Form Abu1140 - Group Life Insurance Plan Employee Enrollment Form - Blue Shield Of California

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Group Life Insurance Plan Employee Enrollment Form
Blue Shield of California Life & Health Insurance Company
Blue Shield Life, 4203 Town Center Blvd., El Dorado Hills, CA 95762, (888) 800-2742.
Note: Please complete the entire enrollment form and return it to your employer. This form cannot be processed if information is incomplete.
Section 1 – Group information
Group name
Group policy number
Section number
(to be completed by Blue Shield Life)
(to be completed by Blue Shield Life)
Section 2 – Employee information
First name
M.I.
Last name
Language preference
Address
City
State
ZIP
Gender
Birthdate
Social Security number
Marital status c Single c Married
c Male c Female
c Domestic Partner
Full-time employment date Average hours
Rehire date
Class/occupation
Earnings $ __________________
worked per week
(excluding overtime, bonuses, etc.)
c Hour
c Week
c Month c Year
Section 3 – Designation of beneficiary
Primary Beneficiary – Blue Shield Life will pay the life insurance benefits to the primary beneficiary. An employee may designate more than
one primary beneficiary. Please show percentages for each primary beneficiary in the “% of benefits” column to total 100% of benefits, if the
percentage information is not included, the benefits will be distributed equally to those primary beneficiaries who survive the employee. To
designate more than two primary beneficiaries, please add more primary beneficiaries on a separate sheet of paper which is to be signed and
dated by the employee. Please attach it to this enrollment form.
First name
M.I.
Last name
Social Security number
Relationship
D.O.B.
% of benefits
Address
City
State
ZIP
First name
M.I.
Last name
Social Security number
Relationship
D.O.B.
% of benefits
Address
City
State
ZIP
Total 100%
Contingent Beneficiary – Proceeds will be paid to a contingent beneficiary only if no primary beneficiary survives the insured.
First name
M.I.
Last name
Social Security number
Relationship
D.O.B.
% of benefits
Address
City
State
ZIP
ABU1140 (11/09)

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