MEMBER SECTION (Required fields are marked with an asterisk *)

Title *First Name: MI: *Last Name: Suffix Gender
*Birth Date (MM/DD/YYYY) : *SSN: *Hourly Salary: Date of Membership (MM/DD/YYYY) : *Local Chapter: Shift:
*Address 1: Address 2: *City: *State: *Zip:
*E-mail Address: *Verify E-mail: *Telephone Number: Cell Phone Number:

SPOUSE SECTION

Title First Name: MI: Last Name: Suffix
Birth Date (MM/DD/YYYY) : Gender SSN: Marriage Date (MM/DD/YYYY) :

DEPENDENTS SECTION

Last Name First Name Date of Birth (MM/DD/YYYY) Gender Full Time Student
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Accident Advance 24 Hour On and Off-the-Job Accident Insurance

Plan Coverage Monthly Premium Amount
Accept
Decline
Member Only
Member plus Spouse
Member plus Children
Member plus Family
$

Term Life Insurance Critical Care Condition Rider

*MEMBER BENEFIT Age Smoker? Life Amount Monthly Premium Amount
20 Year Term
Decline
? Years $

Member must elect at $30,000 for enable spousal coverage. Spouse limited to $15,000

SPOUSE Age Smoker? Life Amount Monthly Premium Amount
Accept
Decline
? Years $

Spouse limited to $15,000.

CHILD(REN) Life Amount Monthly Premium Amount
Accept ($2.50 for all children)
Decline
$10,000 $
Per child All children

Short Term Disability Income Insurance Buy Up

Benefit Plan Age Salary Benefit Amount Monthly Premium Amount
Accept 7 Day Wait 1 Yr Plan
Decline
? Years $ ? $

DETERMINING YOUR MONTHLY PREMIUM FOR ACCOUNT DEDUCTION

Accident Advance Premium $ 0.00 +
Member Life Premium $ 0.00 +
Spouse Life Premium $ 0.00 +
Child Life Premium $ 0.00 +
Short Term Disability Income Insurance Premium $ 0.00 +
Admin. Fee $ 0.00

Total Premium $ 0.00

ENROLLMENT INFORMATION

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.

Signature of Member Date (MM/DD/YYYY)

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.

PRIMARY BENEFICIARY DESIGNATION
*Last Name *First Name Relationship to Insured Date of Birth (MM/DD/YYYY) Address of Beneficiary (Address, City, State, Zip) *Benefit Percentage (%)
Percentage Total (%): 100.00
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CONTINGENT BENEFICIARY DESIGNATION
Last Name First Name Relationship to Insured Date of Birth (MM/DD/YYYY) Address of Beneficiary (Address, City, State, Zip) Benefit Percentage (%)
Percentage Total (%) : 0.00
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Barn Benefits Enrollment Center

Premium Deduction Form

Please Complete the Following Information

Use the same information from above.
Insured Full Name :
Address 1:
Address 2:
City : State : Zip :
Phone :

Total Monthly Premium

From above

$ 0.00

Electronic Funds Transfer (EFT) Arranged by The Capitol Group Payroll Services

Authorization

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

  • Checking Account
  • Savings Account

WITHDRAWAL AUTHORIZATION

Use same Name from above.
Name of Depositor :
To Financial Institution :
TRANSMIT/ROUTING ABA# :
Verify TRANSMIT/ROUTING ABA# :
ACCT. NO. :
Verify ACCT. NO. :
  • I Agree
  • I Disagree
*Please Type Your Name *Password (Last 4 digits of SSN + mother's maiden name) *Re-enter Password Date (MM/DD/YYYY)