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757.985.4225
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admin@mybucketpay.com
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Employer
*
Member (Last, First, M.I.)
*
Date of Birth
*
Date of Hire
*
Avg Hours Worked Per Week
*
Annual Salary
*
Social Security No
Gender
Male
Female
Date of Marriage
Spouse (Last, First, M.I.)
Social Security No
Date of Birth
Date of Marriage
Occupation
Email Address
Home Address (no PO Box)
City
State
Zip Code
Cell Phone
About Children
Name
Date of Birth
Gender
Male
Female
Full Time Student
Yes
No
Name
Date of Birth
Gender
Male
Female
Full Time Student
Yes
No
Beneficiary
Primary Beneficiary (Last, First, M.I.)
Relationship
Percentage
Contingent Beneficiary (Last, First, M.I.)
Relationship
Percentage
“Please select the benefits you are interested in and we will contact you with your rate” “No obligation to purchase"
Accident Insurance
Member – $4.11
Member plus child(ren) – $5.55
Member plus Spouse – $6.35
Member plus Family – $7.96
Short Term Disability Insurance
Monthly Benefit Election
$1000
$2000
$3000
Life Insurance
Guaranteed Whole Life
Member
Spouse
Children
Add Critical Illness Insurance (next to Life Insurance) with following options
Member
Member plus Child(ren)
Member plus Spouse
Member plus Family
Member must purchase in order for spouse and dependent children to purchase life insurance.
Have you or your spouse used tobacco products in the last year?
MEMBER
No
Yes
SPOUSE
No
Yes
If applying for spouse and or child(ren) coverage, is any proposed insured currently disabled?
No
Yes
If yes, list name(s):
who will be excluded from coverage.
1. Are you actively at work on a regular basis and able to perform the regular duties of your occupation?
Yes
No
2. Are you a member in good standing and able to perform the activities of a person of like age and gender?
Yes
No
3. If applying for spouse and/or child(ren) coverage, is any proposed insured currently disabled?
Yes
No
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