LINA | Voluntary Group Term Life - Capital Insurance Agency

LINA | Voluntary Group Term Life

Plan underwritten by Life Insurance Company of North America (LINA), through New York Life Benefits Solutions.

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

GTL Application

1. People First Login ID# *

2. Social Security Number *

3a. Department *

3b. Date of Hire *

4a. First Name *

4b. Middle Initial

4c. Last Name *

4d. Gender 4d. Gender

5a. Street Address *

5b. City *

5c. ST *

5d. Zip *

5e. Work County *

6a. Work Phone Number *

6b. Cell Phone Number *

7. Date of Birth *

The beneficiary for life insurance on the lives of your spouse and children will automatically be you, if surviving, otherwise the estate of the spouse and children, subject to policy provisions. A beneficiary for employee Life Insurance may be changed upon written request. If you need assistance, contact your benefits administrator at (800) 888-5256 or your own legal counsel.

8a. Primary Beneficiary Name(s) *

DOB *

Relationship *

% *

8b. Primary Beneficiary Name(s)

DOB

Relationship

9. Contingent Beneficiary Name(s) *

DOB

Relationship *

% *

The percentages for your beneficiaries should equal 100%. Please adjust accordingly. You will not be able to submit the form until this is corrected.

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.

Signature *

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