Group Life Member Enrollment - OOIDA

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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, 800-715-9369.

New Members have access to term life insurance on a guaranteed issue basis for coverage amounts up to $50,000. The guaranteed issue period starts the first day of the month following the membership effective date and lasts for 60 days.

If you are applying for coverage after the guaranteed issue period has ended, or for any amount of coverage over $50,000, you MUST call our office to start the application process.

Group Life Member Enrollment

MEMBER INFORMATION
Member Number
First Name*
Last Name*
Address*
Street Address City State ZIP Code
Social Security Number*
Date of Birth*
MM slash DD slash YYYY
Home Telephone Number
Cell Phone Number
Email Address*
Bill To Member Number
COVERAGE ELECTION
Amount of coverage requested * (Maximum of $250,000 available in $10,000 increments)*
Note: If you wish to apply for coverage over the guaranteed issue amount (Member - $50,000), you will need to contact the Life & Health Benefits Dept. at 1-800-715-9369. The amount of requested coverage for over the guaranteed issue amount will be subject to medical underwriting approval. If you do not enroll for coverage for yourself during the initial enrollment period, you will need to provide satisfactory evidence of insurability for all amounts of coverage when you apply in the future.
BENEFICIARY INFORMATION
If more than one beneficiary is desired, please write their name(s), relationship(s), and address(es) on the lines below. If more than one primary beneficiary is designated, settlement will be made in equal shares to the designated beneficiaries (or beneficiary) who are then still living, unless their shares are specified. If no named beneficiary, or no beneficiary survives the insured, settlement will be made in accordance with the terms of your Group Contract.
PRIMARY BENEFICIARY
NOTE: Primary beneficiary benefit percentages must total 100.
Primary Beneficiary Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Relationship to You*
Benefit Percent*
Would you like to add a Secondary Primary Beneficiary?
- Yes
- No
SECOND PRIMARY BENEFICIARY
If you choose to fill out this section, all items with a * are required. NOTE: Primary beneficiary benefit percentages must total 100.
Second Primary Beneficiary Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Relationship to You*
Benefit Percentage*
Would you like to add a Contingent Beneficiary?
- Yes
- No
If you choose to fill out this section, all items with a * are required. NOTE: Contingent beneficiary benefit percentages must total 100.
CONTINGENT BENEFICIARY
Contingent Beneficiary Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
XXX-XX-XXXX*
Benefit Percentage*
Would you like to add a Second Contingent Beneficiary?
- Yes
- No
SECOND CONTINGENT BENEFICIARY
Contingent Beneficiary Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Relationship to You*
Benefit Percentage*
Would you like to add a 5th Beneficiary?
- Yes
- No
If you choose to fill out this section, all items with a * are required. If beneficiary(s) above are not living, then pay:
5th Beneficiary
Contingent Beneficiary Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Benefit Percentage*
Social Security Number
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. Receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. Please contact your personal tax advisor for further information. There is no administrative fee to accelerate death benefits. The accelerated amount is not discounted.
YOU MUST SELECT THE CHECKBOXES BELOW AND SIGN:*
- I UNDERSTAND AND AGREE