Fillable Enrollment Form Guardian Ky printable pdf download

Enrollment Form Guardian Ky

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The Guardian Life Insurance Company of America

The Guardian Life Insurance company of America underwrites group term life, accidental death and

Enrollment Form

dismemberment, short term disability, long term disability, critical illness, and accident coverages.

P a g e 1 o f 2

Guardian Life, P.O. Box 14319,

Lexington, KY 40512

Pro-Sphere Tek

00519960

_____________

Benefits Effective:

Employer Name:

Group Plan Number:

PLEASE CHECK APPROPRIATE BOX

Initial Enrollment

Re-Enrollment

Drop/Refuse Coverage

Information Change

Social Security Number

About You:

First, MI, Last Name:

___ ___ ___ - ___ ___ - ___ ___ ___ ___

Address

City

State

Zip

Date of Birth (mm-dd-yyyy) ____ - ____ - ________

Phone: (

)

Gender:

Email Address:

Are you married or do you have a spouse?

Yes

Date of marriage:____-____-_____

Date adoption process began: ____-____-_____

Do you have children or other dependents?

Yes

_______________________

What is your primary language?

Do you have any special needs that affect your ability to complete this form?

Yes

_______

About Your Job:

Hours worked per week:

Job Title:

Work Status:

____ - ____ - ____

____________

Active

Retired

Cobra/State Continuation

Date of full time hire:

Annual Salary: $

Basic Life Coverage with Accidental Death and Dismemberment (AD&D):

Benefit reductions apply. Please see plan administrator.

Name your beneficiaries: (Primary beneficiary percentages must total 100%)

Primary Beneficiaries:

Social Security Number:___ ___ ___-___ ___-___ ___ ___ ___ %

Name:

Date of Birth (mm-dd-yy):____-____-____

Address/City/State/Zip:

Phone: ( ) -

Relationship to Employee:_

Social Security Number:___ ___ ___-___ ___-___ ___ ___ ___ %

Name:

Date of Birth (mm-dd-yy):____-____-____

Address/City/State/Zip:

Phone: ( ) -

Relationship to Employee:_

Social Security Number: ___ ___ ___-___ ___-___ ___ ___ ___

Contingent Beneficiary:

Date of Birth (mm-dd-yy):____-____-____

Address/City/State/Zip:

Phone: ( ) -

Relationship to Employee:_

(In the event the primary beneficiaries are deceased, the contingent beneficiary will receive the benefit. Employer maintains beneficiary information.)

If this Basic Life policy will replace your existing life insurance policy under your current employer, provide the amount of the previous policy $____________

Life Policy Amount:

AD&D Policy Amount:

Important Notes:

Employee Only

• Based on your plan benefits and age, you may be required to complete an evidence of insurability form for Basic Life.

R$50,000

R$25,000

The Guarantee Issue

Amount is $50,000.

Amount is $25,000.

CEF2014-TX

Questions? Call the Guardian Helpline (888) 600-1600