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1 I P a g e Universal Enrollment & Change Form Effective Date Reason for Enrollment: New Hire Date Cobra □ Dependent Change (add/delete) □ Benefit Change/Cancel - Reason Open Enrollment Qualified Life Status Change Date: Event: Part 1. Employee Information (please print) Name SSN Address Date of Birth City / State / Zip Salary Home Phone Hours Per Week Status: Married Single Separated Divorced Job Title PART 2. PROVIDE INFORMATION ABOUT YOURSELF AND YOUR DEPENDENTS (PLEASE PRINT): If you elect vision insurance for yourself and/or dependents, provide information below. If dependent’s address is different from employee, list address below. List additional dependents on separate page. Name (List dependent address if different from employee) Social Security # REQUIRED Date of Birth Sex M/F Vision Employee Enroll Waive Spouse Enroll Waive Child Enroll Waive Child Enroll Waive Child Enroll Waive Child Enroll Waive Child Enroll Waive Child Enroll Waive Child Enroll Waive Please mark appropriate boxes below ---PAGE BREAK--- 2 I P a g e VISION ENROLLMENT Employee Only Employee + Spouse Employee + Child(ren) Family BASIC LIFE & AD&D ENROLLMENT Employee Spouse Child(ren) STD ENROLLMENT Employee Only (except firefighters) MEDICAL & DENTAL ENROLLMENT Employee Only Employee + Spouse Employee + Child(ren) Family VOLUNTARY LIFE AND AD&D ENROLLMENT (Fee Schedule is found in the Employee Benefit Guide) . EMPLOYEE ($10,000 up to $500,000) SPOUSE ($5,000 up to $250,000) LIFE $ AD&D $ LIFE $ AD&D $ CHILD(REN) LIFE - $10,000 AD&D - $10,000 LIFE INSURANCE BENEFICIARY Primary Beneficiary, Relationship, SS#, Date of Birth, Phone # &Percentage % 1. 2. Contingent Beneficiary, Relationship, SS#, Date of Birth, Phone & Percentage% 1. 2. Part 3. Read and complete authorization and sign form: I hereby apply for group benefits(s) indicated above and understand I must be eligible as defined by the group plan, and my coverage will not take effect until I have completed the eligibility period (as defined in the group plan). Changes outside of my eligibility will only be allowed with a qualified life status change, otherwise I must wait for the next open enrollment. I authorize my employer to withhold the required premium for the coverage(s) selected from my pay. Employee Name (please print): Employee Signature: Date: SIGN