HomeMy WebLinkAboutEnrollment Form
Use this form for cases that offer basic coverage only
Instructions: Complete both pages. Type or print with ballpoint pen. The employee and the
policyholder must each receive a copy of the completed Group Enrollment Card.
Reliance Standard Life InsuranceCompanyGroup Enrollment Card
(1) Policyholder (2) Policy No.
___________________________________________________________________________
(3) Location (4) Full Time Employment Date (5) Class
____________________________________________________________________________
(6) Hours Per Week (7) Occupation (8) SalaryHrly. Mthly.
$ Wkly. Yrly.
_____________________________________________________________________________________
(9) Employee’s Last Name FirstMiddleInitial
____________________________________________________________________________
(10) Employee’s Birth Date (11) Social Security No. (12) Sex Male
( month day yearFemale
_______________________________________________________________________________
(13) Beneficiary(ies) Full Name(s) Relationship% of Proceeds
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(14) I request to purchaseLife/AD&D Weekly Income Long Term Disability
_____________________________________________________________________________
(15) I authorize my employer to deduct from my salary or wages, if applicable, the
necessary premium for the coverage(s)requested above. This signature is also to
verify: (1) the accuracy of the information contained on this card; and (2) the
beneficiary(ies) I have designated.
_____________________________________________________ _____________________
Employee Signature Date
LRS-8387-1188 Basic
Use this form for cases that offer basic coverage only
Instructions: Complete both pages. Type or print with ballpoint pen. The employee and the
policyholder must each receive a copy of the completed Group Enrollment Card.
Declination of Group Insurance Coverage
_________________________________________
(17) Employee’s Last Name First Middle Initial
______________________________________________________________________________
This Coverage Can Be Declined Only If You Pay Part Or All Premiums
(18)
_______________________________________________________________________________
(19) I have been offered and have declined to purchase the following GroupInsurance
Coverages:
Life/AD&D Weekly Income Long Term Disability
I understand that in the event I desire such insurance at a later date: (1) I will be
required to furnish evidence of insurability for myself at my own expense; and (2)
the insurance company will have the right to refuse my request.
.
_____________________________________________________ ___________________
Employee Signature Date
LRS-8387-1188 Basic