Page 11 - ILA 970

SECTION 3: Short-Term Disability Income Insurance Underwritten by Transamerica Life Insurance Company Please
select a benefit amount not to exceed 60% of your monthy income but no greater than $5,000*, whichever is less.
c 6 Month Benefit $______________ Monthly Benefit Amount c 12 Month Bene t $______________ Monthly Bene t Amount Disability Income Insurance Premium $______________ Disability Income Insurance Premium $______________
c 24 Month Bene t $______________ Monthly Bene t Amount Disability Income Insurance Premium $______________
DISABILITY INCOME INSURANCE PREMIUM $______________
For benefits exceeding $3,000 per month, please complete the underwriting questions below. If you happened to answer "yes" to the any of the questions, you are eligible for the maximum monthly benefit of $3,000 per month. Please change your benefit amount and premium in appropiate areas.
1. 2.
3. 4.
5.
PREMIUM TOTAL FROM ALL PRODUCTS (Transfer total to ACH form below)
$______________
Step 1 - Complete, sign and date enrollment form. Be sure to include information on all individuals to be covered. Step 2 - Complete, sign and date the payment options form.
Step 3 - Write a check made payable to The Capitol Group for the rst month’s premium.
Step 4 - Return the aforementioned items to:
Local 970 Bene t Center 9609 Gayton Road, Suite 200 Henrico, VA 23238
If you have any questions on the enrollment process or payment options please contact the Local 970 Bene t Center at 757-847-9404.
12
ENROLLMENT STEPS