The Guardian Life Insurance Company Of America Fulton School Enrollment Form
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2GG-013500MO
The Guardian Life Insurance Company of America
The Guardian Insurance & Annuity Company, Inc.
Enrollment Form
Midwest Regional Office
Northeast Regional Office
Bridgewater Office
Western Regional Office
For Non-Medical Coverages
P.O. Box 425
P.O. Box 8012
P.O. Box 26040
P.O. Box 2454
Appleton, WI 54912-8012
Lehigh Valley, PA 18002-6040
E. Bridgewater, MA
Spokane, WA 99210-2454
02333-0425
Planholder Name (Company Name)
Group Plan No.
Division
Class
Fulton Public Schools
443110
Planholder Street Address
City
State
Zip
2 Hornet Drive
Fulton
MO
65251
MARITAL STATUS:
Single
Married
Widowed
Legally Separated
Divorced
:
PLEASE CHECK REASON FOR COMPLETING
INITIAL APPLICATION
:
(
)
CHANGE
ADD DEPENDENT
S
TERMINATE A FAMILY MEMBER
ADDRESS
NAME
DELETE COVERAGE
___/___/___
________________
DATE OF CHANGE
REASON FOR CHANGE
GIVE THE FOLLOWING INFORMATION FOR EACH PERSON TO BE INSURED
Name (Last, First, Middle Initial)
Sex
Birthdate
Employee’s Social Security #
Employee:
M
F
Date of Marriage
Spouse:
M
F
/
/
Full Time
Child:
M
F
Yes
No
Student?
Full Time
Child:
M
F
Yes
No
Student?
Full Time
Child:
M
F
Yes
No
Student?
Full Time
Child:
M
F
Yes
No
Student?
(1) Are any dependent children adopted?
Yes
No
If “yes”, indicate name and date of placement:
(2) Have you included stepchildren?
Yes
No
If “yes”, indicate name(s):
(3) Are they dependent on you for support and maintenance?
Yes
No
Date of Full Time Employment
Hrs. Worked / Week
Annual Salary
Occupation /Job Title
$
Employee’s Street Address
City
State
Zip
Business Phone #
Home Phone #
Beneficiary Name (Last, First, Middle),Relationship and %
Beneficiary Name (Last, First, Middle),Relationship and %
________________________________________________________ _____%
________________________________________________________ _____%
In the last 6 months, have you or any of your dependents received medical treatment, care or services, including diagnostic measures or took prescribed drugs for:
cardiovascular disease; cancer; any condition related to Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex; or any other life threatening
condition?
Employee
Yes
No
Spouse
Yes
No
Child(ren)
Yes
No
AN EVIDENCE OF INSURABILITY FORM(S) MUST BE COMPLETED FOR ANY EMPLOYEE OR DEPENDENT(S) WITH A “YES” ANSWER TO THE ABOVE QUESTION.
BASIC LIFE with Accidental Death & Dismemberment
Employee: Coverage has been paid for you by your company, if you meet eligibility requirements.
Spouse:
Yes
No
Children:
Yes
No
VOLUNTARY TERM LIFE
Employee: (You may elect coverage in $10,000 increments
Spouse: (50% of emp amt to $250,000)
Child(ren): (10% of emp amt to $10,000)
Ranging from $20,000 - $500,000
Yes
No*
Yes
No*
I elect $___________ of coverage.
(Less than 14 days is not covered)
I decline coverage. * (this also waives dependent
coverage).
LONG TERM DISABILITY
Employee:
I elect coverage.
I decline coverage.*
DENTAL
Employee:
Spouse:
Child(ren):
12 MO. STAFF
10 MO. STAFF
I elect coverage.
Yes
No***
Yes
No***
EMPLOYEE
$37.26
$44.71
I decline coverage. I understand if I elect coverage at a later date, late entrant penalties will apply. **
EE & SPOUSE
$69.45
$83.34
** If declining coverage, are you covered under another dental plan?
Yes
No
EE & CHILDREN
$74.30
$89.16
*** If declining dependent coverage, are your dependents covered under another dental plan?
Yes
No
FAMILY
$109.99
$131.99
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