2012 Enrollment Form For Group Insurance
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1
2
3The Lincoln National Life Insurance Company
P.O. Box 2616, Omaha, NE 68103-2616
Phone: (800) 423-2765 Fax: (877) 573-6177
ENROLLMENT FORM FOR GROUP INSURANCE
Your employer provided information
GROUP ID:
GROUP POLICY #:
Billing Division or Location:
used to create this enrollment form.
CENTRLST
Group Name: Central State University
Employee Information (Complete for ALL Enrollments)
Last Name
First Name
MI
Social Security Number
Date of Birth
Address
Home Telephone Number
Gender
City
State
Zip
Work/Home Email Address
Marital Status
Spouse Information
Last Name
First Name
MI
Social Security Number
Date of Birth
Date of Marriage/Civil Union/Domestic Partnership
Date of Family Status Change
Employee Work Information
Date of Hire
Rehire Date
Avg. Hours Worked per Week
Annual Salary
Work Telephone Number
Occupation
Product Selection (Complete for ALL Enrollments)
Contributory/Optional/Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for.
All coverage amounts are subject to the limitations and exclusions as stated in the policy.
Type of Coverage
Selecting Yes authorizes my
Amount of Coverage
Monthly
employer to payroll deduct
Premium
premium(s)
Voluntary Employee Life + AD&D
Yes
No*
$10,000
$50,000
Evidence of Insurability Required for
Employee must elect coverage
$150,000
Coverage Amounts Over $150,000.00
in order to elect spouse and/or
Other $
dependent coverage
Employee coverage selection may
not exceed 5 times employee annual
salary
Voluntary Spouse Life + AD&D
Yes
No*
$5,000
$10,000
Evidence of Insurability Required for
Employee must elect coverage
$30,000
Coverage Amounts Over $30,000.00
in order to elect spouse and/or
Other $
dependent coverage
Spouse coverage selection may not
exceed 50% of employee's coverage
selection
Voluntary Dependent Child Benefit
Yes
No*
$10,000
Employee must elect coverage
in order to elect spouse and/or
dependent coverage
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
STEPS 01/12
Please See Last Page for Beneficiary and Signature
OH
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