Life Insurance Enrollment Form CITY OF BROCKTON Department of Human Resources Group Benefits Enrolment Form Employee/Family InformationGroup Number-Division Number Employer/Policyholder Dept ID Employee Name (Last, First, Middle) Social Security Number Home Address (Street, City, State, Zip) Telephone #Gender (M/F)MaleFemaleOccupation or Job Title Date of Birth MM slash DD slash YYYY Age Paroll Type Weekly Bi-Weekly Monthly Annual Earnings Average Hours Worked Date of Hire MM slash DD slash YYYY Date of Full Time Employment if different Effective Date MM slash DD slash YYYY State Class Rate Basis Spouse (Last, First, Middle) Spouse Gender (M/F)MaleFemaleSpouse Date of Birth MM slash DD slash YYYY Spouse Age No. of Dependents Only Elect Boston Mutual Coverages Made Available to You Through Your Employer. Basic Life Yes No Basic Life Insurance Amt Voluntary Life Yes No Voluntary Life Insurance Amt Basic AD&D Yes No Basic AD&D Insurance Amt Voluntary AD&D Yes No Voluntary AD&D Insurance Amt Basic Dependent Life: Spouse Yes No Basic DL Spouse Insurance Amt Voluntary Dependent Life: Spouse Yes No Voluntary DL Spouse Insurance Amt Basic Dependent Life: Child(ren) Yes No Basic DL Children Insurance Amt Voluntary Dependent Life: Child(ren) Yes No Voluntary DL Children Insurance Amt Basic Short Term Disability Yes No Basic STD Insurance Amt Voluntary Short Term Disability Yes No Voluntary STD Insurance Amt Basic Long Term Disability Yes No Basic LTD Insurance Amt Voluntary Long Term Disability Yes No Voluntary LTD Insurance Amt Basic Other Please Specify Coverage and Amount Voluntary Other Please Specify Coverage and Amount Beneficiary(ies) For Life and/or AD&D Benefits (attach Additional Beneficiaries on a signed and dated separate sheet) Primary Beneficiary(ies): Residential Address Date of Birth MM slash DD slash YYYY Social Security Tel #Relationship % of Benefit Primary Beneficiary(ies): Residential Address Date of Birth MM slash DD slash YYYY Social Security Tel #Relationship % of Benefit Contingent Beneficiary(ies) Contingent Residential Address Contingent DOB MM slash DD slash YYYY Contingent SSN Contingent Tel #Contingent Relationship Contingent % Benefit Contingent Beneficiary(ies) Contingent ResidentialAddress Contingent DOB MM slash DD slash YYYY Contingent SSN Contingent Tel #Contingent Relationship Contingent % Benefit Please upload additional beneficiaries (if needed) Drop files here or Select files Max. file size: 50 MB. If you designate more than one beneficiary, please be sure the total percentages of benefits equals 100%. If you do not designate a percentage payable for each beneficiary, the total proceeds payable will be divided equally among each beneficiary. If an insured dependent dies, we will pay the proceeds to you. Please complete as much beneficiary information as you can provide. Refusal of Insurance I hereby certify that I have been given an opportunity to participate in the Group Insurance Plan offered by my employer (or the Association with whom I am affiliated) and insured by Boston Mutual Life Insurance Company and that I have declined to do so with respect to:Refusal of Insurance All Coverages Life and AD & D Dependent Coverage Short Term Disability Long Term Disability I further understand that if I desire to participate in the Plan at a later date with respect to the coverage(s) checked, I must furnish, at my own expense, evidence of insurability satisfactory to Boston Mutual Life Insurance Company.Signature of Employee RefusalDate MM slash DD slash YYYY Signature of WitnessWitness Date MM slash DD slash YYYY I apply for the insurance for which I am now eligible (or for which I may become eligible) under the provisions of the Group Policy or Group Policies issued to my employer by the Boston Mutual Life Insurance Company and authorize deductions, if any, from my earnings of the required premium contribution toward the cost of the insurance. I understand that if I am disabled on the date my insurance would otherwise become effective, I shall only become insured on the date I return to active full-time work. I further understand that if I decline insurance coverage for which I am now eligible and I desire to participate in the plan at a later date, I must furnish, at my own expense, evidence of insurability satisfactory to Boston Mutual Life Insurance Company.Signature of EmployeeEmployee Date MM slash DD slash YYYY
