|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.||NOTE: TO ALL FULL-TIME EMPLOYEES OF PARTICIPATING DEPARTMENTS. This is your opportunity to enroll in an excellent, low-cost Group Term Life Insurance Plan sponsored by your Department.|
|Employee NameTesting T Guy||DOBJanuary 1, 1970||SSN111-555-9999|
|Employee Home Address100 Main Street, Tallahassee FL 32303|
|Employee ID100||DepartmentDept. of Health||Date of Hire01/01/2020|
|Work CountyLeon||Cell Phone||Work Phone|
|Primary Beneficiary Name(s)Junior Guy||DOB01/01/10||RelationshipSon||%100|
|Primary Beneficiary Name(s)||DOB||Relationship||%|
|Contingent Beneficiary Name(s)Junior Guy||DOBJanuary 1, 1963||RelationshipSon||%100|
|I hereby apply for the amount of Group Term Life Insurance for which I am eligible under my employers Group Insurance plan.
I authorize deductions from my earnings in the amount required to cover my premiums.
|Employee Signature||DATEJune 2, 2020 at 9:41 pm||Personal E-mail Address|
|SAMAS CODE||DISTRICT/DIV CODE||EFFECTIVE DATE||DEDUCTION AMOUNT||DEDUCTION CODE||DATE PROCESSED|