P.O. Drawer 27727 Announcing Voluntary Accidental
Raleigh, NC 27611
Death and Dismemberment Insurance
Tel (919) 833-6436 / 1-800-222-2758
Fax (919) 829-5829 For SEANC Members and Their Families
$25,000 to $500,000 Accidental Death & Dismemberment Insurance
Underwritten by Reliance Standard Life Insurance Company
New Travel Assistance If you enroll for dependent coverage:
Services Program Included • In the event there are no eligible dependent children, your spouse will be insured for 50% of
your Principal Sum.
• In the event there are eligible dependent children, your spouse will be insured for 40% of
Affordable group rates your Principal Sum and each child for 10%.
• In the event there is no spouse, each eligible dependent child will be insured for 15% of your
Payroll deduction Principal Sum.
Insure your dependents Member Member only Member & Family
Amount Cost/Monthly Cost/Monthly
No health evidence $25,000 $0.95 $1.40
required $50,000 $1.90 $2.80
$100,000 $3.80 $5.60
$150,000 $5.70 $8.40
$200,000 $7.60 $11.20
$250,000 $9.50 $14.00
$300,000 $11.40 $16.80
$350,000 $13.30 $19.60
$400,000 $15.20 $22.40
To enroll, fill out the attached
enrollment card and mail to the $450,000 $17.10 $25.20
address above. $500,000 $19.00 $28.00
Reliance Standard Life Insurance Company Personal Accident Enrollment Form
Policyholder Policy No.
State Employees Association of NC VAR 200127
Proposed Insured’s Name Social Security # Date of Birth
-- -- / /
Street City State ZIP
Proposed Insured’s Principal Sum Monthly Premium Beneficiary Relationship Certified Effective Date to
be completed @ processing
Member Member & Family Plan Please Note: An Eligible Person may not have coverage both as an Insured Person and as an State Department/Agency
Only (Including Insured) Insured Dependent. Only one Insured spouse may cover the eligible children as Insured
Dependents. If insurance is in force for an Insured Dependent, any newly eligible Dependents
will be automatically covered.
q I request to purchase this accident insurance coverage. I authorize the Policyholder to deduct from my salary of
wages, if applicable, the necessary premium for this insurance coverage.
q I have been offered and have declined to purchase this accident insurance coverage.
With my signature: (1) I verify that the information provided on this enrollment form is accurate and complete, and (2) I make the necessary authorization for
voluntary payroll deduction in the amount of premium indicated above.
Date Signed Signature of Proposed Insured
GEF 00070-0299 Revision 11/07