Employee Information Effective Date Date of Hire Department Employee ID No. Last Name First Name MI Date of Birth Gender M F Email Address Daytime Phone Number Enrollment Information Employee Coverage – Type of Enrollment (check one): Enroll upon hire Enroll through evidence of insurability Beneficiary change Terminate coverage Reinstate return from leave – Basic 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: 1x or 2x 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 Department Employee ID No. Last Name First Name MI Date of Birth Gender M F Email Address Daytime Phone Number Enrollment Information – Employee Coverage Type of Enrollment (check one): Enroll upon hire Enroll through evidence of insurability Beneficiary change Terminate coverage Reinstate – return from leave Basic 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: 1x or 2x 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-04-11-2017.docx