PERSONAL INFORMATION The best way to reach you: ---E-mailDay PhoneEvening Phone Sex: ---MaleFemale Are you married? ---YesNo Do you have children or other dependants? ---YesNo Work Status: ---Full-TimePart-TimeRetiredCOBRA/State Continuation Date work status began: YOUR BASIC LIFE COVERAGE Policy Amount: $25,000 If this Basic Life policy will replace your existing life insurance policy under your current employer, provide the amount of the previous policy: BENEFICIARIES Primary Beneficiary (Primary beneficiaries must total 100%) Primary Beneficiary 2 (Only fill out if you have more than one primary beneficiary) Contingent Beneficiary In the event the designated primary beneficiaries are deceased, the contingent beneficiary will receive the benefit. IMPORTANT NOTES If you waive life or disability coverage and later decide to enroll, you will have to provide, at your own expense, proof of each person's insurability. Guardian reserves the right to reject your request. SIGNATURE I hereby apply for the group benefit(s) that I have chosen above. I understand that I must meet eligibility requirements for all coverages that I have chosen above. I understand that I must be actively at work or my life and/or disability coverage will not take effect until I have completed a waiting period (as defined in the Group Plan) of full time service. This requirement does not apply to eligible retirees. I agree that my employer may deduct premiums from my pay or add premiums to my dues; if they are required for the coverage I have chosen above. I understand that the premium amounts shown above are estimations. If the premium amounts shown above and the deductions for premiums shown on my paycheck stub do not agree, my paycheck stub will prevail. I understand that the premium amounts may be amended. I attest that the information provided above is true and correct to the best of my knowledge. 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. Use your mouse (or finger if on a mobile device) to sign your name in the box below.