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: _____________________________________________________________________

WAIVER: I certify that I was not pressured, forced or unfairly induced by my employer, the agent, or the insurer(s) into waiving (declining) the above-noted coverage. I understand that in the event that I should decide to apply for such coverage at a later date, the application will be subject to the applicable terms and conditions of the employer’s policy(s), which may require additional limitations and waiting periods. I also understand that I, my spouse and my dependent child(ren) may be required to furnish, at my own expense, evidence of health status/health history representation satisfactory to the insurer(s). I understand that the insurer(s) reserves the right to deny coverage with any future application for coverage.