966111chg form 2026

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The document is a Term Life Insurance Change Form from the Life Insurance Company of North America (LINA), a Cigna Company. It outlines the process for employees to request changes to their life insurance coverage, including options for increasing, decreasing, or canceling coverage due to life status changes such as marriage or birth. The form requires employer verification and includes sections for employee information, medical history questions, and agreements regarding the insurance application process.

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Click ‘Get Form’ to open the 966111chg form in the editor.
Begin by filling out the EMPLOYER USE section. Enter your employer's name, policy number, and other mandatory data required for processing.
In the EMPLOYEE SECTION, select your title (Mr., Mrs., Ms.) and provide your full name, address, phone numbers, Social Security number, employee ID, birthdate, and sex.
Indicate any changes you wish to make regarding your life insurance coverage. Check the appropriate boxes for increases or decreases in coverage and specify if this is due to a life status change.
Complete the medical questions if you are applying for or increasing coverage beyond the guaranteed amount. Ensure all answers are marked clearly.
Sign and date the form in the designated areas to confirm acceptance of coverage and authorization for information disclosure.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (158 Votes)
2015	4 Satisfied (48 Votes)
2009	4.4 Satisfied (271 Votes)

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966111chg form 2026

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