Are you married?
Date of marriage/union
Date of birth
Do you have children or other dependants?
Placement date of adopted children
Date of full time hire
Please include the names of the dependents you wish to enroll for coverage. A dependent is a person that you, as a taxpayer, claim; who relies on you for financial support; and for whom you qualify for a dependency tax exception. Dependency tax exemption are subject to IRS rules and regulations. Additional information may be required for non-standard dependents such as a grandchild, a niece or a nephew.
First, Middle Initial, Last Name
Date of Birth
Child / Dependent 1
State of Residence
Status (Check all that apply)
Child / Dependent 2
Child / Dependent 3
Child / Dependent 4
If you selected Drop Employee or Drop Dependents, what was the last day of coverage
If you selected Termination of Employment or Retirement, what is your last day worked:
If you selected Other event, list the reason of dropped coverage
Date of Event
I have been offered the above coverage(s) and wish to drop enrollment for the following reasons:
If other, please list the reason why
You must be enrolled to cover your dependents. Benefit reductions apply. Please see plan administrator
Employee Policy Amount (select one)
Add Voluntary Life for Spouse
Add Voluntary Life for Dependent/Child(ren) *The amount may not be more than 10% of the employee amount for Voluntary Life.
Primary beneficiaries must total 100%
Primary Beneficiary 2
In the event the designated primary beneficiaries are deceased, the contingent beneficiary will receive the benefit. Employer maintains beneficiary information.
Complete the following question(s) if you are enrolling for one or more of the following benefits listed below. NOTE: Additional information may be required.
In the last 6 months, have you or any of your dependents received medical care, including treatment, consultation services, diagnostic measures or monitoring of a condition in remission; or taken prescribed drugs for: Cancer, Heart Disease, Diabetes; any condition related to Acquired Immune Deficiency Disorder (AIDS) or AIDS Related Complex; or any other Chronic Condition?
An Evidence of Insurability form must be complete for any person with a "Yes" answer to the questions above.
Any person who with intent to defraud any insurance company or other person files an application for insurance or statements of claim containing any materially, false information or conceals for purpose of misleading information concerning any face material herto, commits a fraudulent insurance act, which is a crime, and may also b subject to civil penalties, or denial of insurance benefits.
The state in which you reside may have a specific state fraud warning. Please refer to the attached Fraud Warning Statements page.
If coverage is waived and you later decide to enroll, late entrant penalties may apply. You may also have to provide at your own expense, proof of each person's insurability. Guardian has the right to reject your request.
The laws of New York require the following statement to appear: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. (Does not apply to Life Insurance.)
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Board of Retirement
PO Box 5002
Antioch, TN 37011
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