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Supplemental Life Insurance Plan
Enrollment Form

Click here to estimate your premium. The monthly premium for supplemental life insurance will vary based on age, salary, and the coverage option selected.

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)

Name:

Date:

Employee ID:

1 . Action taken on this form (choose one):

Enroll in this plan; or

Change my enrollment to the following; or

Stop participation in this Plan. (If this action has been selected, move on to #4.)

2. Coverage Option (choose one):

Guranteed issue or Maximum Coverage

3. Amount of Insurance:

4. EMPLOYEE AUTHORIZATION

I understand that if I am applying for coverage after 60 days of becoming eligible to participate in this Plan, or if I elect the Maximum Coverage option, I must also submit a completed Standard Company’s Medical History Statement form and be approved by The Standard Company.

I authorize deductions from my salary based on the amount of coverage I elected and the current premium rate, until revoked by me.

Employee Signature:__________________________________________________

Date Signed: __________________

For Human Resources Use Only

Employee Date of Full-time Appointment: _________________________

Base Salary: $_________________

Note if approval from The Standard Company is required for the following:

Enrollment after 60 days of eligibility.
Coverage exceeds Guaranteed-Issue level.
Change to higher enrollment option.

Date The Standard Company approval received: ___________________

Effective Date:______________ (Attach The Standard Company’s approval letter to this form.)

Print this form using your browser's print function, sign and date it, and return it to UHRS.

Form updated: November 2011