Page 10 - NRLCA RCA Enrollment Kit

NRLCA Bene t Enrollment Form
For More Information (877) 817-4801
SECTION 1: Demographic Information
Member
(Last, First, M.I.)
c Male c Female
Social Security No.
Date of Birth
Date of Marriage***
Spouse
(Last, First, M.I.)
c Male c Female
Social Security No.
Date of Birth
Date of hire
Average hours worked per week
Hourly Salary
Occupation
Rural Carrier
Email Address
Home Address
Home Phone
City
State
Zip Code
Cell Phone
Child(ren) Name
Date of Birth
Gender cM cF
cM cF
Full time student cYes cNo
cYes cNo
Child(ren) Name
Date of Birth
Gender cM cF
cM cF
Full time student cYes cNo
cYes cNo
Primary Bene ciary Relationship Percentage (Last, First, M.I.)
Contingent Bene ciary Relationship Percentage (Last, First, M.I.)
Member will be the bene ciary for any spouse** and/or child(ren) coverage. For additional bene ciaries, attach names separately.
SECTION 2: 24-Hour On- and Off-the-Job Accident Insurance Underwritten by Transamerica Life Insurance Company
c Member - $13.58 c Member plus Child(ren) - $19.14 c Member plus Spouse - $21.36 c Member plus Family - $27.08
ACCIDENT INSURANCE PREMIUM $__________________
SECTION 3: 20-Year Term Life Insurance Underwritten by Transamerica Life Insurance Company (please see rate chart in brochure)
c Member c Spouse c Children
c Fill in Life Insurance Bene t Amount $______________ c $15,000 (maximum)
c $10,000 ($2.50 total for all dependents combined)
Tobacco User
c No c Yes c No c Yes c No c Yes
Member Premium $______________ Spouse Premium $______________ Child(ren) Premium $______________
Do you currently have any other existing life insurance or annuity policies or contracts? c No c Yes
If “Yes” complete the replacement form(s) provided by the NRLCA Bene t Center. Call 1-877-817-4801 for forms or download from the website.
If coverage you are applying for includes and Accelerated Death Bene t Rider, did you receive the applicable Disclosure(s) if required by your state? Critical Care Condition Rider c No c Yes Terminal Illness Rider c No c Yes
LIFE INSURANCE PREMIUM $_______________________
Member must purchase life insurance in order for spouse and dependent children to purchase life insurance.
c No c Yes
If yes, list name(s):______________________________________________, who will be excluded from coverage.
If applying for spouse and/or child(ren) coverage, is any proposed insured currently disabled?
SECTION 4: Short-Term Disability Income Insurance Underwritten by Transamerica Life Insurance Company
Please select a bene t amount not to exceed 60% of your monthy income but no greater than $3,000.
c 6 Month Bene t $______________ Monthly Bene t Amount c 12 Month Bene t $______________ Monthly Bene t Amount Disability Income Insurance Premium $______________ Disability Income Insurance Premium $______________
DISABILITY INCOME INSURANCE PREMIUM $__________
If you have any questions on the enrollment process or payment options please contact the NRLCA Bene t Center at (877) 817-4801
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