Fillable Employee Life Insurance Form (Page 2 of 2) in pdf

JORDAN SCHOOL DISTRICT EMPLOYEE BENEFIT CHANGE FORM

LAST

FIRST

M.I.

SOCIAL

NAME

SECURITY #

F. LIFE INSURANCE OF NORTH AMERICA (CIGNA) LONG TERM DISABILITY

This benefit is offered to Eligible Employees by Jordan School District at no cost to the employee. Eligible Employees receive 66 2/3% of Basic salary up to a maximum of

$5,000 per month after a 180-day elimination period. See District Policy DP317.

G. TERM LIFE: BASIC, VOLUNTARY LIFE AND AD&D BENIFICIARY

• The Basic Life Benefit is offered to Eligible Employees and their dependents by Jordan District at no cost to the employee.

• Selecting this benefit and signing this form will enroll you, your legal spouse, and eligible dependent(s) listed in Section B in a term life insurance policy through Life Insurance

Company of North America (Cigna)

• Employee $50,000, Spouse $2,000 and Child(ren) birth to age 26 and unmarried $2,000. Refer to the Enrollment guide for Eligibility Start date.

• Refer to Plan Document for complete benefits.

Primary Beneficiary(ies)

Relationship

Contingent Beneficiary(ies)

Relationship

Address

City/ST/ZIP

Address

City/ST/ZIP

Phone

Birth Date

Phone

Birth Date

H. LIFE INSURANCE OF NORTH AMERICA (CIGNA) VOLUNTARY LIFE INSURANCE

(100% Employee Paid)

You may select additional Employee Coverage in $10,000 increments up to the lesser of 5x your annual salary or $500,000.

• Guarantee issue is $150,000 if you elect at your initial enrollment. If you elect after your initial enrollment period, you will have to submit evidence of insurability.

• Evidence of Insurability Forms (CIGNA LIFE APPLICATION) may be obtained from the District Insurance Department website.

• Employee must be enrolled for spouse and dependent children to participate.

I wish to:

Enroll

Change

Cancel participation in Voluntary Life insurance for individuals listed below:

Birth Date

Coverage

Monthly

RATE CALCULATOR

Enroll /

Waive /

Member

Name (Last, First, M.I.)

Age

Change

Cancel

Elected Amount

Premium

Employee & Spouse

MM/DD/YY

Coverage Election Amount

$1,000 X Rate

Employee

=Monthly Premium:

• You may select additional coverage for your Spouse in $5,000 increments up to the lesser of 50% of the employee amount or $250,000.

Under -34 . . . . . . $ 0.06

• Guarantee issue is $50,000 not to exceed 50% if you elect at your initial enrollment. If you elect after your initial enrollment period, you will

35-39 . . . . . . . . . $ 0.08

have to submit evidence of insurability. Insurability application forms may be obtained from the District Insurance Department or website.

40-44 . . . . . . . . . $ 0.10

45-49 . . . . . . . . . $ 0.16

50-54 . . . . . . . . . $ 0.22

Birth Date

Coverage

Monthly

Enroll /

Waive /

Member

Name (Last, First, M.I.)

Age

Change

Cancel

MM/DD/YY

Elected Amount

Premium

55-59 . . . . . . . . . $ 0.37

60-64 . . . . . . . . . $ 0.44

Spouse

65-69 . . . . . . . . . $ 0.72

• You may select additional coverage for your eligible dependent Child(ren) in $2,500 increments.

70-74 . . . . . . . . . $ 1.35

• Evidence of dependency per IRS Code for children between the ages of 19 to 26 years of age will be required upon submission of a claim.

75-79 . . . . . . . . . $ 2.35

• You must elect the same amount for all Dependent Children.

Insurance Office Use Only

☐Appr __________________

Flat Rate Premium per month for

Birth Date

Enroll /

Waive /

Member

Name (Last, First, M.I.)

Age

Change

Cancel

☐Denied ________________

MM/DD/YY

ALL children enrolled

Child

Emp:_____________________

Spouse:__________________

Child

☐

$ 2,500 ..................$0.50

Child:____________________

Child

Total:____________________

☐

$ 5.000 ..................$1.00

Child

☐

$ 7,500 ..................$1.50

Notes:

Child

☐

$10,000 .................$2.00

Child

I. LIFE INSURANCE OF NORTH AMERICA (CIGNA) VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT

(AD&D)

(100% Employee Paid)

You may elect coverage from $10,000 up to the lesser of 10X your annual salary or $500,000 of coverage, in units of $10,000 for yourself

Insurance Office Use Only-

Emp:___________________

I wish to:

Enroll

Change

Waive participation in AD&D Life insurance.

or your family

Family_________________

________________

EMPLOYEE ONLY Coverage Election Amount

÷ $1,000 x 0.025 = Monthly Premium $

(Choose only One)

___________________

FAMILY Coverage Election Amount

÷ $1,000 x 0.038 = Monthly Premium $

J. EMPLOYMENT AGREEMENT

I hereby waive or enroll in the coverages to which I may be entitled or to which I may become entitled under the terms of this agreement or the group policy or policies issued by

Jordan School District Benefit Plan. I authorize the deduction from my earnings of any contribution I am required to make toward the cost of this coverage. I agree that

the proposed coverage shall not take effect until this application has been accepted by Jordan School District as applicable and shall become effective only in accordance with

the provisions of such agreements, group policy, or policies. I authorize Public Employees Health Program to share medical information concerning me or my family with any

health care provider providing benefits within the scope of this group contract. I understand that it is my responsibility to read and understand my benefits.

Agreement: I certify that the information provided on this application is correct and complete to the best of my knowledge. I understand that providing false

or misleading information may provide sufficient grounds for my dismissal.

________________________

EMPLOYEE SIGNATURE__________________________________________________________

DATE

Please print, sign and date ---- No Electronic Signatures

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