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SI 7533D-377661 (11/13) Public Employees Benefits Board (PEBB) Program Underwritten by Standard Insurance Company Long Term Disability (LTD) Enrollment/Change Form Employees Personnel, payroll, or benefits office staff x Type or print clearly in ink. x If you do not wish to enroll in optional LTD coverage, complete Sections 1 & 2. x If you wish to enroll in or change optional LTD coverage, complete Sections 1 & 3. Your personnel, payroll, or benefits office will automatically enroll you in Part A (Basic) LTD coverage. x Return this form to your personnel, payroll, or benefits office. x If you’re requesting optional coverage that requires prior approval, you must also complete the LTD Evidence of Insurability Form and send it to Standard Insurance Company. x Review Sections 1 – 3 for completeness and accuracy, and complete Section 4. x Do not send the form to Standard Insurance Company or the PEBB Program. SECTION 1: PERSONAL INFORMATION Employee completes this section. Social Security Number Employee I.D. Number Last Name First Name Middle Initial Street Address Apartment Number City State ZIP Code + 4 Mailing Address (if different from above) Apartment Number City State ZIP Code + 4 Agency Name Agency Code Date of Birth Male Female Phone Number – Daytime Phone Number – Evening SECTION 2: BASIC LTD COVERAGE ONLY Employee completes this section. Your employer pays for Plan A (Basic) LTD coverage. Your personnel, payroll, or benefits office will enroll you in this coverage at no cost to you. If you wish to enroll in Plan A (Basic) LTD coverage only and do not wish to enroll in optional LTD coverage, sign and date below. I hereby reject my opportunity to enroll in optional long term disability coverage. By signing this form, I declare that the information I have provided is true, complete, and correct. I understand that knowingly providing false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company is a crime, and can result in imprisonment, fines, and denial of insurance benefits. This form replaces all previous forms and submissions I have made for PEBB long term disability coverage. Employee’s signature Date SECTION 3: BASIC AND OPTIONAL LTD COVERAGE Employee completes this section. I wish to: Enroll in optional LTD coverage; choose a waiting period. Increase the waiting period for my LTD coverage; choose a waiting period. Decrease the waiting period for optional LTD coverage; choose a waiting period. Cancel my optional LTD coverage. If you wish to enroll in optional LTD coverage after 31 days of becoming newly eligible for PEBB coverage, or decrease the waiting period for your optional LTD coverage, you must also complete the LTD Evidence of Insurability Form. By signing this form, I declare that the information I have provided is true, complete, and correct. I understand that knowingly providing false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company is a crime, and can result in imprisonment, fines, and denial of insurance benefits. I allow my employer to deduct money from my earnings to pay for any optional insurance I requested and approved by Standard Insurance Company. This form replaces all previous forms and submissions I have made for PEBB long term disability insurance. Employee’s signature Date Choose a waiting period: 30 days 60 days 90 days 120 days 180 days 240 days 300 days 360 days SECTION 4: AGENCY/CARRIER INFORMATION Personnel, payroll, or benefits office completes this section. Current Agency Hire Date Initial Eligibility Date for PEBB Benefits Effective Date of Optional Coverage (if no approval required) Standard Insurance Company has: Approved Effective date Declined Pended—information incomplete Employee’s Earnings $ Employee’s Current Coverage Basic LTD only Optional LTD—waiting period days PEBB LONG TERM DISABILITY INSURANCE CONTRACTOR Standard Insurance Company, Attn: Medical Underwriting Department, 900 SW 5th, Portland, OR 97204-1282 Phone: 1-[PHONE REDACTED] 1 of 1 Reset Klickitat County Print