Term Life And Ltd Enrollment Form Page 2

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Instructions: Complete personal information on the front of this form. Please mail to the address noted
below or fax to the number noted below. For your enrollment to be valid, you must sign and date the form.
Please be advised it may take up to 30 days to process the enrollment.
If you have any questions, please call the Unum Client Service Center toll-free at 1-866-762-8705.
Unum
NA Administrative Services – B136
2211 Congress Street
Portland, ME 04122-0001
Or Fax to: 207-575-0745
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