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

Member Number

First Name*

Last Name*

Mailing Address*

Social Security Number*

Date of Birth*

Home Telephone Number

Cell Phone Number

Email Address*

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.

I will be enrolling:*

My spouse
At least one dependent
Both spouse and dependent(s).

SPOUSE INFORMATION

Spouse's Name

Spouse Date of Birth*

Spouse SSN*