Insurer: __________________________________________ Insurer: __________________________________________

Employee Life/AD&D Amounts: Basic Issue $__________ Supplemental $__________ Optional $__________

Primary Beneficiary Name ________________________________ Beneficiary’s Social Security ___________________

Relationship of Beneficiary _____________________

Secondary Beneficiary Name ______________________________ Beneficiary’s Social Security ___________________

Relationship of Beneficiary _____________________

Dependent Life Amounts: Basic Issue $__________ Supplemental $__________ Optional $__________

[ ] Dependent Spouse Only [ ] Dependent Child(ren) Only [ ] Dependent Spouse and Dependent Child(ren)

[ ] Short Term Disability [ ] Long Term Disability Your Annual Salary $__________________

Insurer: _________________________________________ Insurer: ________________________________________

Basic Benefit Amount $______________/ per week Optional Benefit Amount $_____________/ per week

[ ] Employee [ ] Employee and Spouse [ ] Employee and Dependent Child(ren)

[ ] Employee, Spouse and Dependent Child(ren)

Insurer: _________________________________________ Insurer: ________________________________________

[ ] Employee [ ] Employee and Spouse [ ] Employee and Dependent Child(ren)

[ ] Employee, Spouse and Dependent Child(ren)

Insurer: _________________________________________ Insurer: ________________________________________

I understand that I am eligible to apply for coverage through my employer. I do NOT want coverage for (check all that apply):

Employee: [ ] Dental [ ] Basic Life/AD&D [ ] Supplemental Life/AD&D [ ] Optional Life

[ ] Basic Disability [ ] Optional Disability [ ] Drug [ ] Vision

Spouse: [ ] Dental [ ] Basic Life [ ] Supplemental Life [ ] Optional Life [ ] Drug [ ] Vision

Dependent Child(ren): [ ] Dental [ ] Basic Life [ ] Supplemental Life [ ] Optional Life [ ] Drug [ ] Vision

The reason I am waiving group coverage at this time is because of:

[ ] Spousal coverage [ ] Individual Coverage [ ] Medicare [ ] Medical Assistance

[ ] Other: _____________________________________________________________________