2011 Enrollment Form For Group Insurance Page 2
Download a blank fillable 2011 Enrollment Form For Group Insurance in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete 2011 Enrollment Form For Group Insurance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Voluntary Spouse Life
Yes
No*
$5,000
$10,000
Employee must elect coverage
Evidence of Insurability Required for
$15,000
in order to elect spouse and/or
Coverage Amounts Over $30,000.00
$25,000
dependent coverage
$30,000
Spouse coverage selection may not
Other $
exceed 50% of employee's coverage
selection
Voluntary Dependent Child Benefit
$10,000
Yes
No*
Employee must elect coverage
in order to elect spouse and/or
dependent coverage
*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 illustration due to rounding --
Beneficiary Information (Complete ONLY for Life/AD&D Enrollments)
Primary Beneficiary's Last Name
First
MI
Relationship of Beneficiary
Social Security Number
Street Address
City
State
Zip
Contingent Beneficiary's Last Name
First
MI
Relationship of Beneficiary
Social Security Number
Street Address
City
State
Zip
Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate
more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper.
NOTE: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION
TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.
The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln
National Life Insurance Company, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date
will apply if the employee is not Actively at Work or an Active Member, or a dependent is in a period of limited activity on the date insurance
would otherwise take effect.
Employee Full Name: ____________________________________________________
Employee Signature: ____________________________________________________
Date: _____________
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
WA
STEPS 06/11
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business