Enrollment Form Enrollment Form What type of enrollment are you completing? Individual Group Staff Associate Group ID Referred By Name * Name First First Middle Middle Last Last Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone * Business Phone Cell Phone Company Email * Is this the best email to reach you at? Yes No Additional Email Personal and Professional Information Occupation Today's Date * Social Security Number * Gender * Please selectMaleFemale Date Of Birth * Annual Earnings * Benefits Short Term Disability Enrollment and Monthly Premium * Please selectNone$250 weekly benefit- $25.00$500 weekly benefit- $38.75$1000 weekly benefit- $66.25 Long Term Disability Enrollment and Monthly Premium * Please selectNoneAge <30, $2,500 Monthly Benefit- $19.20Age <30, $5,000 Monthly Benefit- $27.10Age <30, $10,000 Monthly Benefit- $45.35Age 30 to 34, $2,500 Monthly Benefit- $20.45Age 30 to 34, $5,000 Monthly Benefit- $30.60Age 30 to 34, $10,000 Monthly Benefit- $60.35Age 35 to 39, $2,500 Monthly Benefit- $23.75Age 35 to 39, $5,000 Monthly Benefit- $36.25Age 35 to 39, $10,000 Monthly Benefit- $93.70Age 40 to 44, $2,500 Monthly Benefit- $29.20Age 40 to 44, $5,000 Monthly Benefit- $47.10Age 40 to 44, $10,000 Monthly Benefit- $135.35Age 45 to 49, $2,500 Monthly Benefit- $38.75Age 45 to 49, $5,000 Monthly Benefit- $66.25Age 45 to 49, $10,000 Monthly Benefit- $185.35Age 50 to 54, $2,500 Monthly Benefit - $51.70Age 50 to 54, $5,000 Monthly Benefit - $92.10Age 50 to 54, $10,000 Monthly Benefit - $233.70Age 55 to 59, $2,500 Monthly Benefit - $64.60Age 55 to 59, $5,000 Monthly Benefit - $117.95Age 55 to 59, $10,000 Monthly Benefit - $295.35Age 60 to 64, $2,500 Monthly Benefit - $67.95Age 60 to 64, $5,000 Monthly Benefit - $124.60Age 60 to 64, $10,000 Monthly Benefit - $250.35Age 65 to 69, $2,500 Monthly Benefit - $75.85Age 65 to 69, $5,000 Monthly Benefit - $140.40Age 65 to 69, $10,000 Monthly Benefit - $198.70 Life Insurance Coverage and Premium. *Ages 65-69 are enrolling in the maximum benefit pay out based on 50k, 100k & 150k. * Please selectNone<25 to 29 $9.40 per month for $50000 Benefit<25 to 29 $16.80 per month for $100000 Benefit<25 to 29 $24.20 per month for $150000 Benefit30 - 34 $9.90 per month for $50000 Benefit30 - 34 $17.80 per month for $100000 Benefit30 - 34 $25.70 per month for $150000 Benefit35-39 $11.90 per month for $50000 Benefit35 - 39 $19.80 per month for $100000 Benefit35-39 $28.70 per month for $150000 Benefit40-44 $13.90 per month for $50000 Benefit40-44 $25.80 per month for $100000 Benefit40-44 $37.70 per month for $150000 Benefit45-49 $18.90 per month for $50000 Benefit45-49 $35.80 per month for $100000 Benefit45-49 $52.70 per month for $150000 Benefit50-54 $30.90 per month for $50000 Benefit50-54 $59.80 per month for $100000 Benefit50-54 $88.70 per month for $150000 Benefit55-59 $44.90 per month for $50000 Benefit55-59 $87.80 per month for $100000 Benefit55-59 $130.70 per month for $150000 Benefit60-64 $51.40 per month for $50000 Benefit60-64 $100.80 per month for $100000 Benefit60-64 $150.20 per month for $150000 Benefit*65-69 $59.21 per month for $32.5k Would you like to add additional Life Insurance coverages? * None Spouse Life Insurance Coverage Child(ren) Life Insurance Coverage Life Insurance Spouse Coverage and Premium. Please note that the premium for spouse is based on the Members date of birth not spouse's date of birth. Member must enroll in one of the Life Insurance Benefits for spouse to be eligible. Please select<25 to 29 - $4.70 per month30 - 34 - $4.95 per month35 - 39 - $5.95 per month40 - 44 - $6.95 per month45 - 49 - $9.45 per month50 - 54 - $15.45 per month55 - 59 - $22.45 per month60 - 64 - $25.70 per month Life Insurance Child(ren) Coverage and Premium. Member must enroll in one of the Life Insurance Benefits for the child to be eligible. Please selectYes please add coverage for $2.00 per month Cigna Plus (Dental) Savings Plan-$10 per month * Please selectNoneIndividualFamily Cigna Plus Dependents Name * Name First First Middle Middle Last Last Date Of Birth * Gender * Male Female plus1 Add Another Dependent minus1 Remove Life Insurance Beneficiary Name * Name First First Last