ENROLLMENT

MEDICAL

I have declined to enroll for coverage for myself, my spouse, and my dependent children due to:

Base ($5000 Deductible-2) PPO
Semi-Monthly (24x) Payroll Deductions

Buy-Up ($2500 Deductible-1) PPO
Semi-Monthly (24x) Payroll Deductions

DENTAL

WAIVE COVERAGE

Value Plan
Semi-Monthly (24x)

Plus Plan
Semi-Monthly (24x)

Vision

WAIVE COVERAGE

Vision Coverage
Semi-Monthly (24x)

Dependent Information

Last Name

First Name

M.I.

Social Security #

Date of Birth

Gender

Male

Female

Relationship

Medical

Enroll

Decline

Dental

Enroll

Decline

Vision

Enroll

Decline

Last Name

First Name

M.I.

Social Security #

Date of Birth

Gender

Male

Female

Relationship

Medical

Enroll

Decline

Dental

Enroll

Decline

Vision

Enroll

Decline

Last Name

First Name

M.I.

Social Security #

Date of Birth

Gender

Male

Female

Relationship

Medical

Enroll

Decline

Dental

Enroll

Decline

Vision

Enroll

Decline

Last Name

First Name

M.I.

Social Security #

Date of Birth

Gender

Male

Female

Relationship

Medical

Enroll

Decline

Dental

Enroll

Decline

Vision

Enroll

Decline

Last Name

First Name

M.I.

Social Security #

Date of Birth

Gender

Male

Female

Relationship

Medical

Enroll

Decline

Dental

Enroll

Decline

Vision

Enroll

Decline

Last Name

First Name

M.I.

Social Security #

Date of Birth

Gender

Male

Female

Relationship

Medical

Enroll

Decline

Dental

Enroll

Decline

Vision

Enroll

Decline

Last Name

First Name

M.I.

Social Security #

Date of Birth

Gender

Male

Female

Relationship

Medical

Enroll

Decline

Dental

Enroll

Decline

Vision

Enroll

Decline

Last Name

First Name

M.I.

Social Security #

Date of Birth

Gender

Male

Female

Relationship

Medical

Enroll

Decline

Dental

Enroll

Decline

Vision

Enroll

Decline

Last Name

First Name

M.I.

Social Security #

Date of Birth

Gender

Male

Female

Relationship

Medical

Enroll

Decline

Dental

Enroll

Decline

Vision

Enroll

Decline

Basic Life & AD&D / $10,000 Benefit - Available to all Full Time Employees (Employer Paid)

Beneficiary #1 Full Name

Relationship

Socil Security #

% Level #1

Beneficiary #2 Full Name

Relationship

Socil Security #

% Level #2

Contingent Beneficiary #2 Full Name

Relationship

Socil Security #

% Level #3

Contingent Beneficiary #2 Full Name

Relationship

Socil Security #

% Level #4

Please note that if the beneficiary is a minor, you will need to set-up a trust

Employee Voluntary Life/AD&D: Increments of $10,000 to a Max of $300,000 - Guarantee Issue of $100,000

Spouse Voluntary Life/AD&D: Increments of $5,000 to a Max of $100,000 - Guarantee Issue of $25,000

Child/ren Voluntary Life/AD&D: $10,000

Name of Dependent #1

Name of Dependent #2

Name of Dependent #3

Name of Dependent #4

Name of Dependent #5

Date of Birth #1

Date of Birth #2

Date of Birth #3

Date of Birth #4

Date of Birth #5

Social Security #1

Social Security #2

Social Security #3

Social Security #4

Social Security #5

Please note that if coverage is not elected during initial enrollment, a physical examination or further medical information is required if applying for coverage at a later date. This will be at your own expense.

AN EVIDENCE OF INSURABILITY FORM(S) MUST BE COMPLETED FOR ANYONE ELECTING VOLUNTARY LIFE COVERAGE ABOVE THE SPECIFIED GUARANTEE ISSUE AMOUNT, OR FOR LATE ENTRANTS, EMPLOYEE / DEPENDENT(S) WHO ARE INCREASING THEIR VOLUNTARY BENEFIT.

* Dependents are eligible for Voluntary Life coverage only if you have elected coverage for yourself.

Please update my Beneficiary Information to the following (as stated below)

Voluntary Life & AD&D - Available to all Full Time Employees (Employee Paid)

Beneficiary Information

Beneficiary #1 Full Name

Relationship

Social Security #

% Level #1

Beneficiary #2 Full Name

Relationship

Social Security #

% Level #2

Contingent Beneficiary #1 Full Name

Relationship

Social Security #

PHONE: 281-392-7747 | FAX: 281-392-7727

MEDICAL

I have declined to enroll for coverage for myself, my spouse, and my dependent children due to:

Base ($5000 Deductible-2) PPO Semi-Monthly (24x) Payroll Deductions

Buy-Up ($2500 Deductible-1) PPO Semi-Monthly (24x) Payroll Deductions

DENTAL

WAIVE COVERAGE

Value Plan Semi-Monthly (24x)

Plus Plan Semi-Monthly (24x)

Vision

WAIVE COVERAGE

Vision Coverage Semi-Monthly (24x)

Dependent Information

Basic Life & AD&D / $10,000 Benefit - Available to all Full Time Employees (Employer Paid)

Please note that if the beneficiary is a minor, you will need to set-up a trust

Employee Voluntary Life/AD&D: Increments of $10,000 to a Max of $300,000 - Guarantee Issue of $100,000

Spouse Voluntary Life/AD&D: Increments of $5,000 to a Max of $100,000 - Guarantee Issue of $25,000

Child/ren Voluntary Life/AD&D: $10,000

Voluntary Life & AD&D - Available to all Full Time Employees (Employee Paid)

Beneficiary Information

Base ($5000 Deductible-2) PPO
Semi-Monthly (24x) Payroll Deductions

Buy-Up ($2500 Deductible-1) PPO
Semi-Monthly (24x) Payroll Deductions

Value Plan
Semi-Monthly (24x)

Plus Plan
Semi-Monthly (24x)

Vision Coverage
Semi-Monthly (24x)