Term Life Insurance
Critical Care Condition Rider
Member must elect at $30,000 for enable spousal coverage.
Spouse limited to $15,000
Spouse limited to $15,000.
Enrollment must occur within 31 days from the date the member 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 benefit and premium amounts indicated on this form are estimates, and are subject to change based on the final terms and conditions of the benefit plan as well as your salary and age on the effective date of the plan.
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 and/or active employment requirements that pertain to the policy to be eligible for coverage. I understand and agree that life insurance coverage for my eligible dependent(s) may be delayed if they are confined (at home, in a hospital, or in any other institution or facility) or disabled on the date insurance would otherwise begin, in accordance with the terms of the policy. Should I decline coverage(s), I understand and accept the Waiver of Group Insurance provisions that follow.
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.
WAIVER OF GROUP INSURANCE
Should I apply for waived coverage(s) in the future, I understand that evidence of insurability may be required, acceptable to the insurance company, at my own expense. The above requirements will apply unless otherwise stated in the policy, or unless prohibited by any applicable state or federal law.
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.
Barn Benefits Enrollment Center
Premium Deduction Form
Please Complete the Following Information
Electronic Funds Transfer (EFT) Arranged by The Capitol Group Payroll Services
The Capitol Group Payroll Services (herein after "the company") will draft the checking or savings account designated on this form for insurance premiums once the policy has been approved for issue, subject to the terms below.
I understand and agree that the authorization is subject to the following conditions:
- This authorization shall remain in effect until revoked in writing.
- Signing this authorization does not mean that coverage is effective. Coverage is effective only as stated by the insurance company.
- Completion of this form will satisfy the requirement for payment method of the insurance premiums and any applicable administrative fees.
- The company will charge an administrative processing fee of $2.00 per ACH transaction in addition to the total monthly premium.
- Use of the selected payment method does not alter any provisions of the policy issued by the insurance company.
- If necessary, refunds of premiums will be refunded by company check or credited via ACH transaction.
- If the payment method selected is not honored upon presentation, the company will make one additional attempt, following this event, for payment. If additional attempt is not honored, the company will terminate any further attempt to use this payment method. The company will charge an administrative processing fee of $15.00 per returned item fee.
The payor hereby authorizes the company to draft, on a monthly basis, the designated checking or savings account on this form for the initial and subsequent premiums for the policy(s) that have been approved for issue, by Electronic Fund Transfer (EFT); certifies the payor has selected the following financial institution; and directs all such EFTs be made as provided below.
Please Select the Account Type for Withdrawal