CAUTION: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTE: TO ALL FULL-TIME EMPLOYEES OF PARTICIPATING DEPARTMENTS. This is your opportunity to enroll in an excellent, low-cost Group Term Life Insurance Plan sponsored by your Department.
I hereby apply for the amount of Group Term Life Insurance for which I am eligible under my employer’s Group Insurance Plan.
I authorize deductions from my earnings in the amount required to cover my premiums.