Page 10 - ILA 970

ILA Local 970 Bene t Enrollment Form
For More Information
757-847-9404
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
Longshoreman
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: TransSelect 10 Year Term Life Insurance with Critical Illness Rider Underwritten by Transamerica Life Insurance Company
c 10-Year Term Life Insurance Underwritten by Transamerica Life Insurance Company (please see rate chart)
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 $______________
The maximum guaranteed issue amount for members is $125,000 and spouses on the 10-Year Term Life Insurance is $15,000. For amounts above, please use the TransSelect Term Life Insurance Application that is enclosed.
Spouses have a maximum simplified issue amount of $100,000 and must use the TransSelect Term Life Insurance Application that is enclosed for amounts over $15,000.
Member must purchase life insurance in order for spouse and dependent children to purchase life insurance.
cNo cYes
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?
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 Longshoremen Benefit Center. Call 844-900-PORT for forms or download from the website. Did you receive the applicable Accelerated Death Benefit 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 $_______________________
If you have any questions on the enrollment process or payment options please call 1-844-900-PORT.
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