Insurance Limited Benefit Application Form printable pdf download

INSURANCE PLAN AND TRUST FUND

LIMITED BENEFIT FORM

ENROLLMENT FORM

Employee status : New school________ New hire ________ Plan change________ Name/Address change______________

Adding dependent __________ Deleting dependent______Dependent(s) name____________________________________

Reason for adding or deleting the dependent(s)______________________________________________________________

Effective date________________If termination, date participant notified of COBRA coverage__________________________

Employee's name _____________________________________________SSN ____________________________________

Address ____________________________________________City_______________________State ____Zip ___________

Email address (important for applicant to view benefits) ________________________________________________________

Phone number_________________________________Date of employment _______________________ Sex: M _____F____

Date of birth_____________________ Single___Married___School ______________________________________________

Name of building (if different from above) ________________________________________

Beneficiary's name_______________________________SSN ___________________Relationship ____________________

Beneficiary's address ______________________________City _______________State _____Zip _____________________

Beneficiary’s date of birth________________________

I would like the following coverage:

_____ Single Limited Benefit (includes Life, AD&D, and LTD) with dental

______ Single Limited Benefit without dental

_____ Family Limited Benefit (includes Life, AD&D and LTD) with dental

______ Family Limited Benefit without dental

______ I am currently covered for dental under my spouse’s (or parent’s) employer plan.

_____I have been given the opportunity to participate in the insurance benefit plan, but am refusing all coverage. *

If choosing Family Limited Benefit, please list each covered dependent including spouse and all dependent children:

1. Name ____________________________ Birth Date___________Sex____SSN ______________Relationship ___________________

2. Name ____________________________ Birth Date___________Sex____SSN ______________Relationship ___________________

3. Name ____________________________ Birth Date___________Sex____SSN ______________Relationship ___________________

4. Name ____________________________ Birth Date___________Sex____SSN ______________Relationship ___________________

I authorize my employer to deduct from my salary or wages, if applicable, the necessary premium for the coverage requested above. This

signature also verifies the accuracy of the information on this form. If I have declined all or portions of coverage, I understand that the

carrier may not approve my request to change this decision unless I provide satisfactory evidence of insurability at my expense. I hereby

certify that I am eligible to participate and that to the best of my knowledge the information given above is correct and tru e to fact. (For

information on eligibility, see below.) Insurance coverage will be delayed if you are not in active employment because of an injury, sickness,

temporary layoff or leave of absence on the date that the insurance would otherwise become effective. For dependents: Insurance

coverage will be delayed if that dependent is totally disabled on the date that the insurance would otherwise be effective. Exception: Infants

are insured from live birth.

Signed __________________________________________________________Date _______________________________________

ELIGIBILITY:

Each school may choose the eligibility level for their employees. The choices are 50 percent, 62.5 percent or 75 percent of a full

time position during a plan year (September 1-August 31). All educational employees are considered full time if they spend at

least 1,000 hours in the classroom with students. All other employee are considered full time who work 40 hours per week (at

least 2,000 hours in plan year).

10 percent of all eligible employees may decline participation of all coverage in addition to the employees and dependents who

decline coverage because they are covered under a dental plan provided through a spouse’s or parent’s employer plan. Other

exceptions may apply (government plans, etc.).

Please have your Employer complete. Yearly salary_______________ School Number 5439- _______________

S:\US\US INSURANCE\ENROLLMENT\FORMS\PARTICIPANTS\2016-2017\LBP Employee Application.docx

Revised 5/2016

Insurance Limited Benefit Application Form

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