LE For HRRIS BTT Use Only
Event Date ________________________
University of Michigan Input Elections _____________________
Health Statement Mailed _____________
Optional Group Term Life Insurance Application
Please print all information in black ink. A short-form or long-form health statement may be required. Review the information and instructions on
the back of this form.
1. Faculty or Staff Member Information.
Name (Last, First, Middle Initial) UMID U.S. Social Security Number
(if UMID is unknown)
Street Address City State Zip
Date of Birth Date of Hire (Service Date) Email Address Daytime Phone Number
2. Your Optional Life Insurance. Check one coverage level.
1 x annual salary 5 x annual salary Check one:
2 x annual salary 6 x annual salary
Standard Rate Nonsmoker Discount Rate (I have not smoked
3 x annual salary $5,000
within the last 12 months.)
4 x annual salary $50,000
The maximum life insurance benefit is $1,000,000. You may be required to complete the Short Form Health Statement if you are a current
participant who is increasing coverage to a level not exceeding $500,000. Coverage in excess of $500,000 requires completion of a Long Form
Health Statement satisfactory to the insurance company. Short and Long Form Health Statements are available from the Benefits Office Web
site at www.umich.edu/~benefits/forms/life.html or from the HR/Payroll Service Center.
3. Your Life Insurance Beneficiary Designation.
Primary (one or more) – A primary beneficiary receives payment first. The percentage amounts must total 100%.
1. Legal Name___________________________________ 2. Legal Name___________________________________
Address _____________________________________ Address _____________________________________
Relationship ___________________________________ Relationship ___________________________________
Date of Birth ______________ Percentage _________ Date of Birth ______________ Percentage _________
Contingent (one or more) – A contingent beneficiary receives payment only if all primary beneficiaries (above) are deceased. The percentage
amounts must total 100%.
1. Legal Name___________________________________ 2. Legal Name_________________________________
Address _____________________________________ Address ___________________________________
Relationship ___________________________________ Relationship ________________________________
Date of Birth ______________ Percentage _________ Date of Birth _____________ Percentage __________
4. Authorization and Signature.
I hereby authorize the University of Michigan, the employer, to deduct from my wages (salary), until further notice, amounts equal to the
contributions required of me for Group Insurance under the policy issued to the employer by Metropolitan Life Insurance Company (MetLife).
Signature of Faculty or Staff Member Date Signed
Optional Group Term Life Insurance Application
Terms and Conditions • If you list more than one beneficiary, and you wish the beneficiaries to receive
You must be enrolled in the University Plan to enroll in the Optional Plan. If you are specific percentages, enter the percentage in the space provided under the
a new hire or are newly eligible and enroll in the Optional Plan within 30 days (or person’s name. List whole percentages only. Actual dollar amounts are not
as specified by your bargaining agreement), you will not be required to provide a valid. Check your math to be sure the percentages listed equal 100%.
health statement as evidence of insurability as long as your Optional coverage is • You can name a single beneficiary or you can name two or more joint ben-
less than $500,000. You can enroll in the Optional Plan at any time, but after 30 eficiaries to receive the insurance payment.
days you will be required to provide evidence of insurability that is satisfactory
to the Metropolitan Life Insurance Company (MetLife). MetLife may also require • You may change your beneficiary at any time by completing a Beneficiary for
a physical examination. See the Health Statement section below. Group Life Insurance form.
Health Statement • If your beneficiary is not related to you, show the relationship as “Friend.”
The type of health statement you need depends on when you enroll and the amount
• If you name a beneficiary who is a permanent resident of a foreign country,
of coverage you purchase. Long-form and short-form health statements are avail- furnish that person’s full current address to assist in locating the person.
able from the Benefits Office Web site at www.umich.edu/~benefits/forms/life.
html, or from the HR/Payroll Service Center. • If you wish to name your estate, insert “Estate” on the first Name line under
• If you enroll in the Optional Plan within 30 days as a new hire or newly Primary Beneficiary.
eligible employee, you do not need to submit a health statement if you elect
coverage less than $500,000. • If you wish to name a trust, under Primary Beneficiary, write the complete
• If you enroll in Optional Plan coverage after 30 days for less than $500,000, name(s) of the trustee(s) and successor(s), and the date of the trust. Note:
This document does not create a trust.
or increase your current coverage to less than $500,000, you will need to
complete and submit a short-form health statement. A long-form health • If you wish to name more beneficiaries than there are spaces provided on
statement may be required if you do not successfully pass the short form. this form, please attach a separate sheet. Include on that sheet your name,
• If you elect coverage above $500,000 or increase your coverage to $500,000 your UMID or U.S. Social Security Number (if UMID is unknown), and the
or more, you must complete a long-form health statement. name, address, relationship to you, and percentage (if you wish to indicate
a specific percentage) for the additional named beneficiary or beneficiaries.
Your Cost Sign and date the separate sheet so that it will be valid.
Your cost for the Optional Plan depends on the coverage you select, your age, • Consider discussing your beneficiary with your attorney when completing
your smoking status, and your salary. See the Benefits Office Web site at www. this form. The Benefits Office cannot provide legal advice.
umich.edu/~benefits/plans/life/index.html for more information on life insurance
plans and rates. • Keep a copy of this form for your records.
Effective Date Payment of Group Life Insurance Benefits
If you are newly eligible, your insurance will become effective on your service • If your insurance is in force when death occurs, the full amount of your insur-
date or the first day you are newly eligible if you enroll within 30 days. If you ance will be paid to your beneficiaries when MetLife receives written proof
are not actively at work on the day your insurance would otherwise become of your death. A certified copy of the death certificate is required.
effective, you will become insured on the day you return to active work. If proof
• Your life insurance will be paid in a lump sum, however, other methods of
of insurability is required, your insurance will become effective on the day the
payment may be arranged with MetLife.
health statement is approved by MetLife, the Benefits Office has been notified,
and you are actively at work. • If you name more than one beneficiary, payment will be made in equal shares
to the named beneficiaries who survive you (or in full to the survivor if only
Your Beneficiary one beneficiary survives you), unless you enter a specific percentage for each
• When you elect life insurance coverage for the first time, you must complete person.
the beneficiary designation section of the form.
• If you do not designate a beneficiary, or if none of the beneficiaries you name
• You may choose any beneficiary you wish, such as a family member, a friend, survives you, death benefits will be paid to the first of the following:
a trust fund, or an organization. • Your surviving spouse;
• Under Primary Beneficiary, list the person(s) whom you wish to be paid first. • Surviving children in equal shares;
Under Contingent Beneficiaries, list person(s) whom you wish to be paid only
if no Primary beneficiary survives you.
• Surviving parents in equal shares;
• Surviving siblings in equal shares;
If you have questions, view the Benefits Office Web site at www.umich.edu/~benefits, or call the HR/Payroll Service
Center at 734-615-2000 or 866-647-7657 (toll free for off-campus long-distance calls within the U.S.).
How to Return Your Signed and Completed Form
By FAX By Mail Drop It Off In Person
Fax it to 734-763-0363. Make a copy for your records and send the Bring a photocopy of your completed form and ask the receptionist to stamp
Keep a copy of the fax original by Campus Mail or U.S. Mail to: your form “received” for your records.
transmission report with your HRRIS Benefits Transaction Team U-M Ann Arbor U-M Flint
form in your records. 4073 Wolverine Tower HR Service Center UHR - Flint
3003 South State Street Wolverine Tower – Low Rise G250 213 University Pavilion
Ann Arbor, MI 48109-1281 3003 South State Street 303 East Kearsley Street
Ann Arbor, MI 48109-1278 Flint, MI 48502-1950