Enrollment Form/Change Form 2026

1. Click ‘Get Form’ to open the Enrollment Form/Change Form in the editor.
2. Begin by filling out Section 1, which requires your proposed insured information. Ensure you print using dark ink and include details such as your employer name, group number, employee name, and social security number.
3. In Section 2, select the coverages you wish to elect. If applicable, check the boxes for Basic Life/AD&D or any voluntary options and enter the requested amounts.
4. If applying for dependent coverage, complete Section 3 with information about your spouse and children. Include their names, dates of birth, and genders.
5. Designate beneficiaries in Section 4. Clearly list their names, addresses, social security numbers, relationships to you, and percentage shares.
6. Finally, review Section 5 for acknowledgments before signing and dating the form to confirm your understanding of the terms.

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