Group Life & Disability Enrollment / Change Card - The Prudential Insurance Company Of America
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1
2GROUP LIFE & DISABILITY
ENROLLMENT/CHANGE CARD
The Prudential Insurance Company of America
Please refer to the description of your plan for coverage options and amounts available to you.
Employee’s Last Name
First Name
MI
Name of Employer
Group Policy No.
Claim Branch
Employee’s Address
Employee’s Annual Salary
$
Social Security No.
Date of Birth
Date Employed
Married
Widowed
Male
-
-
/
/
/
/
Single
Divorced
Female
Please mark the appropriate box according to your plan.
Type of
Basic Term
Optional
Dependent
Accidental Death
Optional
Short Term
Long Term
Life (Non
Term Life
Term Life
& Dismemberment
Accidental Death
Disability
Disability
Coverage
Contrib.)
(Non Contrib.)
& Dismemberment
Enter Amount
Effective Date
EMPLOYEE’S DEPENDENT INFORMATION
Dependent’s Last Name
First Name
MI
Date of Birth
Relationship to Employee
/
/
/
/
/
/
My Dependent coverage is for:
Spouse Only
Spouse & Children
MY BENEFICIARY’S NAME (PLEASE PRINT) Example: Mary A. Doe, not Mrs. J. Doe
___________________________________________________________________________________________________________
First Name
Middle Initial
Last Name
Relationship To Employee
% of Benefit
___________________________________________________________________________________________________________
Address
___________________________________________________________________________________________________________
First Name
Middle Initial
Last Name
Relationship To Employee
% of Benefit
___________________________________________________________________________________________________________
Address
___________________________________________________________________________________________________________
First Name
Middle Initial
Last Name
Relationship To Employee
% of Benefit
___________________________________________________________________________________________________________
Address
If more than one primary beneficiary is designated, settlement will be made in equal shares to the designated beneficiaries
(or beneficiary) who are then still living, unless their shares are specified. If there is no named beneficiary, or no beneficiary survives
the insured, settlement will be made in accordance with the terms of your Group Contract.
EMPLOYEE’S SIGNATURE
I am enrolling for coverage and I authorize my employer to deduct from my earnings until further notice my contributions for
insurance under a contract issued by The Prudential Insurance Company of America. I understand that if I desire to increase the
amount of my insurance or add dependent coverage hereafter, I may be required to furnish evidence of insurability for myself
and/or my dependents. I declare the statement above is true and understand it is the basis for determining the monthly
contribution for coverage.
I do not wish to enroll for any of the above optional coverages. I certify that I have been given the opportunity by my above
named employer to enroll for coverage. I understand that if I desire to enroll hereafter, I may be required to furnish evidence of
insurability for myself and/or my dependents.
Employee Signature __________________________________________ Date (Month/Day/Year)________
_______
/ ________ /
GL.2003.011 Ed. 4/2005
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