Reliastar Life Insurance Company - DOC by fsq79985

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									ING RELIASTAR                                             Enrollment/New Hire/Change Form
ReliaStar Life Insurance Company


INSTRUCTIONS: White portion to be completed by the Employee. Shaded portion to be completed by the Employer/Plan
Sponsor. Print clearly in dark ink, sign the form, and return as instructed. ** Refer to reverse side of form for a description of
these fields.

  NAME OF EMPLOYER/PLAN SPONSOR                                                              GROUP/PLAN NUMBER                     ACCOUNT NUMBER/
  Diocese of San Diego                                                                       GLH-29092-1                           LOCATION

 This change is due to: (Check all that apply)                                                                             EFFECTIVE DATE OF        DATE OF
                                                                                                                             COVERAGE OR             HIRE
           Initial Enrollment                              Address Change                    Other:____________             DATE OF CHANGE
           Regular Enrollee** (New Hire)                   Termination
           Entrant** (Life and LTD)


 SECTION 1. Employee Information. If additional space is required, complete and attach a separate sheet of paper (signed and dated).
 EMPLOYEE NAME (last first middle initial)                       FEMALE           DATE OF BIRTH                    SOCIAL SECURITY #       EMPLOYEE ID. #
                                                                 MALE


 MARITAL STATUS **                          JOB TITLE OR OCCUPATION               ANNUAL SALARY                    EMPLOYMENT                  Active Full-Time
                                                                                                                   STATUS:                     Active Part-Time

 HOME ADDRESS (street address, city, state, zip code)                                                           TELEPHONE
                                                                                                                Work (   )
                                                                                                                 Home (  )

 SECTION 2. Coverage Selection (ReliaStar Life).
 BASIC LIFE/BASIC AD&D Employee Only- $10,000 paid by employer
 BASIC LONG-TERM       Employee Only- 40% paid by employer
 DISABILITY
 OPTIONAL LONG-TERM Employee Only-
 DISABILITY BUY-UP       Yes, I wish to purchase optional Long Term Disability, 20% paid by employee (Total 60%).
                          Fill out the attached EOI form.
                          No, I do not wish to purchase optional Long Term Disability.

 SECTION 3. Beneficiary Information. If additional space is required. complete and attach a separate sheet of paper.
 BENEFICIARY NAME **                               BENEFICIARY’S    BENEFICIARY’S ADDRESS                      RELATIONSHIP     BENEFICIARY’S PERCENT OF
 (If person, enter last, first, middle initial)   SOCIAL SECURITY   (street address, city, state, zip code)    TO EMPLOYEE      PHONE NUMBER BENEFIT
                                                                                                                                                (Must add up to 100%)
 PRIMARY:


 SECONDARY:




READ THE REVERSE SIDE AND THEN SIGN AND DATE BELOW
To the best of my knowledge and belief the information on this form is correct. I understand that false or inaccurate information may result in the
termination of coverage or the nonpayment of benefits. I have read and understand the authorization, included on this form, and consent to its
terms. Also, subject to revocation by me by written notice to my employer, I request the coverage provided from time to time by my employer’s
group plan(s), as elected on this form, and authorize the required deduction (if any) from my wages.

 Employee’s Signature                                       Date Signed                   Signature or Name of Benefits Person Date Signed

                                                                                                              Olivia Granados

47071-1 This form can be used in all states except: Florida, Minnesota, New York, Virginia                                                   March 1999
4722B0A

								
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