PERSONAL INFORMATION Gender: ---MaleFemale Are you married? ---YesNo Date of marriage/union Date of birth Do you have children or other dependants? ---YesNo Placement date of adopted children ABOUT YOUR JOB Work Status ---ActiveRetiredCobra/State Continuation Date of full time hire ABOUT YOUR FAMILY 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. Spouse First, Middle Initial, Last Name Gender---MaleFemale Date of Birth Child / Dependent 1 AddDrop Gender---MaleFemale Date of Birth State of Residence Status (Check all that apply)StudentDisabledNon standard dependent Child / Dependent 2 AddDrop Gender---MaleFemale Date of Birth State of Residence Status (Check all that apply)StudentDisabledNon standard dependent Child / Dependent 3 AddDrop Gender---MaleFemale Date of Birth State of Residence Status (Check all that apply)StudentDisabledNon standard dependent Child / Dependent 4 AddDrop Gender---MaleFemale Date of Birth State of Residence Status (Check all that apply)StudentDisabledNon standard dependent DROP COVERAGE ---Drop EmployeeDrop DependentsTermination of EmploymentRetirementOther Event 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 COVERAGE BEING DROPPED ---Voluntary LifeEmployeeSpouseChild(ren) I have been offered the above coverage(s) and wish to drop enrollment for the following reasons: ---Covered under another insurance planOther If other, please list the reason why VOLUNTARY TERM LIFE COVERAGE WITH ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) You must be enrolled to cover your dependents. Benefit reductions apply. Please see plan administrator Employee Policy Amount (select one)$25,000$50,000$75,000$100,000I do not want this coverage Add Voluntary Life for Spouse %50% of employee's amount to maximum $50,000I do not want this coverage Add Voluntary Life for Dependent/Child(ren) *The amount may not be more than 10% of the employee amount for Voluntary Life. 10% of employee's amount to maximum $10,000I do not want this coverage BENEFICIARIES Primary Beneficiary Primary beneficiaries must total 100% Primary Beneficiary 2 Contingent Beneficiary In the event the designated primary beneficiaries are deceased, the contingent beneficiary will receive the benefit. Employer maintains beneficiary information. HEALTH HISTORY 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. Voluntary Life 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? Yes, I haveNo, I haven'tYes, my spouse hasNo, my spouse hasn'tYes, my dependent children haveNo, my children haven't An Evidence of Insurability form must be complete for any person with a "Yes" answer to the questions above. SIGNATURE I understand that life insurance coverage for a dependent, other than a newborn, will not take effect if that dependent is confined to a hospital or other health care facility, or is home confined, or is unable to perform the normal activities of someone of like age and sex I understand that my dependent(s) cannot be enrolled for a coverage if I am not enrolled for that coverage I understand that the premium amounts shown above are estimations and are for illustrative purposes only You must be legally working in the United States in order to be eligible for coverage. Underwriting must approve coverage for employees on temporary assignment (a) exceeding 1 year; (b) in an area under travel warning by the US Department of State, subject to state specific variations. You must be legally working in the United States or working outside of the United States for a United States based employer in a country or region approved by us. I understand that I must be actively at work or my elected coverage will not take effect until I have met the eligibility requirements (as defined in the benefit booklet.) This does not apply to eligible retirees. Plan design limitations are exclusions may apply. For complete details of coverage, please refer to your benefit booklet. State limitations may apply. Your coverage will not be effective until approved by a Guardian underwriter 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 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 acknowledge and consent to receiving electronic copes of Guardian insurance related documents, in lieu of paper copies, to the extent permitted by applicable lay. I may change this election only by providing Guardian thirty (30) day prior written notice. I attest that the information provided above is true and correct to the best of my knowledge 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.) Use your mouse (or finger if on a mobile device) to sign your name in the box below.