office P.O. Box 981624 El Paso, Texas 79998-1624
T 800.733.7879
Form 13 (10/99) (NJ)
KC2928NJ (03/2012)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go