Please print clearly in blue or black ink. RENEWAL Employee Application
Check one — Employer Use o New Employee
o Change
o COBRA
Employee Information — Failure to accurately complete the questions on this application may affect the existence or amount of coverage. Please correct any errors in the information listed below. Employee name (last, first, initial) B Employer B Employment location C Buchanan Hauling & Rigging, Inc. Group policy/participant # B Account # or Bill Group Name B Cert. # B Employee SSN B Employee birthdate Multiple Sex B Job title or position B Employee hire date B # hours per week B Earnings $____________________ B Married B Children m M o Hourly o Weekly o Monthly o Yes o Yes f F o Yearly o Other____________ o No o No Address B City B State B Zip
ELECTIONS ARE NOT VALID WITHOUT A SIGNATURE AT THE END OF THIS APPLICATION.
Dependent Information — Required if Dependent coverage applies Name (Last Name, First Name) B Date of Birth
B Gender B
Relationship
:
:
:
:
:
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NOTE — Coverage not elected will be assumed refused even if not specifically refused Dental Benefits You may select the benefit(s) below. If you enroll, you will pay all or a portion of the premium. Low Plan Option: Accept Refuse Coverage Accept Refuse Coverage o o Employee o o
Employee + Child(ren) Employee + Family
o
o
o
o
Employee +
Spouse
High Plan Option:
Accept Refuse Coverage
Accept Refuse Coverage
o o
o o
o o
o o
Employee Employee +
Employee + Child(ren) Employee + Family
Spouse
o Refuse Dental Benefits
Union Security Insurance Company Mail To: Attn: Worksite, P.O. Box 419596 Kansas City, MO 64141-6596 Form 61 (03/2010)
Application 197790_219521_1_082304_00001_00001 Page 1 of 4
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