294125 2026

1. Click ‘Get Form’ to open the Life and Disability Income Insurance Enrollment Form in the editor.
2. Begin by completing the top box with your Employer/Plan Sponsor's information, including the name and group/plan number.
3. Fill in your employment status, date of hire, and annual salary. Make sure to check any applicable boxes regarding changes in coverage.
4. Provide your personal details in the Employee Information section, including your name, date of birth, social security number, and contact information.
5. Select your desired coverage options for Disability Income and Employee Life Insurance based on your age group. Ensure you understand the evidence of insurability requirements.
6. Designate beneficiaries by filling out their names, addresses, relationships to you, and benefit percentages in the Beneficiary Information section.
7. Review all entered information for accuracy before signing and dating the form at the bottom.

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