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OPTIONAL & DEPENDENT LIFE INSURANCE ENROLLMENT FORM
Board of Trustees of the NE State Colleges - #89067
Your Full Legal Name (Last, First, M.I.) (Please print) Soc. Sec. # Date of Birth Date of Hire
Spouse Full Legal Name (Last, First, M.I.) Soc. Sec. # Date of Birth Date of Marriage
Coverage Options
For yourself: You can purchase $10,000, $20,000, $50,000, $100,000 or $180,000 of coverage. Amounts available with
no evidence of insurability required: $180,000 if under age 60, $40,000 if age 60-69, $20,000 if age 70-79 and $1,000 if
age 80 and over. Age Reductions: To 50% at age 70. Benefits cease at retirement. Basic annual earnings do not
include bonuses, commissions, or overtime pay.
For your dependents: Option 1: You can purchase $2,000 for your spouse and $2,000 for your dependent child(ren) or
Option 2: You can purchase $10,000 for your spouse and $5,000 for your children. For a description of children eligible for
coverage, refer to your booklet or ask your H.R. representative.
I accept I decline Coverage Amount Selected
Employee Coverage: ___________________
Dependent Coverage: Option 1 Option 2
There is a one time totally open enrollment for late entrants from 9/1 - 9/19, 2003.
Names of Child(ren) to be Covered (Attach additional pages if necessary) Date of Birth
About Proof of Good Health (or Evidence of Insurability):
Proof of good health, also known as evidence of insurability, is needed if:
You or your spouse applies for higher coverage than the limits described in the Coverage Options above.
You want to increase your existing coverage now (whether your existing coverage had been with Sun Life or with a prior
insurance carrier).
You want to increase or add coverage at a later date for you or your family members.
You decline coverage and then want coverage for you/your family at a later date.
If proof of good health is needed, coverage will not go into effect until Sun Life approves it.
IMPORTANT: You must read and sign to apply for coverage
I understand that:
I am requesting Optional Life coverage under a Group Insurance policy offered by my employer. This coverage will end
when my employment terminates.
My employer will deduct all or part of the premiums from my pay.
If I decline coverage for me or my family now and want it at a later date, I/we will have to provide (proof of good health/
evidence of insurability) acceptable to Sun Life.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects a person
to criminal and civil penalties.
If I am not actively at work due to injury, illness, layoff or leave of absence on the date that any initial or increased Optional
Life coverage is scheduled to start under the Sun Life policy, such coverage will not start until the date I return to work.
If my spouse or any of my dependent children are hospital-confined or are disabled due to an injury or illness on the
date that any initial or increased coverage is scheduled to start under the Sun Life policy, such coverage will not start until
the date they are no longer hospital-confined or disabled and are able to perform their normal activities.
Employee Signature Today’s Date
SLPC 4445 3/00
Naming a Beneficiary
On the lines below, list the individual(s) who you want to receive Optional Life Insurance proceeds in the event of
your death. You may specify as many individuals as you like, but the total shares must equal 100%. This is your
primary beneficiary. Attach additional pages if needed. Proceeds for the loss of a covered family member will be
paid to you. If you do not name a beneficiary or if no beneficiaries are alive at the time of your death, proceeds will be
payable to your estate.
Primary Beneficiary(ies) (Last, First, M.I.) Relationship Percent Share
Include Social Security numbers to Employee of Proceeds
(Total must equal 100%)
%
%
%
On the lines below, list the individual(s) who should receive proceeds only if ALL of the individuals listed above are not
living at the time of your death. This is your secondary or contingent beneficiary. They are not paid if anyone listed above is
alive when you die. Attach additional pages if needed.
Secondary Beneficiary(ies) (Last, First, M.I.) Relationship Percent Share
Include Social Security numbers to Employee of Proceeds
(Total must equal 100%)
%
%
%
Calculating Your Cost
Employee coverage
1. Find your cost in the chart below.
2. Multiply the cost per $1,000 by your amount of coverage (divided by 1,000).
Family Unit coverage
1. Find the cost per dependent unit in the chart below.
EMPLOYEE DEPENDENT COVERAGE
Monthly cost per Monthly cost per
$1,000 of coverage* family unit
$ 0.33 Option 1: $ 0.80
Option 2: $ 3.25
*Includes Optional AD&D
Employee: Make a copy of this form for your records before submitting it to your employer.
Employer: This original enrollment form should remain at the employer’s site. Family status, coverage, or beneficiary
changes should be recorded on another Optional Life Enrollment Form.
SLPC 4445 3/00
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