COMPANION LIFE VOLUNTARY ENROLLMENT

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VOLUNTARY BENEFITS ENROLLMENT

Please fill out all of the applicable fields (*required), then click the SUBMIT

button at the end of the form.

If you have any questions about or need assistance with your enrollment,

call our broker at 800-527-1397.

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Your connection to this website is encrypted to assure privacy and prevent eavesdropping.

Name of Employer

Group Number

Effective Date

Your Name

First Name

Initial (optional)

Last Name

Your Address

Address Line 1

Address Line 2

City

State

ZIP Code

Occupation

Date Employed

Your Social Security Number

Your Date of Birth

Hours Worked Per Week

Gender

Male Female

Marital Status

Single Married

Your Email Address

Example: myaddress@yahoo.com

Gross Earnings $

Indicate Weekly, Monthly, or Annually

Employee Life Insurance Beneficiary & Relationship

Employee is beneficiary for spouse coverage

Life Insurance Employee

Life Insurance Spouse

Life Insurance Children

Long Term Disability Benefit

Enter Monthly Benefit

Short Term Disability Benefit

Enter Weekly benefit

Dental Coverage

Vision Care Coverage

VOLUNTARY BENEFITS ENROLLMENT

Please fill out all of the applicable fields (*required), then click the SUBMIT

button at the end of the form.

If you have any questions about or need assistance with your enrollment,

call our broker at 800-527-1397.

This form is Secured with SSL technology.

Your connection to this website is encrypted to assure privacy and prevent eavesdropping.

Name of Employer

Group Number

Effective Date

Your Name

First Name

Initial (optional)

Last Name

Your Address

Address Line 1

Address Line 2

City

State

ZIP Code

Occupation

Date Employed

Your Social Security Number

Your Date of Birth

Hours Worked Per Week

Gender

Male Female

Marital Status

Single Married

Your Email Address

Example: myaddress@yahoo.com

Gross Earnings $

Indicate Weekly, Monthly, or Annually

Employee Life Insurance Beneficiary & Relationship

Employee is beneficiary for spouse coverage

Life Insurance Employee

Life Insurance Spouse

Life Insurance Children

Long Term Disability Benefit

Enter Monthly Benefit

Short Term Disability Benefit

Enter Weekly benefit

Dental Coverage

Vision Care Coverage

REFUSAL OF GROUP INSURANCE (Check all that apply)

Life Insurance Long Term Disability Short Term Disability Dental Vision

I have been offered this insurance coverage and DECLINE TO PURCHASE it at this time. I understand that in the event I desire such insurance at a later date, I will be required to furnish evidence at my own expense, and the company will have the right to refuse any request.

SPOUSE Information

Spouse Name

First Name

Initial (optional)

Last Name

Spouse's Date of Birth

Spouse's Gender

Male Female

Spouse's Social Security Number

Spouse

Any other dental coverage? (Sp)

Yes No

If yes, name of carrier (Sp)

CHILDREN Information

Children Under the Age of 26 are eligible

1st CHILD: NAME

First Name

Initial (optional)

Last Name

Full time Student (Ch1)

Yes No

Date of Birth (Ch1)

Gender (Ch1)

Male Female

Any other dental coverage? (Ch1)

Yes No

If yes, name of carrier (Ch1)

2nd CHILD: NAME

First Name

Initial (optional)

Last Name

Full time Student (Ch2)

Yes No

Date of Birth (Ch2)

Gender (Ch2)

Male Female

Any other dental coverage (Ch2)?

Yes No

If yes, name of carrier (Ch2)

3rd CHILD: NAME

First Name

Initial (optional)

Last Name

Full time Student (Ch3)

Yes No

Date of Birth (Ch3)

Gender (Ch3)

Male Female

Any other dental insurance? (Ch3)

Yes No

If yes, name of carrier (Ch3)

4th CHILD: NAME

First Name

Initial (optional)

Last Name

Full time Student (Ch4)

Yes No

Date of Birth (Ch4)

Gender (Ch4)

Male Female

Any other dental insurance (Ch4)?

Yes No

If yes, name of carrier (Ch4)

5th CHILD: NAME

First Name

Initial (optional)

Last Name

Full time Student (Ch5)

Yes No

Date of Birth (Ch5)

Gender (Ch5)

Male Female

Any other dental insurance (Ch5)?

Yes No

If yes, name of carrier (Ch5)

6th CHILD: NAME

First Name

Initial (optional)

Last Name

Full time Student (Ch6)

Yes No

Date of Birth (Ch6)

Gender (Ch6)

Male Female

Any other dental insurance (Ch6)?

Yes No

If yes, name of carrier (Ch6)

SIGNATURE

Fraud Warning (Not Applicable in AZ, FL, GA, MD, OR, VA): Any person who knowingly and with intent to defraud any Insurance company or other person filesan application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits (in TX, may be committing) a fraudulent insurance act, which is a crime and subjects (in KS, which may be determined by a court of law to be a crime which subjects) such person to criminal and civil penalties. Fraud Warning (FL only): Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Today's Date

SIGNED AT

City and State

EMPLOYEE SIGNATURE VERIFICATION (Check box)

I AGREE that by clicking this check box, this acts as a legal signature, and I certify that all information provided as part of this application are complete, accurate, and true to the best of my knowledge.

Type your name here:

Notes or comments:

Is your SPOUSE or CHILDREN to be covered for any of the selected benefits?

SPOUSE Information

CHILDREN Information

SIGNATURE