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Enrollment Application For Group Term Life Insurance Coverage

Plan underwritten by Life Insurance Company of North America (LINA), A Cigna Company, Now Known as New York Life Group Benefits Solutions
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
CountyLeon Cell Phone Work Phone
The beneficiary for life insurance on the lives of your spouse and children will automatically be you, if surviving, otherwise the estate of the spouse and children, subject to policy provisions. A beneficiary for employee Life Insurance may be changed upon written request. If you need assistance, contact your benefits administrator at (800) 888-5256 or your own legal counsel.
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
FOR PERSONNEL USE ONLY: PLEASE FILE IN EMPLOYEE’S PERSONNEL FILE. DO NOT MAIL TO COMPANY.
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SAMAS CODE DISTRICT/DIV CODE EFFECTIVE DATE DEDUCTION AMOUNT DEDUCTION CODE DATE PROCESSED