Vision Benefits You may select the benefit(s) below. If you enroll, you will pay all or a portion of the premium. Accept Refuse Coverage Accept Refuse Coverage o o Employee o o
Employee + Child(ren) Employee + Family
o
o
o
o
Employee +
Spouse
o Refuse Vision Benefits Employee Choice Life, Short Term Disability, Long Term Disability, Accident, Cancer, Critical Illness Benefits You may select the benefit(s) below. If you enroll, you will pay all or a portion of the premium. Accept Refuse Coverage o o Employee Voluntary Life - Amount ___________ o o Employee Matching Voluntary AD&D o o Spouse Voluntary Life - Amount ___________ o o Spouse Matching Voluntary AD&D o o Child(ren) Voluntary Life - Amount ___________ o o Child Matching Voluntary AD&D o o Short Term Disability - Amount ___________ o o Long Term Disability - Amount ___________ o o Accident o Employee o Employee + Spouse o Employee + Child(ren) o Employee + Family o o Critical Illness o Employee Critical Illness - Amount ___________ Have you used tobacco, in any form in the past 12 months? o Yes o No
Cancer: Employee only
o
o
Beneficiaries - Applies to all coverages for which a beneficiary designation is required Last Name First MI B Relationship B
o Primary o Secondary B o Primary o Secondary
B
If beneficiary is not related to you, please provide Date of Birth, Social Security Number, and full address. 1) Give FULL names and relationships of each beneficiary. 2) Beneficiaries elected will apply to all coverages elected on this form for which a beneficiary designation is required. 3) If primary/secondary election is not noted, the beneficiary will be considered primary. 4) Proceeds will be paid in equal shares to those primary beneficiaries who survive you. If no primary beneficiaries survive you, the proceeds will be paid in equal shares to the surviving secondary beneficiaries. 5) If your designation does not fit in the above arrangement, or you want to specify a beneficiary by coverage, please contact Union Security Insurance Company for the appropriate forms.
Application 197790_219521_1_082304_00001_00001 Page 2 of 4
Form 61 (03/2010)
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