Buffalo City School District Employee Health Insurance Enrollment Form Page 3
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15BUFFALO TEACHERS FEDERATION
LIFE INSURANCE ENROLLMENT/CHANGE FORM
Guardian Life Insurance
Plan Holder: Buffalo Board of Education
Northeast Regional Office
Group Plan Number: 334052
PO Box 26040
LehighValley, PA 18002-6040
Coverage: Basic Life (with Accidental Death & Dismemberment)
CLASS
AGE
VALUE
11
Age 70 and older
$1,000
12
Age 60 but less than 70
$3,600
13
Age 50 but less than 60
$6,000
14
Less than age 50
$12,000
EMPLOYEE INFORMATION
LAST NAME
FIRST NAME
MIDDLE INITIAL
STREET ADDRESS
CITY
STATE
ZIP CODE
__________________________
____________________________________
____________________________
_
SOCIAL SECURITY NUMBER
DATE OF BIRTH
TELEPHONE NUMBER
Marital Status:
Single
Married
Divorced
Widowed
BENEFICIARY DESIGNATION:
(Include full proper name and relationship; i.e. Meryl M. Klein, Husband)
NAME:
RELATIONSHIP TO YOU:
ADDRESS:
PHONE:
I hereby apply for the group benefit(s) indicated above. I know my coverage will not take effect unless I am actively at
work and life insurance coverage for my dependents will not take effect if a dependent, other than a newborn is confined to
a hospital or other health care facility, or is unable to perform the normal activities of someone of like age and sex.
I authorize my employer to take deductions from my pay or agree that the contributions be added to my dues; if
contributions are required for the insurance. The information provided above is true and correct to the best of my
knowledge. Any person, who, with intent to defraud or knowing that he/she 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.
_________________________________________
_________________
SIGNATURE OF EMPLOYEE
DATE
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