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GLAD 4 01/12 The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE 68103-2616 Phone: (800) 423-2765 Fax: (877) 573-6177 ENROLLMENT FORM FOR GROUP INSURANCE Please Use Ink or Type GROUP ID: NYECOUNTY GROUP POLICY 000010177362; 000010177364; 000010177363; 000400001000-17020; 000403002244 Billing Division or Location: 1499566; 1500620 A. Employee Information (Complete for ALL Enrollments) Employer Name/Company Name (Please Print) Nye County County Employer ZIP State Employee Last Name First Name Middle Initial Social Security Number Date of Birth Spouse Last Name First Name Middle Initial Social Security Number Date of Birth Street Address City State Zip Gender: Male Female Marital Status: Married Single Home Phone ( ) Work Phone ( ) Completed By Employer Average Hours Worked Per Week: Occupation: Earnings: Hourly Weekly Yearly $ Date of Full-Time Employment: Rehire Date: B. Product Selection (Complete for ALL Enrollments) Basic Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. Class Effective Date Type of Coverage Amount of Coverage Total Premium Basic Group Life/AD&D Yes No $ Employer Paid Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. TYPE OF COVERAGE AMOUNT OF COVERAGE TOTAL PREMIUM Voluntary Employee Life Insurance Yes No* $20,000 $50,000 $100,000 $150,000 $200,000 $ Voluntary Spouse Life Insurance Yes No* $10,000 $20,000 $30,000 Other $ $ Voluntary Dependent Child Benefit Yes No* $2,000 $5,000 $10,000 Other ($1,000 increments only) $ Voluntary Short Term Disability Yes No* Weekly Benefit Amount $ $ Voluntary Long Term Disability Yes No* Benefit Amount $ $ *By selecting No, application for coverage at a later date may require further medical information and/or a physical exam, which will be at my own expense. --Actual deductions may vary from above illustrations due to rounding— ---PAGE BREAK--- GLAD 4 01/12 TYPE OF COVERAGE AMOUNT OF COVERAGE TOTAL PREMIUM Voluntary Accidental Death & Dismemberment (Standalone) Yes No $20,000 $50,000 $100,000 $150,000 $200,000 $ Voluntary Accidental Death & Dismemberment (Standalone) - Spouse Yes No $10,000 $20,000 $30,000 Other $ Voluntary Accidental Death & Dismemberment (Standalone) - Child Yes No $2,000 $5,000 $10,000 Other ($1,000 increments only) C. Beneficiary Information (Complete ONLY for Life/AD&D) Primary Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Street Address City State Zip Contingent Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Street Address City State Zip Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper. E. Request for Coverages This coverage has been offered to me and after careful consideration of the benefits, I have decided to: REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby enroll for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. NOT ENROLL myself in the Program. I understand that if I enroll for coverage at a later date, and if a physical examination or further medical information is required, it will be at my own expense. NOT ENROLL my dependents in the Program. I understand that if I enroll for coverage for my dependents at a later date, and if a physical examination or further medical information is required, it will be at my own expense. NOTE: A PERSON MAY BE COMMITTING INSURANCE FRAUD, IF HE OR SHE SUBMITS AN APPLICATION OR CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, or its insurance partners, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not Actively at Work or an Active Member, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. Employee Full Name: Employee Signature: Date: