Page 44 - The Technician October-November 2017 Flip Book

ACT Benefit Enrollment Form
For More Information
844-236-1002
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
Civilian Technician
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 Beneficiary Relationship Percentage (Last, First, M.I.)
Contingent Beneficiary Relationship Percentage (Last, First, M.I.)
Member will be the beneficiary for any spouse** and/or child(ren) coverage. For additional beneficiaries, attach names separately.
SECTION 2: TransElite Universal Life with Accelerated Death Benefit for Chronic Condition Rider Underwritten by Transamerica Life Insurance Company
c TransElite Universal Life with Chronic Care Rider Underwritten by Transamerica Life Insurance Company (please see rate chart)
c Member c Spouse c Children
c Fill in Life Insurance Benefit 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 $______________ Term Child(ren) Premium $______________
Members can select a combination of TransElite UL and 10 year term up to the guaranteed issue limit of $125,000. For amounts that total over the guaranteed issue maximum of $125,000, please use the enclosed TransElite Universal Life Insurance long form.
*If you are enrolling a spouse over the guaranteed issue maximum of $15,000, please use the TransElite Univeral LIfe Insurance long form. 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 Benefit Amount $______________ c $15,000 (maximum)
c $10,000 ($2.50 total for all dependents combined)
Tobacco User
cNo cYes c No c Yes c No c Yes
Member Premium $______________ Spouse Premium $______________ Child(ren) Premium $______________
The maximum issue amount for spouses on the 10-Year Term Life Insurance is $15,000, if you are also enrolling your spouse in the TransElite Universal LIfe Insurance, please complete the TransElite Universal LIfe Insurance long form.
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?
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 ACT Benefit Center. Call 844-236-1002 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 contact the ACT Benefit Center at 844-236-1002.