Guardian Enrollment 2024

PLEASE CHECK APPROPRIATE BOX
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(Please obtain this from your Employer

About You

Name
Address
Gender 1
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Are you married or do you have a spouse?
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Do you have children or other dependents?
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About Your Job

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Hidden
Work Status
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Hidden
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Hidden

About Your Family

Spouse (First, MI, Last Name)
Gender
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Child/Dependent 1
Add/Drop
Gender
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Status (check all that apply)
Child/Dependent 2
Add/Drop
Gender
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Status (check all that apply)
Child/Dependent 3
Add/Drop
Gender
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Status (check all that apply)
Child/Dependent 4
Add/Drop
Gender
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Status (check all that apply)

Dental Coverage

You must be enrolled to cover your dependents. Check only one box. Your Bi-weekly Premium
I do not want coverage. If you do not want this Dental Coverage, please mark all that apply:

Vision Coverage

You must be enrolled to cover your dependents. Check only one box. Your Bi-weekly Premium
I do not want coverage. If you do not want this Vision Coverage, please mark all that apply:

Basic Life Coverage (Name of Beneficiaries)

Tralo Sponsored
Employee Only
$25,000

Name
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Address
Name
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Address

Contingent Beneficiary
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Address
Are any of the beneficiaries identified above considered a minor in the sate in which they reside? Check one box only.
If you answered "Yes", please name the legally designated UTMA Custodian for all minor beneficiaries you have designated:

Name
Custodian to Minor Beneficiaries
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Address

Add Voluntary Life

Policy Amount
Policy Amount
Policy Amount
Policy Amount
Policy Amount
Voluntary Term Life Coverage

Add Voluntary Life for Spouce

You must be enrolled to cover your spouse.
Policy Amount
Policy Amount
Policy Amount
Policy Amount
Policy Amount
Policy Amount
Policy Amount
Policy Amount
Policy Amount
Policy Amount
Voluntary Life for Spouse

Add Voluntary Life for Dependent/Child(ren)

You must be enrolled to cover your dependents.
Policy Amount
Add Voluntary Life for Dependent/Child(ren)

Add VoluntaryAD&D

Add Voluntary AD&D
Add Voluntary AD&D
Add Voluntary AD&D
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.

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
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Address
Beneficiaries Name 2
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Address
Contingent Beneficiary 1:
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Address
Custodian to Minor Beneficiaries
Custodian to Minor Beneficiaries
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Address
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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

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

Critical Illness Coverage

You must be enrolled to cover your dependents. Benefit reductions apply. Please see plan administrator.
Employee Insurance Amount
Spouse Insurance Amount
Up to 50% of the employee's amount to a maximum of $10,000
Dependent / Child(ren)
Employee
Spouse

Accident Coverage

You must be enrolled to cover your dependents
Your Bi-weekly premium

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 1
Beneficiaries Name 2
Check one box only
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:

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
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Address
Beneficiaries Name
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Address
Contingent Beneficiary:
In the event the primary beneficiaries are deceased, the contingent beneficiary will receive the benefit.
MM slash DD slash YYYY
Address
Check one box only
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.
Beneficiaries Name
Custodian to Minor Beneficiaries
MM slash DD slash YYYY
Address
MM slash DD slash YYYY