Form 5-301A "Enrollment or Change Form - Active Group Life Insurance Select Life and Ad&d" - Alaska

What Is Form 5-301A?

This is a legal form that was released by the Alaska Department of Administration - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Alaska Department of Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 5-301A by clicking the link below or browse more documents and templates provided by the Alaska Department of Administration.

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Download Form 5-301A "Enrollment or Change Form - Active Group Life Insurance Select Life and Ad&d" - Alaska

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Active Group Life Insurance
FOR OFFICE USE ONLY
Select Life and AD&D
Enrollment or Change Form
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
Enrollment is available online at myRnB.alaska.gov
SECTION I: MEMBER INFORMATION
THIS FORM IS SUBMITTED FOR (check all that apply):
BENEFICIARY CHANGE
CANCELLATION OF ACTIVE GROUP LIFE INSURANCE
SELECT LIFE ENROLLMENT (CHECK ONE)
Within 30 days of hire
During the annual open enrollment
Within 30 days of a change in your marital or family status due to such events as marriage, divorce, death, birth or adoption of a child.
EVENT
DATE OF EVENT
EMPLOYEE NAME
RIN OR LAST FOUR OF SOCIAL SECURITY NUMBER
DATE OF BIRTH
EMPLOYMENT DATE
DEPARTMENT
TELEPHONE NUMBER
_________
I wish to purchase Group Select Life and Accidental Death & Dismemberment Insurance in an amount equal to my annual salary. I understand
initial
this is in addition to the Group Basic Life and Accidental Death & Dismemberment Insurance coverage provided by the State. I authorize the
appropriate payroll deduction from my earnings each month for the cost of this coverage. I reserve the right to discontinue this Group Select
Life and Accidental Death & Dismemberment coverage by submitting a written notice to the Division of Retirement and Benefits at any time.
_________
I wish to cancel my Group Select Life and Accidental Death & Dismemberment Insurance Coverage.
initial
SECTION II: PRIMARY BENEFICIARY DESIGNATION
FULL LEGAL NAME OF PERSON,
RELATIONSHIP TO
DATE OF
SOCIAL SECURITY
% OF
TRUST, OR INSTITUTION
ADDRESS, CITY, STATE, ZIP+4
MEMBER
BIRTH
NUMBER (OR TIN)
BENEFIT
1.
2.
3.
4.
SECTION III: SECONDARY BENEFICIARY DESIGNATION
(will only receive benefits if all primary beneficiaries are deceased.)
FULL LEGAL NAME OF PERSON,
RELATIONSHIP TO
DATE OF
SOCIAL SECURITY
% OF
TRUST, OR INSTITUTION
ADDRESS, CITY, STATE, ZIP+4
MEMBER
BIRTH
NUMBER (OR TIN)
BENEFIT
1.
2.
3.
4.
On this form, I have made my beneficiary designations for member Group Select Life and Accidental Death & Dismemberment Insurance. I have read
the instructions and understand that this form supersedes and revokes all prior designations and will become effective only when it is received by the
Alaska Division of Retirement and Benefits.
SIGNATURE
DATE
5-301a (Rev. 3/17)
G:\Communications_Only\200 Products\206\Benefits\5-301a.indd
Active Group Life Insurance
FOR OFFICE USE ONLY
Select Life and AD&D
Enrollment or Change Form
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
Enrollment is available online at myRnB.alaska.gov
SECTION I: MEMBER INFORMATION
THIS FORM IS SUBMITTED FOR (check all that apply):
BENEFICIARY CHANGE
CANCELLATION OF ACTIVE GROUP LIFE INSURANCE
SELECT LIFE ENROLLMENT (CHECK ONE)
Within 30 days of hire
During the annual open enrollment
Within 30 days of a change in your marital or family status due to such events as marriage, divorce, death, birth or adoption of a child.
EVENT
DATE OF EVENT
EMPLOYEE NAME
RIN OR LAST FOUR OF SOCIAL SECURITY NUMBER
DATE OF BIRTH
EMPLOYMENT DATE
DEPARTMENT
TELEPHONE NUMBER
_________
I wish to purchase Group Select Life and Accidental Death & Dismemberment Insurance in an amount equal to my annual salary. I understand
initial
this is in addition to the Group Basic Life and Accidental Death & Dismemberment Insurance coverage provided by the State. I authorize the
appropriate payroll deduction from my earnings each month for the cost of this coverage. I reserve the right to discontinue this Group Select
Life and Accidental Death & Dismemberment coverage by submitting a written notice to the Division of Retirement and Benefits at any time.
_________
I wish to cancel my Group Select Life and Accidental Death & Dismemberment Insurance Coverage.
initial
SECTION II: PRIMARY BENEFICIARY DESIGNATION
FULL LEGAL NAME OF PERSON,
RELATIONSHIP TO
DATE OF
SOCIAL SECURITY
% OF
TRUST, OR INSTITUTION
ADDRESS, CITY, STATE, ZIP+4
MEMBER
BIRTH
NUMBER (OR TIN)
BENEFIT
1.
2.
3.
4.
SECTION III: SECONDARY BENEFICIARY DESIGNATION
(will only receive benefits if all primary beneficiaries are deceased.)
FULL LEGAL NAME OF PERSON,
RELATIONSHIP TO
DATE OF
SOCIAL SECURITY
% OF
TRUST, OR INSTITUTION
ADDRESS, CITY, STATE, ZIP+4
MEMBER
BIRTH
NUMBER (OR TIN)
BENEFIT
1.
2.
3.
4.
On this form, I have made my beneficiary designations for member Group Select Life and Accidental Death & Dismemberment Insurance. I have read
