Waiver Of Coverage Form - United Transportation Union printable pdf download

Waiver Of Coverage Form - United Transportation Union

WAIVER OF COVERAGE FORM

ANTHEM LIFE

VOLUNTARY SHORT-TERM DISABILITY (VSTD) INSURANCE

GROUP

RAIL MEMBERS ONLY

DO NOT COMPLETE THIS FORM IF YOU WANT THE ANTHEM GROUP VSTD INSURANCE.

YOU WILL BE AUTOMATICALLY ENROLLED.

COMPLETE THIS FORM ONLY IF YOU DO NOT WANT THE ANTHEM GROUP VSTD

INSURANCE.

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I DECLINE GROUP VSTD INSURANCE THAT WAS OFFERED TO ME

By signing below, I am waiving the disability coverage that has been offered to me by the

UTU and decline to be automatically enrolled. Should I apply for waived coverage in the

future, I understand that evidence of insurability, acceptable to Anthem Life, may be

required at my own expense. I further understand that should I apply for disability benefits

in the future, I may be declined coverage by the Underwriting Department at Anthem Life.

UTU Local # _________ Member Name (Printed): _______________________

Member Address: _________________________________________________

Member Signature: ________________________________ Date: ___________

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THIS FOR M MUST BE CO MPLETED FULLY AND SIGNED TO BE VALID!

Mail this completed Waiver of Coverage form to:

Attn: Updating Department

United Transportation Union

14600 Detroit Avenue, Suite 200

Cleveland, OH 44107-4250

Waiver Of Coverage Form - United Transportation Union