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Are you married?
Do you have children or other dependants?
Date work status began:
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:
Primary Beneficiary (Primary beneficiaries must total 100%)
Primary Beneficiary 2 (Only fill out if you have more than one primary beneficiary)
In the event the designated primary beneficiaries are deceased, the contingent beneficiary will receive the benefit.
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.
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Board of Retirement
PO Box 5002
Antioch, TN 37011
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