I authorize deductions from my earnings in the amount required to cover my premiums.
| Available to all full-time employees in participating agencies. This is your opportunity to enroll in an excellent, low-cost Group Term Life Insurance Plan sponsored by your Department. | |||
| NEW ENROLLEE: If you elect to have coverage, complete and sign this application of apply online at capitalins.com/enroll-gtl. | |||
| 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. |
| Employee NameTesting T Guy | DOBJanuary 1, 1970 | SSN111-555-9999 | Gender |
| Employee Home Address100 Main Street, Tallahassee FL 32303 | Personal E-mail Address | ||
| People First Login ID#100 | Agency and County of Work LocationDept. of Health | Date of Hire01/01/2020 | |
| Employment Address (work location)Leon | Work Phone | Cell Phone | |
| 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. | |||
| Primary Beneficiary Name(s)Junior Guy | DOB01/01/10 | RelationshipSon | %100 |
| Primary Beneficiary Name(s) | DOB | Relationship | % |
| Contingent Beneficiary Name(s)Junior Guy | DOBJanuary 1, 1963 | RelationshipSon | %100 |
| I hereby apply for the amount of Group Term Life Insurance for which I am eligible under my employers Group Insurance plan. I authorize deductions from my earnings in the amount required to cover my premiums. |
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| Employee Signature: |
Date:June 2, 2020 at 9:41 pm | ||
| Agent Name: | |||
| 262 | |||||
| SAMAS CODE | DISTRICT/DIV CODE | EFFECTIVE DATE | DEDUCTION AMOUNT | DEDUCTION CODE | DATE PROCESSED |