Accidental Death & Dismemberment Census Form

  • Individual Census Form

    This is not an application for insurance. Please submit a separate census form for each person requesting a proposal.
  • If dependent coverage is being requested:

  • Benefit Amount: ($30,000 - $400,000 in increments of $10,000):

    Spouse's benefit amount cannot exceed Member's/Employee's benefit amount. Children's benefit amount cannot exceed 50% of Member's/Employee's benefit amount.