»
Eligibility
»
Term Life Insurance
Application Forms:
•
basic life application form
(160K pdf)
•
basic life application / enrollment form
(173K pdf)
•
spouse life application form
(190K pdf)
•
voluntary life application form
(191K pdf)
Census Forms:
•
basic life online census form
•
basic life census form
(295K pdf)
•
voluntary / dependent life online census form
•
voluntary / dependent life census form
(379K pdf)
Brochure:
•
brochure
(807K pdf)
»
Short Term Disability
»
Long Term Disability
»
Hospital Indemnity
»
Business Overhead Expense
Basic Term Life Program
Census Form
This is not an application for insurance.
PLEASE NOTE: This online form will accommodate up to 15 employees. If you have more than 15 employees, please
download the census form as a PDF
, complete, and mail/fax to us. Thank you.
Agency Name
Sponsoring Member's Name
Effective Date of Membership
Address
City
State
Zip Code
Phone Number
Fax Number
E-Mail Address
MEMBER / EMPLOYEE 1
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 2
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 3
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 4
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 5
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 6
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 7
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 8
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 9
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 10
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 11
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 12
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 13
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 14
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
MEMBER / EMPLOYEE 15
Name
Gender
Male
Female
Date of Birth
Date of Hire
Hours/Week
Class (If you are not sure what class to choose,
See Class Details
for help.)
Select
Class 1 - Owner, Partner, Officer, Agency Manager ($50,000)
Class 2 - Agent ($30,000)
Class 3 - Other ($20,000)
Amount of Coverage
CERTIFICATION
I certify that this is a complete list of eligible employees and I agree to pay 100% of the premium for these employees.
----
Yes
Agency Owner/Partner/Officer/Agency Manager
Date
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