Form 5-301a - Enrollment Or Change Form
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1Basic and Optional Life Insurance
ENROLLMENT OR CHANGE FORM
Division of Retirement and Benefits
P.O. Box 110203
Juneau, Alaska 99811-0203
Phone: Juneau—(907) 465-8600, Anchorage—(907) 269-0333
FAX: (907) 465-4668 or TDD: (907) 465-2805
THIS FORM IS SUBMITTED FOR (check all that apply):
BASIC LIFE & AD&D
OPTIONAL LIFE ENROLLMENT
BENEFICIARY CHANGE
CANCELLATION OF OPTIONAL LIFE
EMPLOYEE NAME:
SOCIAL SECURITY NUMBER:
DATE OF BIRTH:
EMPLOYMENT DATE:
DEPARTMENT:
TELEPHONE NUMBER:
_______
I want Basic Life and Accidental Death & Dismemberment Insurance Coverage only.
(initial)
_______
I wish to purchase Optional Life and Accidental Death & Dismemberment Insurance in an amount equal to my
(initial)
annual salary. I understand this is in addition to the Basic Life and Accidental Death & Dismemberment
Insurance coverage provided by the State. I authorize the appropriate payroll deduction from my earnings
each month for the cost of this coverage. I reserve the right to discontinue this Optional Life and Accidental
Death & Dismemberment coverage by submitting a written notice to the Division of Retirement and Benefits,
at any time.
_______
I wish to cancel my Optional Life and Accidental Death & Dismemberment Insurance Coverage.
(initial)
BENEFICIARY DESIGNATION:
BENEFICIARY LAST NAME
FIRST NAME
M.I.
RELATIONSHIP
MAILING ADDRESS
CITY AND STATE
ZIP CODE + 4
THIS BENEFICIARY RECEIVES THE FOLLOWING BENEFITS IF I DIE:
THIS BENEFICIARY IS:
PERCENTAGE
%
BASIC LIFE
OPTIONAL LIFE
PRIMARY
CONTINGENT
BENEFICIARY LAST NAME
FIRST NAME
M.I.
RELATIONSHIP
MAILING ADDRESS
CITY AND STATE
ZIP CODE + 4
THIS BENEFICIARY RECEIVES THE FOLLOWING BENEFITS IF I DIE:
THIS BENEFICIARY IS:
PERCENTAGE
%
BASIC LIFE
OPTIONAL LIFE
PRIMARY
CONTINGENT
BENEFICIARY LAST NAME
FIRST NAME
M.I.
RELATIONSHIP
MAILING ADDRESS
CITY AND STATE
ZIP CODE + 4
THIS BENEFICIARY RECEIVES THE FOLLOWING BENEFITS IF I DIE:
THIS BENEFICIARY IS:
PERCENTAGE
%
BASIC LIFE
OPTIONAL LIFE
PRIMARY
CONTINGENT
BENEFICIARY LAST NAME
FIRST NAME
M.I.
RELATIONSHIP
MAILING ADDRESS
CITY AND STATE
ZIP CODE + 4
THIS BENEFICIARY RECEIVES THE FOLLOWING BENEFITS IF I DIE:
THIS BENEFICIARY IS:
PERCENTAGE
%
BASIC LIFE
OPTIONAL LIFE
PRIMARY
CONTINGENT
Signature of Employee
Date
S:/BENEFITS/5-301A.p65 (Rev. 7/00)
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