Supplemental Life Insurance Enrollment Form printable pdf download

SUPPLEMENTAL LIFE INSURANCE

Policyholders Name: State of Ohio

ENROLLMENT FORM

Group Policy Number: LG-93046-OH

FOR EXEMPT EMPLOYEES OF THE STATE OF OHIO

(PLEASE PRINT)

Last Name__________________________________________First_______________________________________MI___________

Street Address_____________________________________City_______________________State_________Zip Code___________

Social Security Number___________________________Date of Birth________________Office Telephone (____) _______________

Occupation_____________________________________Date Employed_____________ Base Annual Earnings ________________

Sex_________

Marital Status__________ Agency Payroll Number_________________ Employee ID number________________

Enrollment

Change

Beneficiary Designation

Terminate Member Coverage (includes spouse/children coverage)

Please mark the appropriate boxes if you are making a change (Check all that apply)

Increase employee coverage

Add spouse coverage

Add children coverage

Change smoker status

Change spouse smoker status

Increase spouse coverage

Drop spouse coverage

Drop children coverage

Change to exempt from union–represented

Decrease employee coverage

Decrease spouse coverage

Other (Name change, address change, etc.) _________________________________________________________________________________

*Note: Increases in coverage amounts can only be requested during the open enrollment period usually held in the spring.

Total amount of insurance requested: ___________________ Include the total amount of supplemental coverage desired, including your

current amount if you are increasing your coverage. Coverage amounts must be in $10,000 increments. Do not include spouse/children

coverage. The amount which Prudential approves will be the amount you may port (take with you) when you leave State service.

Have you used tobacco in the past 12 months?

Yes

Has your spouse used tobacco in the past 12 months?

Yes

You must have supplemental life coverage in order to enroll your spouse and/or children.

The beneficiary on the lives of your spouse and children will automatically be you, if you survive them; otherwise the beneficiary will be

the estate of your spouse and children, subject to policy provisions.

Spouse coverage desired?

Yes

Spouse insurance total amount requested

10,000

20,000

30,000

40,000

(20,000, 30,000 and 40,000 subject to approval by carrier)

________________________________________

__________________________

_____________

Spouse’s Name (Last, Middle, First)

Spouse Social Security Number

DOB

Children coverage desired? ($7,000 per child)

Yes

Number of children_____________

You have 90 days from your hire date to purchase supplemental life coverage for you, your spouse, and your dependent children. Coverage

may also be elected or changed during each Open Enrollment period.

The right to change your beneficiary is reserved; to name beneficiaries, please use spaces on the back of this form. Your employee ID

number is the eight digit number found on your payroll stub. Agency payroll number is three digit code and six digit number found on your

payroll stub.

This plan is totally separate from your basic life insurance plan with the State of Ohio and the amount of insurance elected as supplemental

does not change your basic life coverage. If you and your spouse are both state employees, you may have coverage as either a spouse or

an employee, but not both. Children may only be covered as a dependent of one employee.

Please make a copy of this form for your own records. Mail this form to: The Prudential Insurance Company of America, P.O. BOX

5072 Millville, NJ 08322-9931. Prudential’s phone number is: 1-800-778-3827.

Note: Any person who, with intent to defraud of knowing that he is facilitating a fraud against an insurer, submits an application or files a

claim containing a false or deceptive statement is guilty of insurance fraud.

CERTIFICATION

I hereby request term insurance for myself and/or for my dependents and hereby authorize my employer or successor to make deductions from my

earnings of the required contributions to apply towards the premiums for the insurance provided for in the policy of insurance issued to the stat of Ohio by The

Prudential Insurance Company of America.

Employee Signature____________________________________________________________________ Date____________________

032000

01/2008

Supplemental Life Insurance Enrollment Form

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