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					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 second page 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 benefits.umich.edu/forms/life.html or from the HR/Payroll Service Center.

3. Your Life Insurance Beneficiary Designation.
    Primary Beneficiary (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 Beneficiary (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 04062010
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 Plan coverage
is less than $500,000. You can enroll in the Optional Plan at any time, but after 30     •	   You	can	name	a	single	beneficiary	or	you	can	name	two	or	more	joint	ben-
                                                                                              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 a            •	   You	may	change	your	beneficiary	at	any	time	by	completing	a	Beneficiary	for	
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 of coverage you purchase. Long-form and short-form health statements              •	   If	you	name	a	beneficiary	who	is	a	permanent	resident	of	a	foreign	country,	
                                                                                              furnish that person’s full current address to assist in locating the person.
are available from the Benefits Office Web site at benefits.umich.edu/forms/life.
html, or from the HR/Payroll Service Center.                                             •	   If	you	wish	to	name	your	estate,	insert	“Estate”	on	the	first	Legal	Name	line	
•	 If	you	enroll	in	the	Optional	Plan	within	30	days	as	a	new	hire	or	newly	                  under 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:
      or increase your current coverage to less than $500,000, you will need to               This document does not create a trust.
      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, your
                                                                                         •	   Consider	discussing	your	beneficiary	with	your	attorney	when	completing	
smoking status, and your salary. See the Benefits Office Web site at benefits.umich.
                                                                                              this form. The Benefits Office cannot provide legal advice.
edu/plans/life/index.html for more information on life insurance plans and rates.
                                                                                         •	   Keep	a	copy	of	this	form	for	your	records.
Effective Date
If you are newly eligible, your insurance will become effective on your service          Payment of Group Life Insurance Benefits
date or the first day you are newly eligible if you enroll within 30 days. If you        •	 If	your	insurance	is	in	force	when	death	occurs,	the	full	amount	of	your	insur-
are not actively at work on the day your insurance would otherwise become                    ance will be paid to your beneficiaries when MetLife receives written proof
effective, you will become insured on the day you return to active work. If proof            of your death. A certified copy of the death certificate is required.
of insurability is required, your insurance will become effective on the day the
health statement is approved by MetLife, the Benefits Office has been notified,          •	   Your	life	insurance	will	be	paid	in	a	lump	sum,	however,	other	methods	of	
and you are actively at work.                                                                 payment may be arranged with MetLife.

                                                                                         •	   If	you	name	more	than	one	beneficiary,	payment	will	be	made	in	equal	shares	
Your Beneficiary                                                                              to the named beneficiaries who survive you (or in full to the survivor if only
•	 When you elect life insurance coverage for the first time, you must complete               one beneficiary survives you), unless you enter a specific percentage for each
     the “Your Life Insurance Beneficiary Designation” section of the form.                   person.
•	     You	may	choose	any	beneficiary	you	wish,	such	as	a	family	member,	a	friend,	      •	   If	you	do	not	designate	a	beneficiary,	or	if	none	of	the	beneficiaries	you	name	
       a trust fund, or an organization.                                                      survives you, death benefits will be paid to the first of the following:
•	     Under	“Primary	Beneficiary”,	list	the	person(s)	whom	you	wish	to	be	paid	                    • Your surviving spouse;
       first. “Under Contingent Beneficiary”, list person(s) whom you wish to be         	          • Surviving children in equal shares;
       paid only if no Primary Beneficiary survives you.                                 	          • Surviving parents in equal shares;
                                                                                         	          •	Surviving siblings in equal shares;
                                                                                         	          • Estate

                                                           Questions?
                                                           If you have questions, view the Benefits Office Web site at benefits.umich.edu, 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.) Monday
                                                           through Friday from 8 a.m. to 5 p.m.

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
Optional 04062010
                                                                                              Ann Arbor, MI 48109-1278               Flint, MI 48502-1950

				
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