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 |
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. |
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Employee Signature![]() |
DATEJune 2, 2020 at 9:41 pm | Personal E-mail Address |
262 | |||||
SAMAS CODE | DISTRICT/DIV CODE | EFFECTIVE DATE | DEDUCTION AMOUNT | DEDUCTION CODE | DATE PROCESSED |