Last Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Percentage Of Benefit * plus1 Add Another Beneficiary minus1 Remove Fraud Terms I am applying for Voluntary Group Insurance. I represent that the statements contained herin are true and complete to the best of my knowledge and belief. I acknowledge I have read the appropriate fraud notice below, which pertains to my state of residency. For Residents of Arkansas, Colorado, Kentucky, New Mexico, and Ohio: Some states require us to inform you that any person who knowingly and with intent to injure, defraud, or deceive and insurance company or other person files a statement containing false or misleading information concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines may be imposed For Residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive an insurance company, files a statement of claim or an applicaiton containing false, incomplete or misleading information is guilty of a felony of the third degree. For Residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is crime and subjects such person to criminal and civil penalties. I have read and understand the Fraud Terms and the policy(ies) * AgreeDisagree You must "agree" to reading and understanding the Fraud Terms and policies in order for your enrollment to be processed. Payment Information How would you like to pay for your monthly premiums? * Credit/Debit Card (please note there will be a 3% additional charge for this payment type) Automatic Bank Draft (Cheking/Savings) Name On Credit/Debit Card * Name On Credit/Debit Card First First Middle Middle Last Last Credit/Debit Card Information (ALL FIELDS REQUIRED INCLUDING CVC) * Expiration Month * JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Expiration Year * 202420252026202720282029203020312032203320342035 Enter Security Code (CVC) * Credit Card Type * VisaMastercardAmerican ExpressDiscover Name On Bank Account * Name On Bank Account First First Middle Middle Last Last Type of Account * Please selectBusiness CheckingBusiness SavingsPersonal CheckingPersonal Savings Account Routing Number * Bank Account Number * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Mothers Maiden Name * Automatic Bank Draft Authorization * I authorize the financial institution named above to accept Direct Payment instructions and to debit my account indicated below or credit my account if it is necessary to make corrections. I understand if my electronic payment is not made due to insufficient funds there will be a $25.00 NSF service charge added to my payment. I hereby authorize Company, to initiate debit entries to my bank account. This authorization is to remain in full force until Company has received written notification from me of its termination in such time and in such manner as to afford Company a reasonable opportunity to act on it (30 days). I understand that this payment plan may be cancelled by Company at any time. I represent and warrant that I am authorized to execute this Authorization Agreement and I indemnify and hold the Company, bank and their agents harmless from damage, loss or claim resulting from all authorized actions hereunder. Automatic Credit/Debit Card Authorization * I authorize the financial institution named above to accept Direct Payment instructions and to debit my account indicated below or credit my account if it is necessary to make corrections. I understand if my electronic payment is not made due to insufficient funds there will be a $25.00 NSF service charge added to my payment. I hereby authorize Company, to initiate debit entries to my bank account. This authorization is to remain in full force until Company has received written notification from me of its termination in such time and in such manner as to afford Company a reasonable opportunity to act on it (30 days). I understand that this payment plan may be cancelled by Company at any time. I represent and warrant that I am authorized to execute this Authorization Agreement and I indemnify and hold the Company, bank and their agents harmless from damage, loss or claim resulting from all authorized actions hereunder. Signature * signature keyboard Clear Date Submit If you are human, leave this field blank.
