Enrollment Form
4. Benefit Elections You need to complete all sections of the enrollment form including electing or refusing insurance coverage below and sign it. This must be done either during the enrollment period or within 31 days of your eligibility date. Benefits completely paid by your employer ("non-contributory benefits") cannot be refused. Not all of the benefit options listed below will be necessarily available to you. Your employer will tell you which benefits are available and what your Maximum Guaranteed Issue amount is.
Elect Refuse Coverage
Dental:
Employee
Employee + Spouse
Employee + Child(ren) Employee + Family Were you covered under another dental plan within the last 31 days? .................... Yes No
If "Yes," provide the termination date: Reason for termination of coverage?
Vision:
Employee
Employee + Spouse Employee + Family
Employee + Child(ren)
Employer provided benefits --Your employer pays the premiums for the following benefits if you are eligible for them. Enrollment is automatic; no election is required.
Employee Basic Life and Accidental Death & Dismemberment (AD&D)
5. Beneficiary Designation Information Primary Beneficiary Designation
On the lines below, list the individual(s) who should receive proceeds in the event of your death. You may specify as many individuals as you like, but the total proceeds must equal 100%. This is your primary beneficiary. Attach additional pages if necessary. If you do not name a beneficiary or if no beneficiary is alive at the time of your death, proceeds will be payable in accordance with your Group insurance policy. Designation applies to all coverages for which a beneficiary designation is required. Primary Beneficiary(ies)
Percent share of proceeds*
1 Name (First, M.I., Last)
Relationship to employee Social Security number
%
Address
Phone number
Date of birth
2 Name (First, M.I., Last)
Relationship to employee Social Security number
%
Address
Phone number
Date of birth
*Must equal 100%
14 LOOP RECRUITING 2023 BENEFITS GUIDE
GVMPEM-5627 (Rev 4/20)
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