Retirement Life Insurance Enrollment

Personal Information

Name(Required)

First Middle Last

Date of Birth(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Social Security Number(Required)

Job Title(Required)

Annual Salary/Earnings(Required)

The best way to reach you:(Required)

Email Address(Required)

Day Phone(Required)

Evening Phone(Required)

Sex:(Required)

Married?(Required)

Do you have children or other dependants?(Required)

Work Status:(Required)

Date work status began:(Required)

Your Basic Life Coverage

If this Basic Life policy will replace your existing life insurance policy under your current employer, provide the amount of the previous policy:

Basic Life Coverage(Required)

Primary Beneficiaries

Primary Beneficiary(Required)

First Middle Last

(Primary beneficiaries must total 100%)

Relationship to Employee(Required)

Percent(Required)

Primary Beneficiary 2

First Middle Last

(Only fill out if you have more than one primary beneficiary)

Relationship to Employee

Percent

Contingent Beneficiaries

Contingent Beneficiary 1

First Middle Last

Relationship to Employee

Percent

Contingent Beneficiary 2

First Middle Last

Relationship to Employee

Percent

Contingent Beneficiary 3

First Middle Last

Relationship to Employee

Percent

Contingent Beneficiary 4

First Middle Last

Relationship to Employee

Percent

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.

Date(Required)

Please enter todays date (mm/dd/yyyy)

Signature(Required)

Use your mouse (or finger if on a mobile device) to sign your name in the box below.