Form 5-301a - Basic And Optional Life Insurance Enrollment Or Change - Alaska Department Of Administration
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1
2Basic and Optional Life Insurance
FOR OFFICE USE ONLY
Enrollment or Change form
Division of Retirement and Benefi ts
Juneau: 465-8600
Toll-Free: 1-800-821-2251
PO Box 110203
TDD: (907) 465-2805
Fax: (907) 465-4668
doa.alaska.gov/drb
Juneau, Alaska 99811-0203
THIS FORM IS SUBMITTED FOR (check all that apply):
❑
❑
❑
BASIC LIFE & AD&D
BENEFICIARY CHANGE
CANCELLATION OF OPTIONAL LIFE
❑
OPTIONAL LIFE ENROLLMENT (check one)
❑
Within 30 days of hire
❑
During the annual open enrollment
❑
Within 30 days of a change in your marital or family status due to such events as marriage, divorce, death, birth or adoption of a child.
EVENT:
DATE of EVENT:
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
(initial)
my 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 Ben-
efi ts, 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
Signature of Employee
Date
5-301a (Rev. 6/10)
g:/publications/forms/benefi ts/5-301a.indd
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