Enrollment Form


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Member Demographics









MaleFemale
















About Children




MaleFemale


YesNo




MaleFemale


YesNo


Beneficiary








“Please select the benefits you are interested in and we will contact you with your rate” “No obligation to purchase"q

Accident Insurance

Member - $4.11Member plus child(ren) - $5.55Member plus Spouse - $6.35Member plus Family - $7.96

Short Term Disability Insurance

Monthly Benefit Election

$1000$2000$3000

Life Insurance

Guaranteed Whole LifeMemberSpouseChildren

Member must purce in order of spouse pendent children to purchase insurance. Have you or your spouse used tobacco products in the last year?
MEMBER NoYes SPOUSE NoYes If applying for spouse and or child(ren) coverage, is any proposed insured currently disabled? NoYes

If yes, list name(s): who will be excluded from coverage.