Employee Information Effective Date Date of Hire Employee ID Employee Group Department / / / / Last Name First Name MI Date of Birth Gender / / M F Enrollment Information Employee Coverage – Type of Enrollment (check one): Enroll Upon Hire Enroll through Evidence of Insurability Reinstate-RFL Terminate Coverage Beneficiary Change Life Insurance (automatic enrollment) Please provide beneficiaries – Beneficiary Designation Primary or % Total Primary = 100% Last Name, First Name MI Change Contingent Contingent = 100% Add Primary Remove Contingent Add Primary Remove Contingent Add Primary Remove Contingent Add Primary Remove Contingent Additional 1 Life Insurance Waive Coverage Beneficiary Designation Primary or % Total Primary = 100% Last Name, First Name MI Change Contingent Contingent = 100% Add Primary Remove Contingent Add Primary Remove Contingent Add Primary Remove Contingent Add Primary Remove Contingent Additional 2 Life Insurance Waive Coverage Please select amount: 1 times or 2 times annual base salary Beneficiary Designation Primary or % Total Primary = 100% Last Name, First Name MI Change Contingent Contingent = 100% Add Primary Remove Contingent Add Primary Remove Contingent Add Primary Remove Contingent Add Primary Remove Contingent Please complete page 2 Beneficiary Information, Employee Signature and Date – Beneficiary Information Please complete for each beneficiary listed on Page 1
Employee Information Effective Date / / Date of Hire / / Employee ID Employee Group Department Last Name First Name MI Date of Birth / / Gender M F Enrollment Information – Employee Coverage Type of Enrollment (check one): Enroll Upon Hire Enroll through Evidence of Insurability Reinstate-RFL Terminate Coverage Beneficiary Change Life Insurance (automatic enrollment) – Please provide beneficiaries Beneficiary Designation Last Name, First Name MI Change Primary or Contingent % Total Primary = 100% Contingent = 100% Add Remove Primary Contingent Add Remove Primary Contingent Add Remove Primary Contingent Add Remove Primary Contingent Additional 1 Life Insurance Waive Coverage Beneficiary Designation Last Name, First Name MI Change Primary or Contingent % Total Primary = 100% Contingent = 100% Add Remove Primary Contingent Add Remove Primary Contingent Add Remove Primary Contingent Add Remove Primary Contingent Additional 2 Life Insurance Please select amount: 1 times or 2 times annual base salary Waive Coverage Beneficiary Designation Last Name, First Name MI Change Primary or Contingent % Total Primary = 100% Contingent = 100% Add Remove Primary Contingent Add Remove Primary Contingent Add Remove Primary Contingent Add Remove Primary Contingent Please complete page 2 – Beneficiary Information, Employee Signature and Date Beneficiary Information Please complete for each beneficiary listed on Page 1
hr-form-life-insurance.docx