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Enrollment / Change Form

The Guardian Life Insurance Company of America

Planholder Name (Company Name)

Guardian Group Plan No.:

Planholder Street Address

City

State

Zip

EMPLOYER USE ONLY

New Enrollment

Add Dependent(s)

Drop Dependent(s)

Change Address

Change Name

Drop Coverage as of:

Class

Hours Worked

Division

Benefit Effective

Midwest Regional Office, P.O. Box 8012, Appleton, WI 54912-8012

Keep a copy for your records and return to:

EMPLOYEE

Please provide this information about YOURSELF.

First, Middle Initial, Last Name

Sex

Date of Birth (mm/dd/yyyy)

Social Security Number

Address

City

State

Zip

Business Phone#

Home Phone #

Preferred Email

The best way to reach you:

Day Phone

Evening Phone

Date work status began:

Job Title:

Work Status/Eligibility:

Annual Salary/Earnings:

Full Time

Part Time

Retired

Cobra/State Continuation

ARE YOU MARRIED

Yes

DO YOU HAVE CHILDREN OR OTHER DEPENDENTS

Yes

IF YOU HAVE A DOMESTIC PARTNER

IS YOUR PARTNERSHIP REGISTERED WITH THE STATE OF CALIFORNIA

Yes

DEPENDENTS

Please provide this information about your DEPENDENTS.

A dependent is a person that you, as a taxpayer, claim; who relies on you for financial support; and for whom you qualify for a dependency tax exception.

Dependency tax exemptions are subject to IRS rules and regulations. Additional information may be required for non-standard dependents such as a

grandchild, a niece or a nephew.

Spouse First, Middle Initial, Last Name

Sex

Date of Birth (mm/dd/yyyy)

Social Security Number

Marriage Date

Add

Change

Drop

Sex

Child (1):

Date of Birth (mm/dd/yyyy)

Add

Attending Since

Full-time student, at

City/State

Change

(school):

Drop

Sex

Add

Date of Birth (mm/dd/yyyy)

Child (2):

City/State

Attending Since

Full-time student, at

Change

(school):

Drop

Sex

Add

Child (3):

Date of Birth (mm/dd/yyyy)

City/State

Attending Since

Full-time student, at

Change

(school):

Drop

Sex

Add

Child (4):

Date of Birth (mm/dd/yyyy)

City/State

Attending Since

Full-time student, at

Change

(school):

Drop

To drop coverage for yourself or your dependents, check the box(es) to the left of the name(s) and select the coverage(s) to drop below. Attach a separate sheet if you

wish to drop more than one dependent from different coverage’s.

Dental

DENTAL

CHOOSE YOUR DENTAL COVERAGE: Check one box only

Find dental providers online at

or check the directory of providers.

Employee Alone

I Waive This Coverage

Employee & Spouse

I Waive This Coverage

Employee & Child(ren)

I Waive This Coverage