Colonial Life Supplemental Insurance printable pdf download

Colonial Life Supplemental Insurance

COLONIAL LIFE SUPPLEMENTAL INSURANCE

“EMPLOYEE INFORMATION FORM”

If you would like additional information or to Enroll, please complete this form and send

to our office by fax or e-mail to:

Phone: 713-774-6110

Fax: 713-774-7708

EMPLOYER: STAR FURNITURE COMPANY

Date: _____________________

Employee: ______________________________________ Marital Status: ______________

Gender: ______________________

Date of Birth: __________________________

Employee Home Address: _____________________________________________________

___________________________________________________________________________

Best Time to Contact You: __________________

Work Phone: ____________________

Home/Cell Phone: ___________________________ Fax No: ________________________

Social Security #:

________________________

Annual/Hourly Salary: _____________

Job Title: __________________________________ Date of Employment: ______________

E-mail Address:

___________________________________________________________

Beneficiary: _________________________________________________________________

Relationship: ___________________________ Age: _______ D.O.B. _________________

Employee Signature: _________________________________________________________

DATE OF FIRST PAYROLL DEDUCTION: _______________________________________

PAY PERIODS PER YEAR: (Please circle)

Sales “Straight Commission” Associates - should indicate 12 pay periods per year –

benefits are only taken out of your 15

of the month paycheck.

Bi-weekly associates (Incl. Sales “Guaranteed Income Associates) - (paid every 2 weeks)

should indicate 26 pay periods per year.

Salaried Associates - (paid on the 15

and last day of the month) should indicate 24 pay

periods per year.

Colonial Life Supplemental Insurance