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Enrollment Forms

  • Apply Online!
    You can apply for Disability and Life coverage with our online enrollment form.
  • Disability and Life Insurance Enrollment Form (Print)
    Use this link if you prefer to print the enrollment form. You can then mail or fax the application to us. Please refer to the Member Enrollment Booklet for coverage details, premium amounts and terms and exclusions.
  • Medical History Statement (Submit Online or Print)
    Use this form to provide proof of good health when it is a requirement of your enrollment. You may need to complete separate forms for yourself, spouse or domestic partner, or dependent children.
  • Beneficiary Designation/Change (Submit Online)
    Use this form to specify beneficiaries for benefits related to your voluntary Life and Disability coverage. Designating beneficiaries is an optional process.

Change Forms

  • Participant Change
    Use this form to reinstate your coverage or update your address, name and salary information.
  • Beneficiary Designation/Change (Submit Online)
    Use this form to specify beneficiaries for benefits related to your voluntary Life and Disability coverage. Designating beneficiaries is an optional process.
  • Coverage Termination
    Use this form to terminate part or all of your coverage(s).

Claim Forms

Continuation Forms

  • Temporary Leave Continuation of Life Insurance
    Use this form to continue your life insurance during a temporary leave of absence resulting from a temporary layoff, a scheduled leave of absence approved by your employer, a state mandated Family or Medical Leave Act, or a strike, lockout or other work stoppage caused by a labor dispute.
  • Request for Group Life Conversion Materials
    Use to request application to convert group life insurance to an individual policy after insurance ends.