Standard Insurance Company - Enrollment and Change Form
Check all boxes and complete all sections that apply. Return completed form to OGME, Fax 619.543.7850 or Mail Code 8829.| APPLICANT | ||||||||||||||||||||||||||||||||||
| Your Name (Last, First, Middle) | Group Name | Group Number(s) | ||||||||||||||||||||||||||||||||
| Your Address | City | State | Zip | |||||||||||||||||||||||||||||||
| Social Security # | Date of Birth | M F | Job Title/Occupation | |||||||||||||||||||||||||||||||
| COVERAGE SECTION | ||||||||||||||||||||||||||||||||||
| Life Insurance - Employer Paid; Long Term Disability - Employer Paid; Dental - Employer Paid | ||||||||||||||||||||||||||||||||||
| DENTAL | ||||||||||||||||||||||||||||||||||
Marital Status Single Married Divorced
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| Dental Insurance Waiver: Contributory Dental Insurance The Dental Insurance coverage availabe to me and my Dependents has been explained to me and I do not want to enroll at this time. I understand that if I elect to enroll in the future, the Dental Insurance coverage may be subject to a Late Enrollment Penalty. I decline Dental Insurance for myself I decline Dental Insurance for one or more Dependents | ||||||||||||||||||||||||||||||||||
| BENEFICIARY | ||||||||||||||||||||||||||||||||||
This designation applies to coverage available through your Employer, if any, under Coverage Section 1. Designations are not valid unless signed, dated, and delivered to the Employer during your lifetime. See page 2 for further information.
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| CHANGE | ||||||||||||||||||||||||||||||||||
Use this section only when you wish to make a change after insurance becomes effective. Complete all boxes and sections that apply.
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| Member/Employee Signature Required | Date | |||||||||||||||||||||||||||||||||
| Human Resources Department - Complete this section. Retain form for your records. | ||||||||||||||||||||||||||||||||||
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Beneficiary Information
- Your designation revokes all prior designations.
- Benefits are only payable to a contingent Beneficiary if you are not survived by one or more primary Beneficiary(ies).
- If you name two or more Beneficiaries in a class:
- Two or more surviving Beneficiaries will share equally, unless you provide for unequal shares.
- If you provide for unequal shares in a class, and two or more Beneficiaries in that class survive, we will pay each surviving Beneficiary his or her designated share. Unless you provide otherwise, we will then pay the share(s) otherwise due to any deceased Beneficiary(ies) to the surviving Beneficiaries pro rata based on the relationship that the designated percentage or fractional share of each surviving Beneficiary bears to the total shares of all surviving Beneficiaries.
- If only one Beneficiary in a class survives, we will pay the total death benefits to the Beneficiary.
- If a minor (a person not of legal age), or your estate, is the Beneficiary, it may be necessary to have a guardian or a legal representative appointed by the court before any death benefit can be paid. If the Beneficiary is a trust or trustee, the written trust must be identified in the Beneficiary designation. For example, "Dorothy Q. Smith, Trust under the trust agreement dated ..."
- A power of attorney must grant specific authority, by the terms of the document or applicable law, to make or change a Beneficiary designation. If you have questions, consult your legal advisor.
