Enrollment Form
Secondary Beneficiary Designation On the lines below, list the individual(s) who should receive the proceeds ONLY IF ALL of the individuals listed above are not living at the time of your death. This is your secondary (or contingent) beneficiary. The Secondary beneficiary is not paid if a primary beneficiary is alive at the time of your death. Attach additional pages if necessary. Secondary 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%
6. Signature and authorization information
I understand that:
I am requesting coverage under a Group Insurance policy offered by my employer. This coverage will end when my employment terminates, subject to any portability or continuation provisions available under the Group Insurance policy.
My employer will deduct all or part of the premium for contributory coverage from my pay.
For Life insurance, Evidence of Insurability may be required for amounts over my Guarantee Issue for this enrollment. For Dental coverage, I understand that I will not be entitled to benefits until the expiration of any Late Entrant benefit waiting period specified in the certificate of insurance.
For Dental Insurance plans, I have the right to select any dental care provider of my choice.
The dental plan includes a pre-determination provision that will advise me in advance of the benefits I may be eligible for if the procedure is performed. Coverages include benefit waiting periods, limitations and exclusions that may affect my entitlement to benefits. If I am not actively at work due to injury, illness, layoff or leave of absence on the date that any initial or increased coverage is scheduled to start under the plan, such coverage will not start until the date I return to work. When required by the coverage, if my spouse or any of my dependent children are confined due to an injury or illness, as required by the coverage, on the date that any initial or increased coverage is scheduled to start under the plan, such coverage will not start until the date they are no longer confined and are able to perform their normal activities. By signing below, I am representing that the information I have provided is true and correct to the best of my knowledge and belief. X Employee Signature Today's Date To the Employee: Make a copy of this form for your records before submitting it to your employer. To the Employer: This original enrollment form should remain at the employer's site. Family status, coverage, or beneficiary changes should be recorded on another copy of the Enrollment Form.
15 LOOP RECRUITING 2023 BENEFITS GUIDE
GVMPEM-5627 (Rev 4/20)
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