the instructions and understand that this form supersedes and revokes all prior designations and will become effective only when it is received by the
Alaska Division of Retirement and Benefits.
SIGNATURE
DATE
5-301a (Rev. 3/17)
G:\Communications_Only\200 Products\206\Benefits\5-301a.indd
Beneficiary Designation Instructions and Information
Select Life and AD&D Insurance
Designating a Minor as Beneficiary
You may choose to enroll in Select Life for a very low cost. The
A minor can be named as your beneficiary. When no custodian
amount of Select Life available to you is equal to your annual
has been named, and the amount the minor will receive is more
income rounded to the next highest $1,000. The maximum
than $5,000, payment is guided by the Alaska Uniform Transfers
available is $60,000 ($100,000 for Supervisory and Confidential
to Minors Act. The Alaska Uniform Transfers to Minors Act AS
Unit employees). The plan pays double the face value if your
13.46.010-999 permits transfers of property and money to a
death is accidental. This plan does not cover your dependents.
person nominated as a custodian for a minor. The custodian
must obtain a conservatorship prior to payment of the funds.
You may enroll in Select Life Insurance within 30 consecutive
This is true even if the custodian is the parent or legal guardian of
calendar days from the date you were hired as a permanent or
the minor.
long-term nonpermanent employee. If you do not enroll within that
time, you may enroll during the annual open enrollment period or
Naming Additional Beneficiaries
within 30 days of a change in your marital or family status such as
If you need to name more beneficiaries than space allows on this
marriage, divorce, death, or birth or adoption of a child.
form, use an Additional Beneficiary Designation page. This page
must be received with your completed Beneficiary Designation
For more detailed information regarding the Select Life Insurance
form to be valid. You can download an additional page at
and AD&D plans, please refer to your Employee Group Insurance
Alaska.gov/drb or contact the Division to receive one by mail.
Information Booklet.
Whom Can You Name as Beneficiary?
NOTICE
You can choose:
BENEFICIARY REVOCATION BY
• A living person.
DISSOLUTION, DIVORCE, OR ANNULMENT:
• An institution.
• Your estate.
AS 13.12.804 provides that a dissolution, divorce, or
• A trust.
annulment, as it relates to beneficiary designations:
• Any combination of these options.
• Revokes any revocable “disposition or
Primary Versus Secondary Beneficiaries
appointment of property,” made to a former
spouse.
• Primary beneficiaries are “first in line” to receive benefits in
the event of your death. All primary beneficiaries share
• Revokes the beneficiary designation of a former
equally, unless otherwise noted on the form.
spouse’s family member(s).
• Secondary beneficiaries only receive benefits in the event
all primary beneficiaries die before or simultaneously with
Each time you complete a beneficiary form, it cancels all
the member. All secondary beneficiaries share equally,
prior beneficiary designations with the Division for these
unless otherwise noted on the form.
death benefits. Your designations do not become effective until
this form is signed and received in the Division office.
Information to Provide
Each time you complete a new form, it is important you provide
For more information, please contact the Member Services
the full legal name, address, relationship, date of birth and Social
Contact Center toll-free at (800) 821-2251, in Juneau at (907)
Security number of each individual person (or taxpayer
465-4460 from 8:30 a.m. to 4 p.m. Monday-Thursday and 8:30
identification number (TIN) of each institution) you designate. You
a.m. to 3 p.m. Friday Alaska Time. You may also contact
must also designate whether the beneficiary is primary or
customer service representatives by email at doa.drb.mscc@
secondary. Each piece of information helps ensure the named
alaska.gov.
beneficiary is located and the proper person or institution
When you have completed and signed this form, please return
receives the correct distribution.
the original form to the Division at:
Designating an Institution as Beneficiary
Alaska Division of Retirement and Benefits
To name an institution (charity, church, etc.), please provide all of
P.O. Box 110203
the information requested in Parts 2 and/or 3.
Juneau, Alaska 99811-0203
Designating a Trust as Beneficiary
To designate a trust as beneficiary, you should provide the name
of the trust and the date the trust was created in the space
provided for naming a beneficiary. Please also provide a copy of
the Memorandum of Trust with your beneficiary designation.
If you are completing this form because you recently divorced, please send a complete
court-certified copy of your divorce or dissolution documents to the Division.
5-301a (Rev. 3/17)
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