Short Term & Long Term Disability Income Protection Insurance Enrollment Form printable pdf download

SHORT TERM & LONG TERM DISABILITY

INCOME PROTECTION INSURANCE

ENROLLMENT FORM

for

Underwritten by:

MTA Benefits, Inc.

Unum Life Insurance Company of America

Policy#: 570975

ENROLLER: ________

Applicant Name:_________________________

Social Security #:_______________________________

Date of MTA Membership: __ __ / __ __ / __ __ __ __

Address: _______________________________

MTA Membership Number: ___________________

_______________________________________

School District/Name: _______________________

Date of Hire: __ __ / __ __ / __ __ __ __

_______________________________________

Payroll Frequency ______ (10, 12, 24, 26, 52)

Date of Birth: __ __ / __ __ / __ __ __ __

Home Phone: (____) _____________________

Gender: ___ Male

___ Female

Work Phone: (____) _____________________

Annual Earnings: $______________

E-mail Address: ________________________

Hours Worked per Week: _________

You may choose from 2 Income Protection Plans: Short Term Disability and/or Long Term Disability

Please check the option(s) you wish to choose:

STD:

60% of your weekly salary to a maximum weekly benefit of $1,150

Cost per pay period $__________ (see reverse side of this page for calculation instructions)

LTD:

60% of your monthly salary to a maximum monthly benefit of $5,000

Cost per pay period $__________ (see reverse side of this page for calculation instructions)

*For rates, please refer to the rating grid on the reverse side of this page

 Yes, I would like to participate in the plan(s) I checked above. I authorize my employer to deduct from my salary

or wages the necessary premium for this coverage. My signature verifies the accuracy of information contained on this

form. I understand that my premium is based on my current salary and will increase as my salary increases. I

understand a confirmation of coverage statement will be provided to me prior to the policy effective date.

I understand the effective date of my coverage will be delayed if I am not in active employment because of an injury,

sickness, temporary lay-off or leave of absence on the date this insurance would otherwise become effective. I have

also read and understand the information in the Enrollment Kit, including all statements regarding exclusions.

 Yes, I am interested, please have an MTA Benefits representative contact me at _____________(Phone#).

Applicant Signature: ________________________________________ Date: __ __/__ __/__ __ __ __

Return this form using the enclosed envelope or mail to:

MTA Benefits, c/oVista Financial Group, P.O. Box 447, Grafton, MA 01519

1-877-401-4083

~ OR ~

Fax to 1-850-521-0111

Short Term & Long Term Disability Income Protection Insurance Enrollment Form

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