Enrollment Form For Group Insurance
ADVERTISEMENT
1
2The Lincoln National Life Insurance Company
A Stock Company
Home Office Location: Fort Wayne, Indiana
Group Insurance Service Office: P.O. Box 2616, Omaha, NE 68103-2616
Phone: (800) 423-2765 Fax: (877) 573-6177
ENROLLMENT FORM FOR GROUP INSURANCE
Please Use Ink or
GROUP ID:
GROUP POLICY #:
Billing Division or Location:
Type
LONGBUILD
A. Employee Information (Complete for ALL Enrollments)
Employer Name/Company Name (Please Print)
County
Employer ZIP
State
LONG Building Technologies
Employee Last Name
First Name
Middle Initial
Social Security Number
Date of Birth
Spouse Last Name
First Name
Middle Initial
Social Security Number
Date of Birth
Street Address
City
State
Zip
Gender: Male
Female
Marital Status:
Married
Single
Home Phone
Work Phone
(
)
(
)
Completed By Employer
Average Hours Worked Per Week:
Occupation:
Earnings:
Hourly
Monthly
Weekly
Yearly
Date of Full-Time Employment:
Rehire Date:
$
B. Product Selection (Complete for ALL Enrollments)
Basic Coverage NOTE: Please mark the box or boxes for each coverage you are applying for.
All coverage amounts are subject to the limitations and exclusions as stated in the policy.
Class
Effective
Type of Coverage
Amount of Coverage
Total
Date
Premium
Basic Group Life/AD&D
Yes
No
$
Employer Paid
Long Term Disability
Yes
No
$
Employer Paid
Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for.
All coverage amounts are subject to the limitations and exclusions as stated in the policy.
TYPE OF COVERAGE
AMOUNT OF COVERAGE
TOTAL PREMIUM
Voluntary Employee Life Insurance
Yes
No
$
$
Voluntary Spouse Life Insurance
Yes
No
$
$
Voluntary Dependent Child Benefit
Yes
No
$250
$10,000
$
C. Beneficiary Information (Complete ONLY for Life or AD&D Enrollments)
Primary Beneficiary's Last Name
First
MI
Relationship of Beneficiary
Social Security Number
Street Address
City
State
Zip
Contingent Beneficiary's Last Name
First
MI
Relationship of Beneficiary
Social Security Number
Street Address
City
State
Zip
Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than
one Primary or Contingent Beneficiary, please attach a separate sheet of paper.
GLAD 4 11/00
Rev. 04/07 CO
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business