CIGNA | Voluntary Long Term Disability Enrollment Form

CAUTION: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

CAUTION: Employee must complete sections 1 – 18. Please print or type. Review plan brochure before completing this Enrollment Form. BI-WEEKLY & MONTHLY

NOTE: Eligible employees – all active full-time employees of participating employers who are under the age of 70

Disability Enrollment Form

Submission Type *

1. Employee ID *

2. Social Security Number *

3. Agency and County of Work Location *

4a. First Name *

4b. Middle Initial

4c. Last Name *

5a. Street Address *

5b. City *

5c. State *

5d. Zip *

6. Cell Phone Number *

7. Work Phone Number *

8. Date of Birth *

9. Sex *

10a. Employment Address (work location) *

10b. Employment City *

10c. Employment Zip *

11. Full Time Employment Date *

12. Hours Worked Weekly *

13. Annual Salary *

Monthly Rates
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Bi-Weekly Rates
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14. Do you have other sources of Income? *

15. Group Coverage Desired? *

16. OPS *

If you answered YES to Q.14 above, benefits will coordinate with other sources of income and will reduce your Cigna benefit amount.

For Q.15 above, determine the group that you are eligible for based on your salary, or you may select a lower group for a shorter elimination period and lower benefit amount.

17. Occupation or Title *

I hereby apply to Life Insurance Company of North America (LINA), a Cigna Company, for Disability Salary Continuation Insurance. I understand that the Company may decline to accept this application if it is not completed during the enrollment periods predetermined by the Company and the Sponsoring Employer. I further understand that, if accepted, my coverage will take effect (if actively at work) on the day following the end of the payroll period in which the first payroll deduction is made. I also certify that I am an Employee of the Sponsoring Employer in an Eligible Class (as specified above), and authorize my Employer to deduct from my earnings an amount sufficient to pay the premium for this insurance, including Age Band changes. I hereby acknowledge that I have received the outline of coverage (brochure) (PLAN BROCHURES: BI-WEEKLY & MONTHLY) describing insurance for which I am now applying.

18. Signature *

Clear

Personal Email *