Personal Accident Insurance
Enrollment Form

Complete this form to enroll in the Personal Accident Insurance Plan.

This form can be completed online, but it cannot be submitted online. The information you enter is not saved or submitted to any system. Enter the information in the fields below, then print the form using your browser's print function. If you wish, you may print a PDF of this form and complete it manually. (About PDFs)

Life Insurance Company of North America      
Policy Holder: INDIANA UNIVERSITY                   Policy No. OK-980032

Complete the following to enroll:
Name:     Campus:

               Last                                                   First                       M.I.

Social Security #: - -           Date of Birth: / /

Address:

                           Number, Street, Apt. #                       City                        State         Zip

Select Coverage Option and Benefit Amount (select one):

 Employee Only  --  Benefit Amount:

Employee and Family* -- Benefit Amount:
*For Employee and Family coverage, benefits for family members will be a percentage of the Benefit Amount selected.

Primary Beneficiary(ies):

Name

 DOB: / /

 SSN: - -

Address

Relationship:    Percentage: %

Name

 DOB: / /

 SSN: - -

Address

Relationship:    Percentage: %

Name

 DOB: / /

 SSN: - -

Address

Relationship:    Percentage: %


Contingent Beneficiary(ies):

Name

 DOB: / /

 SSN: - -

Address

Relationship:    Percentage: %

Name

 DOB: / /

 SSN: - -

Address

Relationship:    Percentage: %

The employee will be the family member's beneficiary unless otherwise indicated in writing.

I enroll and authorize my employer to deduct the premiums from my earnings. I understand that the insurance selected will begin on the effective date as described in the brochure. If I am not actively at work, the effective date of coverage will be delayed until I return to work.

 

Employee Signature ______________________________________________Date ____/____/____

PRINT this form using your browser's print function.

Mail to your campus HR Office.

UHRS 7/04

CIGNA Group Insurance
Life - Accident - Disability