Puritan Life Insurance Company of Scottsdale, AZ
Administrative offices PO Box 11823
Winston-Salem, NC 27116
READ BEFORE FILLING OUT THIS FORM!
YOU DO NOT HAVE COVERAGE UNTIL PREMIUM IS PAID.CALL FOR PAYMENT OPTIONS, 800-715-9369.
Dependent Life Insurance allows your legal spouse or domestic partner $10,000 and each eligible child over 14 days to age 21 (25 if full-time student) $5,000 in life insurance for only $11.40 a month.
Please complete for all eligible dependents you wish to enroll. Dependent children are eligible for coverage between the ages of 14 days and 21 years of age. Coverage can be extended to age 25, if dependent child is a full-time student.
(* If you are eligible as a Primary member, you cannot be covered as a dependent)
Your spouse or at least one dependent is required.
"Group Life coverage is issued by Puritan Life Insurance Company of America. Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group Contract issued by Us, the terms of the Group Contract will govern."