294125 2025

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 name, class/occupation, group/plan number, and account number/location.
3. Fill in your date of hire and annual salary. Indicate your employment status by checking the appropriate box (Active Full-Time, Active Part-Time, or Retired).
4. In the 'Change' section, check all applicable reasons for coverage changes and specify the effective date of coverage.
5. Provide your personal information including name, date of birth, social security number, telephone numbers, address, and employee ID.
6. Select your desired disability income coverage and life insurance options based on your age group as outlined in the form.
7. Designate beneficiaries by filling out their names, addresses, relationships to you, benefit percentages, dates of birth, and social security numbers.
8. Finally, read the authorization statement carefully before signing and dating the form to confirm accuracy.

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