Term Life And Ltd Enrollment Form
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1
2Policy:
University System of
Life 115327
Maryland
LTD 510162
Term Life and LTD Enrollment
Form
Please print or type all information in BLACK INK for electronic imaging.
ˆ
ˆ
Payroll System:
Regular
University of Maryland
Agency Code:
ˆ 12 ˆ 21 ˆ 22 ˆ 26
Pay Frequency:
(See your pay stub for this information)
ˆ
(
Direct Bill
Contract Employee Dates: _______________
only applies to Contract Employees)
Social Security #: __ __ __ - __ __ - __ __ __ __
Employee Name: ____________________________
Action Requested:
Campus Location (check one):
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Term Life
LTD
BSU (15)
CSU (13)
FSU (24)
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ˆ
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SU (21)
TU (19)
UB (17)
ˆ New
ˆEmployee
ˆ New
ˆ
ˆ
ˆ
UMB (12)
UMBC (22)
UMBI (16)
ˆ Change
ˆ Spouse
ˆ Change
ˆ
ˆ
ˆ
UMCES (25)
UMCP (11)
UMES (14)
ˆ Cancel
ˆ Child
ˆ Cancel
ˆ
ˆ
UMUC (MD location only 18)
USMO (23)
ˆ Rehire
ˆ Rehire
ˆ
ˆ
UMUC/Eur (4)
UMUC/Asia (5)
ˆ Transfer to new campus location from
______ to ______ (see code above)
Home Address: __________________________________
Date of Birth: __________________
City, State, Zip: __________________________________
Date of Hire: ___________________
Salary: ____________________
Date of Transfer: ________________
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ˆ
Gender:
Male
Female
Term Life Insurance
Spouse Information:
(complete only if spouse coverage is elected)
Name: ___________________________ DOB: __ __ / __ __ / __ __ __ __ Social Security __ __ __ - __ __ - __ __ __ __
Coverage Elections:
Note: If you choose an amount over the Guarantee Issue limit for you (any amount over $50,000) or
your spouse (any amount over $20,000),or if you do not apply when you are first eligible, you will need to complete an Evidence
of Insurability form. The amount of coverage over your Guarantee Issue amount will be subject to medical underwriting approval
and will become effective on the first of the month coincident with or next following the date Unum approves your Evidence of
Insurability form. If your election requires Evidence of Insurability, an application will be mailed to your home.
Employee Coverage Amount: $__________________
$10,000 increments (minimum coverage $10,000; maximum coverage the lesser of 6x’s earnings or $750,000)
Spouse Coverage Amount: $___________
$10,000 increments (minimum coverage $10,000; maximum coverage can not exceed the lesser of 100% of employees coverage or the plan
maximum of $150,000)
ˆ $5,000
ˆ $10,000
Child Coverage Amount:
Long Term Disability
Elimination Period:
_____ 90 days _____365 days
Coverage Elections:
Note: If you do not apply when you are first eligible or if you later change to the 90 day plan, you will
need to complete an Evidence of Insurability form and will become effective on the date that Unum approves your Evidence of
Insurability form. If your election requires Evidence of Insurability, an application will be mailed to your home.
I authorize the deduction for the Employee LTD, Employee Life, and Spouse/Children Life (if elected) insurance premium from
my earnings, and understand these premiums can be changed in accordance with the plan. I verify that the information provided
on this sheet is accurate. I understand that I must be actively at work on both the enrollment and effective dates for any coverage
to be effective; and that the plan does not cover any losses where death is caused by, contributed by, or results from suicide
occurring within 24 months after my or my dependent’s original effective date and/or after the date any additional insurance
becomes effective for me or my dependents.
Employee Signature: _________________________________
Date: __ __ / __ __ / __ __ __ __
See instructions on reverse side.
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