Guardian Application

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Complete the enrollment form below, then click Complete and Continue to advance to the next section.

Benefits Effective Date

PLEASE CHECK APPROPRIATE BOX

Initial Enrollment

Add Employee/Dependents

Drop/Refuse Coverage

Information Change

Division

Subtotal Code:

(Please obtain this from your Employer

Name

First Middle Last

About You:

Hidden

Social Security

Hidden

SSN 2

Hidden

SSN 3

Address

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

Gender 1

Male

Female

Date of Birth

Phone (Work)

Phone (Home)

Phone (Mobile)

Email Home

Email Work

Are you married or do you have a spouse?

Yes

Date of marriage/union

Do you have children or other dependents?

Yes

Placement date of adopted child

About Your Job (Job Title)

Work Status

Active

Retired

Cobra/State Continuation

Hours Worked Per Week:

Date of full time hire:

Annual Salary:

Hidden

About Your Family

Spouse (First, MI, Last Name)

First Middle Last

Gender

Male

Female

Date of Birth

Child/Dependent 1

First Middle Last

Add/Drop

Add

Drop

Gender

Male

Female

Date of Birth

Status (check all that apply)

Student (post high school)

Non standard dependent

Disabled

Child/Dependent 2

First Middle Last

Add/Drop

Add

Drop

Gender

Male

Female

Date of Birth

Status (check all that apply)

Student (post high school)

Non standard dependent

Disabled

Child/Dependent 3

First Middle Last

Add/Drop

Add

Drop

Gender

Male

Female

Date of Birth

Status (check all that apply)

Student (post high school)

Non standard dependent

Disabled

Child/Dependent 4

First Middle Last

Add/Drop

Add

Drop

Gender

Male

Female

Date of Birth

Status (check all that apply)

Student (post high school)

Non standard dependent

Disabled

Dental Coverage

You must be enrolled to cover your dependents. Check only one box. Your Bi-weekly Premium

Employee Only $13.50

EE & Spouse $30.49

EE & Dependent/Child(ren) $36.55

EE, Spouse & Dependent/Child(ren) $54.23

I do not want coverage. If you do not want this Dental Coverage, please mark all that apply:

I do not want coverage

I am covered under another Dental Plan

My spouse is covered under another Dental Plan

My dependents are covered under another Dental Plan

Vision Coverage

You must be enrolled to cover your dependents. Check only one box. Your Bi-weekly Premium

Employee Only $3.01

EE & Spouse $5.06

EE & Dependent/Child(ren) $5.17

EE, Spouse & Dependent/Child(ren) $8.18

I do not want coverage. If you do not want this Vision Coverage, please mark all that apply:

I do not want coverage

I am covered under another Vision Plan

My spouse is covered under another Vision Plan

My dependents are covered under another Vision Plan

Basic Life Coverage (Name of Beneficiaries)

Name

First Last

Social Security Number

Date of Birth

Address

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

Phone

Relationship to Employee

Name

First Last

Social Security Number

Date of Birth

Address

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

Phone

Relationship to Employee

Contingent Beneficiary

First Last

Social Security Number

Date of Birth

Address

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

Phone

Relationship to Employee

Are any of the beneficiaries identified above considered a minor in the sate in which they reside? Check one box only.

Yes

If you answered "Yes", please name the legally designated UTMA Custodian for all minor beneficiaries you have designated:

Name

First Last

Custodian to Minor Beneficiaries

Social Security Number (or FEIN/TIN# if a corporate entity):

Date of Birth

Address

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

Phone

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

Add Voluntary Life for Spouse

Policy Amount

$10,000

$20,000

$30,000

$40,000

$50,000

Policy Amount

$60,000

$70,000

$80,000

$90,000

$100,000

Policy Amount

$110,000

$120,000

$130,000

$140,000

$150,000

Policy Amount

$160,000

$170,000

$180,000

$190,000

$200,000

Policy Amount

$210,000

$220,000

$230,000

$240,000

$250,000

Voluntary Term Life Coverage

I do not want this coverage

Add Voluntary Life for Dependent/Child(ren)

Policy Amount

$5,000

$10,000

$15,000

$20,000

$25,000

Policy Amount

$30,000

$35,000

$40,000

$45,000

$50,000

Policy Amount

$55,000

$60,000

$65,000

$70,000

$75,000

Policy Amount

$80,000

$85,000

$90,000

$95,000

$100,000

Policy Amount

$105,000

$110,000

$115,000

$120,000

$125,000

Policy Amount

$130,000

$135,000

$140,000

$145,000

$150,000

Policy Amount

$155,000

$160,000

$165,000

$170,000

$175,000

Policy Amount

$180,000

$185,000

$190,000

$195,000

$200,000

Policy Amount

$205,000

$210,000

$215,000

$220,000

$225,000

Policy Amount

$230,000

$235,000

$240,000

$245,000

$250,000

Voluntary Life for Spouse

I do not want this coverage

Add Voluntary Life for Dependent/Child(ren)

Policy Amount

$5,000

$10,000

Add Voluntary Life for Dependent/Child(ren)

I do not want this coverage

Add VoluntaryAD&D

Add Voluntary AD&D

Employee

I do not want this coverage

You must enroll for voluntary term life to be eligible for this coverage. Your elected amount of coverage will be 1 time(s) the coverage elected for voluntary life. You must be enrolled to cover your dependents.

