Plan underwritten by Life Insurance Company of North America (LINA), a Cigna Company

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.


GROUP TERM LIFE INSURANCE COVERAGE

CHECK HERE IF NAME CHANGE

CHECK HERE IF BENEFICIARY CHANGE
If more names are needed please contact Capital Insurance.

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.