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Complete the following to enroll in the Group Long Term
Disability Insurance Plan.
Name:Campus:
E-mail:
Employee ID:
I hereby request the following:
I wish to elect Group Long Term Disability
coverage (applying 30 days or more after date of hire):
I wish to change the coverage under which I
am now insured to the following (check one):
Option A - 180-Day Benefit Waiting Period
Option B - 90-Day Benefit Waiting Period
Option C - 180-Day Benefit Waiting Period and Annuity Contribution
Benefit
Option D - 90-Day Benefit Waiting Period and Annuity Contribution
Benefit
I wish to terminate my Group Long Term Disability
coverage.
PLEASE NOTE: The Standard pays for
any expenses related to requested medical information as it pertains to the Evidence of Insurability, if:
you are applying for insurance more than 30 days after first becoming
eligible for it;
you are electing a new option which provides a shorter benefit waiting
period and/or the addition of the Monthly Annuity Premium Benefit;
you previously terminated your insurance and are now re-electing coverage.
I hereby authorize Indiana University
to make the appropriate deductions from my earnings for my
contributions toward the cost of this insurance, under the Group Long
Term Disability Insurance
Policy administered by The Standard.
Date Signed: __________________ Employee Signature:__________________________________
Date Employed:__________
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