"Life Insurance Enrollment Form - Omaha Life Insurance Company"

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Enrollment Form
Underwritten by:
United of Omaha Life Insurance Company
Employer Section
(To be completed by the employer/plan administrator. Required fields are marked with an asterisk (*).)
*Employer's Name:
*Effective Date:
Group ID:
Radnor Township School District
G000AXCN
Sub Group ID:
Location Code:
Class:
*Occupation:
*Salary:
Hourly
Weekly
Bi-Weekly
*Date of Hire:
Hours Worked Per Week:
$
Monthly
Semi-Monthly
Annually
Employee Section
Enrollment ID: 21553
(Please print clearly. Required fields are marked with an asterisk(*).)
*Last Name:
*First Name:
MI:
*Social Security Number:
*Birth Date (MM/DD/YYYY):
*Gender:
Male
*Marital Status:
Single
Married
Female
Divorced
Widowed
*Street Address:
E-Mail Address:
*City:
*State:
*Zip Code:
Telephone:
Voluntary Short-Term Disability Coverage Election
Premium Amount
Employee Coverage Only
Enroll
Decline
Benefit Amount
(Per Paycheck = 0/Year)
Short-Term Disability
$____________
$____________
Voluntary Life Coverage Election
Benefit Amount -
Premium Amount
Employee Only Coverage
Select One Option
(Per Paycheck = 0/Year)
Voluntary Life - Employee
$20,000
$____________
$50,000
$____________
$100,000
$____________
$150,000
$____________
Other
$______________
$____________
Decline
If you are enrolling for Voluntary Term Life coverage in excess of the Guarantee Issue Amount of 5 times your annual salary or $150,000 (whichever is less), you
must complete and submit an Evidence of Insurability form. The form is available from your employer, or complete online at www.mutualofomaha.com/eoi.
PAGE 1 OF 2
ID: B-56430, FORM CONTINUES ON PAGE 2
Enrollment Form
Underwritten by:
United of Omaha Life Insurance Company
Employer Section
(To be completed by the employer/plan administrator. Required fields are marked with an asterisk (*).)
*Employer's Name:
*Effective Date:
Group ID:
Radnor Township School District
G000AXCN
Sub Group ID:
Location Code:
Class:
*Occupation:
*Salary:
Hourly
Weekly
Bi-Weekly
*Date of Hire:
Hours Worked Per Week:
$
Monthly
Semi-Monthly
Annually
Employee Section
Enrollment ID: 21553
(Please print clearly. Required fields are marked with an asterisk(*).)
*Last Name:
*First Name:
MI:
*Social Security Number:
*Birth Date (MM/DD/YYYY):
*Gender:
Male
*Marital Status:
Single
Married
Female
Divorced
Widowed
*Street Address:
E-Mail Address:
*City:
*State:
*Zip Code:
Telephone:
Voluntary Short-Term Disability Coverage Election
Premium Amount
Employee Coverage Only
Enroll
Decline
Benefit Amount
(Per Paycheck = 0/Year)
Short-Term Disability
$____________
$____________
Voluntary Life Coverage Election
Benefit Amount -
Premium Amount
Employee Only Coverage
Select One Option
(Per Paycheck = 0/Year)
Voluntary Life - Employee
$20,000
$____________
$50,000
$____________
$100,000
$____________
$150,000
$____________
Other
$______________
$____________
Decline
If you are enrolling for Voluntary Term Life coverage in excess of the Guarantee Issue Amount of 5 times your annual salary or $150,000 (whichever is less), you
must complete and submit an Evidence of Insurability form. The form is available from your employer, or complete online at www.mutualofomaha.com/eoi.
PAGE 1 OF 2
ID: B-56430, FORM CONTINUES ON PAGE 2
Beneficiary for Death Benefits (Right to change beneficiary is reserved to the insured.)
If more than one beneficiary is named, the beneficiaries shall share benefits equally unless otherwise stated below. If indicating benefit percentages, the percentages
must total 100% for Primary Beneficiaries and 100% for Secondary Beneficiaries. Some states have laws regarding beneficiary designation. Please consult your
employer/benefits administrator for additional information. If you need to designate more beneficiaries than space will allow, please include this information on a
separate piece of paper and submit it with this form, clearly stating your name. Information is not required but will help ensure your beneficiary receives payment.
Primary Beneficiary Designation
#
Last Name
First Name
Relationship to
Date of Birth
SSN
Benefit
Insured
(MM/DD/YYYY)
Percentage
(%)
1
Telephone:
Address of Beneficiary
(Address, City, State, Zip):
2
Telephone:
Address of Beneficiary
(Address, City, State, Zip):
3
Telephone:
Address of Beneficiary
(Address, City, State, Zip):
Percentage Total:
100%
Secondary Beneficiary Designation
#
Last Name
First Name
Relationship to
Date of Birth
SSN
Benefit
Insured
(MM/DD/YYYY)
Percentage
(%)
1
Telephone:
Address of Beneficiary
(Address, City, State, Zip):
2
Telephone:
Address of Beneficiary
(Address, City, State, Zip):
3
Telephone:
Address of Beneficiary
(Address, City, State, Zip):
Percentage Total:
100%
Enrollment Information
Enrollment must occur within 31 days from the date the employee becomes eligible (or as otherwise stated in the policy). If you are required to pay premiums for any
coverage, the enrollment form MUST be signed and dated to authorize payroll deductions. The premium amounts indicated on this form are estimates, and are
subject to change based on the final terms and conditions of the policy as well as your salary and age on the effective date of the policy.
Agreement and Signature
I represent that the information I have provided in this enrollment form is complete, true and accurate to the best of my knowledge. I understand that payment of
premium does not ensure my eligibility for coverage. I understand and agree that I must satisfy all active work, active employment and/or active eligibility
requirements that pertain to the policy to be eligible for coverage. Should I apply for waived coverage in the future, I understand that evidence of insurability may be
required, acceptable to the insurance company, at my own expense. I understand that if coverage is applied for in the future, it must be during an enrollment period
or due to a life change event as defined by the policy, and that a waiting period may apply.
By signing below, I acknowledge that I understand and agree to the above statements, and that I have read and understand the benefit summaries provided to me
for each line of coverage. The above requirements will apply unless otherwise stated in the policy, or unless prohibited by any applicable state or federal law.
SIGNATURE OF EMPLOYEE
DATE
Additional Information
Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of
claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to criminal and civil penalties.
United of Omaha Insurance Company · Mutual of Omaha Plaza · Omaha, NE 68175
NAME:________________________________________
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