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Group Life Dependent Enrollment

Group Life Dependent Enrollment

  • Puritan Life Insurance Company of Scottsdale, AZ Administrative offices PO Box 11823 Winston-Salem, NC 27116

    FOR MEMBER TO COMPLETE

    READ BEFORE FILLING OUT THIS FORM!

    YOU DO NOT HAVE COVERAGE UNTIL PREMIUM IS PAID.
    CALL FOR PAYMENT OPTIONS, 816-229-5791.

  • MEMBER INFORMATION

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  • 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 NOTE: Dependent Life Insurance is only available if the member is insured. The combined amounts of the spouse/domestic partner’s life insurance cannot exceed 100% (or a maximum of $125,000) of the combined amounts of the member’s life insurance.
  • PERSONS TO BE COVERED

    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.

  • SPOUSE INFORMATION

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  • DEPENDENT(S) INFORMATION

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
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  • FORM CERTIFICATION & SUBMISSION

  • Certification: I certify that all statements are true to the best of my knowledge and belief, and I understand that a copy of this form will be made available at my request.*
  • "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."

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