Enrollment Form City of Chicago 2025

1. Click ‘Get Form’ to open the Enrollment Form in the editor.
2. Begin by filling out the General Information section. Enter your last name, first name, middle initial, address, city, state, zip code, and social security number.
3. Indicate your marital status by selecting one of the options: Married, Widowed, Single, or Divorced.
4. Provide your date of employment and annual earnings in the designated fields.
5. In the Optional Term Life section, select the coverage amount you wish to enroll in based on your annual earnings. You can choose from 1 to 10 times your earnings.
6. For Optional Dependent Term Life coverage, indicate if you want to cover your spouse or children and select the desired coverage amounts.
7. Complete the Acceptance or Waiver of Coverage section by signing and dating the form.
8. Finally, ensure all information is accurate before submitting. Mail the completed form to Prudential at the provided address.

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