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CITY OF BROCKTON

Department of Human Resources

 

 

Life Insurance Enrollment and Waiver Form

Group Benefits Enrollment Form

Employee/Family Information

Date of Birth
MM slash DD slash YYYY
Paroll Type
Date of Hire
MM slash DD slash YYYY
Effective Date
MM slash DD slash YYYY
Spouse Date of Birth
MM slash DD slash YYYY

Only Elect Boston Mutual Coverages Made Available to You Through Your Employer.

Basic Life
Voluntary Life
Basic AD&D
Voluntary AD&D
Basic Dependent Life
Voluntary Dependent Life: Spouse Life
Voluntary Dependent Life: AD&D Child(ren)

Beneficiary(ies) For Life and/or AD&D Benefits (attach Additional Beneficiaries on a signed and dated separate sheet)

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Drop files here or
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

    Employee Signature Required

    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.
    Employee Date
    MM slash DD slash YYYY
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