Group Insurance Enrollment Form - Guardian Life Insurance Company Of America

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Guardian Life Insurance Company of America
Group Insurance Enrollment Form
Check reason for completing form:
Western Regional Office
Northeast Regional Office
New Subscriber
Delete Coverage
Add a Family Member
PO Box 2454
P.O. Box 26050
Change Address
Change Name
Terminate a Family Member
Spokane, WA 99210-2454 Lehigh Valley, PA 18002-6050
Date of Change ____________ Reason for Change_____________________________
PLANHOLDER NAME (COMPANY NAME)
GROUP PLAN NO.
DIVISION
PLANHOLDER STREET ADDRESS
CITY
STATE
ZIP
EMPLOYEE INFORMATION
(PLEASE PRINT LEGIBLY AS THIS INFORMATION WILL BE DIRECTLY INPUT INTO OUR SYSTEM)
FIRST NAME
MIDDLE
LAST NAME
SOC. SEC. NO.
BIRTHDATE
SEX
EMPLOYEE’S STREET ADDRESS
CITY
STATE
ZIP
SALARY
OCCUPATION/JOB TITLE
CLASS
DATE OF FULL-TIME
HOURS WORKED PER WEEK
EMPLOYMENT
MARITAL STATUS:
DEPENDENT CHILDREN?
Single
Married
Widowed
Legally Separated
Yes
No
Divorced
COVERAGE ELECTION
BASIC LIFE & AD&D
EMPLOYEE:
This is a Company paid coverage which you will receive if eligible.
DENTAL
EMPLOYEE: _ I elect coverage. SPOUSE: _ Yes _ No** CHILD(REN): _ Yes _ No**
_ I decline coverage (this also waives ALL dependent Dental coverage). I understand if I elect coverage at a later date, late entrant
penalties will apply.*
* If declining coverage, are you covered under another Dental plan? _ Yes _ No
** If declining dependent coverage, are your dependents covered under another Dental plan? _ Yes _ No
DEPENDENT INFORMATION
NAME FIRST, MIDDLE INITIAL, LAST
SEX
RELATIONSHIP
BIRTHDATE
STUDENT
F
Yes
M
No
F
Yes
M
No
F
Yes
M
No
F
Yes
M
No
Are any dependent children adopted?
Yes
No
If “yes,” indicate name and date of adoption:
_____________________________________
Have you included stepchildren as dependents?
Yes
No
If “yes,” indicate name(s):
______________________________________________
Do your stepchildren reside with you?
Yes
No
Are they dependent upon you for support and maintenance?
Yes
No
EMPLOYEE BENEFICIARY DESIGNATION (Include full proper name and relationship; i.e.: Mary A. Jones, wife.)
NAME
RELATIONSHIP
I hereby (1) request coverage for the Group Insurance for which I am or may become eligible; (2) authorize my employer to make necessary deductions for the contributions,
if any, required for insurance, or agree that the contributions be added to my dues; (3) state that I became an employee on the date stated above, and do currently work the
number of hours per week stated above; and (4) designate the beneficiary named on this form to receive the proceeds, if any, payable in the event of my death. Any person
who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may
be guilty of insurance fraud. I have reviewed the statements on this application and they are true and complete.
SIGNATURE OF EMPLOYEE
DATE
PLEASE RETAIN A PHOTOCOPY FOR YOUR RECORDS AND SUBMIT THIS FORM TO THE GUARDIAN

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