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Voluntary Life Insurance Enrollment

PERSONAL INFORMATION


Gender:

Are you married?

Date of marriage/union

Date of birth

Do you have children or other dependants?

Placement date of adopted children


ABOUT YOUR JOB


Work Status

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

Date of Birth

Child / Dependent 1

Gender

Date of Birth

State of Residence

Status (Check all that apply)

Child / Dependent 2

Gender

Date of Birth

State of Residence

Status (Check all that apply)

Child / Dependent 3

Gender

Date of Birth

State of Residence

Status (Check all that apply)

Child / Dependent 4

Gender

Date of Birth

State of Residence

Status (Check all that apply)


DROP COVERAGE

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

I have been offered the above coverage(s) and wish to drop enrollment for the following reasons:

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)

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.


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?

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.


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