2012 Enrollment Form For Group Insurance Page 2
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3Accident Coverage NOTE: Please mark the box or boxes for each plan/benefits 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)
Choice
Choice
Accident
Yes
No*
Employee Only
$13.63
Employee Plus Spouse
$19.85
Accident - Choice Plan
Employee Plus Child(ren)
$23.43
$31.74
Family
The following Optional Benefit(s) may be elected if Accident coverage is elected
Accident coverage for Dependents must be elected in order to elect any Dependent coverage for the Optional Benefits
Type of Coverage
Selecting Yes authorizes my
Amount of Coverage
Monthly
employer to payroll deduct
Premium
premium(s)
Choice
Choice
Health Assessment - $50
Yes
No*
Employee Only
$2.21
$4.40
Employee Plus Spouse
$2.76
Employee Plus Child(ren)
$5.07
Family
Critical Illness Coverage NOTE: Please mark the box or boxes for each plan/benefits you are applying for.
All coverage amounts are subject to the limitations and exclusions as stated in the policy.
Type of Coverage
Plan Option(s)
Amount of Coverage
Monthly
Selecting yes authorizes my employer
Premium
to payroll deduct premium(s)
To apply the appropriate tobacco/non-tobacco rates, please answer the following question:
Has Employee or Spouse used any type of tobacco or nicotine in the past 12 months? Employee:
Yes
No Spouse:
Yes
No
Critical Illness
Smoker
Non-Smoker
Smoker
Non-Smoker
Smoker
Non-Smoker
Yes
No*
Employee
$5,000
Evidence of Insurability
$10,000
Base Plan includes:
Required for Coverage
$15,000
Wellness Category
Amounts Over $10,000
$20,000
Heart Category
Smoker
Non-Smoker
Smoker
Non-Smoker
Smoker
Non-Smoker
Cancer Category
Spouse*
$5,000
Organ Category
*Spouse amount cannot
$10,000
Quality of Life Category
exceed Employee amount.
$15,000
Evidence of Insurability
$20,000
Required for Coverage
Amounts Over $5,000
Benefit equals 25% of the
Non-Smoker
Child
Employee's approved amount
*By selecting No, application for coverage at a later date may require further medical information and/or a physical exam, which will be at my own expense
-- Actual deductions may vary slightly from above illustrations due to rounding --
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
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