Add Voluntary AD&D

Child(ren)

I do not want this coverage

Add Voluntary AD&D

Spouse

I do not want this coverage

Life Insurance (Continued)

Name your beneficiaries: (Primary beneficiary percentages must total 100%) If electing different beneficiaries that are not the same as those named Basic Life, please name below. If additional space is needed, please attach a separate

Beneficiaries Name 1

First Last

Social Security Number

Date of Birth

Address

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

Phone

Relationship to Employee

Name_5

First Last

Social Security Number

Date of Birth

Address

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

Phone

Relationship to Employee

Contingent Beneficiary 1:

First Last

Social Security Number (or FEIN/TIN# if a corporate entity)

Date of Birth

Address

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

Relationship to Employee

Phone

Beneficiaries Name 3

First Last

Custodian to Minor Beneficiaries

Social Security Number (or FEIN/TIN# if a corporate entity)

Date of Birth

Address

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

Phone

Short-Term Disability (STD) Coverage:

The amount of STD coverage you select may be either a specific dollar amount or an amount that is a multiple of your salary and may be subject to certain reductions as stated in the certificate of coverage covering you.

Weekly Benefit

60% of salary to a maximum of $1000

I do not want this coverage

Long-Term Disability (LTD) Coverage:

The amount of LTD coverage you select may be either a specific dollar amount or an amount that is a multiple of your salary and may be subject to certain reductions as stated in the certificate of coverage covering you.

Weekly Benefit

60% of salary to a maximum of $5000

I do not want this coverage

Critical Illness Coverage

You must be enrolled to cover your dependents. Benefit reductions apply. Please see plan administrator.

Employee Insurance Amount

$10,000

$20,000

I do not want this coverage

Spouse Insurance Amount

$5,000

$10,000

I do not want this coverage

Up to 50% of the employee's amount to a maximum of $10,000

Dependent / Child(ren)

50% of the employee's amount

I do not want this coverage

Employee

Yes

Spouse

Yes

Accident Coverage

You must be enrolled to cover your dependents

Your Bi-weekly premium

Employee Only $4.28

EE & Spouse $6.95

EE & Dependent/Child(ren) $7.09

EE, Spouse & Dependent/Child(ren) $9.76

I do not want this coverage.

Name your beneficiaries (Primary beneficiary percentages must total 100%)

(In the event the designated beneficiaries are deceased, the contingent beneficiary will receive the benefit. Employer maintains beneficiary information.)

Beneficiaries Name 4

First Last

Relationship to Employee:

Beneficiaries Name 5

First Last

Relationship to Employee:

Check one box only

Yes

Are any of the beneficiaries identified above considered a minor in the state in which they reside? If you answered "Yes" please name the legally designated UTMA Custodian for all minor beneficiaries you have designated.

Contingent Beneficiary 2:

First Last

Relationship to Employee:

Name your beneficiaries (Primary beneficiary percentages must total 100%)

Name your beneficiaries: (Primary beneficiary percentages must total 100%) If additional space is needed, please attach a separate sheet of paper with this information along with your enrollment form. Be sure to sign and date the paper and keep a copy for your records.

Beneficiaries Name 6

First Last

Social Security Number

Date

Address

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

Phone

Relationship to Employee:

Beneficiaries Name 7

First Last

Social Security Number

Date

Address

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

Phone

Relationship to Employee:

Contingent Beneficiary 3:

First Last

In the event the primary beneficiaries are deceased, the contingent beneficiary will receive the benefit.

Social Security Number

Date

Address

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

Phone

Relationship to Employee:

Check one box only

Yes

Beneficiaries Name 8

First Last

Custodian to Minor Beneficiaries

Social Security Number (or FEIN/TIN# if a corporate entity)

Date of Birth

Address

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

Phone

Signature

Date

Specialized Driver Onboarding

Guardian Application

About Your Family

Dental Coverage

Vision Coverage

Basic Life Coverage (Name of Beneficiaries)

Add Voluntary Life for Spouse

Add Voluntary Life for Dependent/Child(ren)

Add Voluntary Life for Dependent/Child(ren)

Add VoluntaryAD&D

Life Insurance (Continued)

Short-Term Disability (STD) Coverage:

Long-Term Disability (LTD) Coverage:

Critical Illness Coverage

Accident Coverage

Name your beneficiaries (Primary beneficiary percentages must total 100%)

Name your beneficiaries (Primary beneficiary percentages must total 100%)