Indiana University
Revised: December 2013 University Human Resources
University-wide form

Group Long Term Disability (LTD) Insurance Plan
Enrollment/Change/Termination Form

Estimate your premium
The monthly premium of the LTD insurance selected will vary based on age, salary, and the coverage option selected.

This form can be completed online, but it cannot be submitted online. The information you enter is not saved or submitted to any system. Enter the information in the fields below, then print the form using your browser's print function. If you wish, you may print a PDF of this form and complete it manually. (About PDFs)
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Complete the following to enroll in the Group Long Term Disability Insurance Plan.


Name:     Campus:

E-mail:

Employee ID:

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I hereby request the following:

I wish to elect Group Long Term Disability coverage

I wish to change the coverage under which I am now insured to the following (check one):

Option A - 180-Day Benefit Waiting Period
Option B - 90-Day Benefit Waiting Period
Option C - 180-Day Benefit Waiting Period and Annuity Contribution Benefit
Option D - 90-Day Benefit Waiting Period and Annuity Contribution Benefit

I wish to terminate my Group Long Term Disability coverage.

Please note:

Evidence of Insurability is required if:

  1. You are applying for insurance more than 30 days after first becoming eligible for it.
  2. You are electing a new coverage option which provides a shorter benefit waiting period and/or the addition of the Annuity Contribution Benefit.
  3. You previously terminated your LTD insurance and are now re-electing coverage.

If your enrollment or change in coverage requires Evidence of Insurability, please attach a completed Medical History Statement form to your LTD enrollment/change/termination form and mail both documents to Standard Insurance Company (addressnoted at the top left hand corner of the Medical History Statement) for review and determination of approval. Your coverage request will be processed after the University receives notification of approval from Standard Insurance.

Employee's Medical History Statement for Indiana Residents (PDF) or
Employee's Medical History Statement for Indiana Non-Residents (PDF)

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I hereby authorize Indiana University to make the appropriate deductions from my earnings for my
contributions toward the cost of this insurance, under the Group Long Term Disability Insurance
Policy administered by The Standard.

Date Signed: __________________ Employee Signature:__________________________________

Date Employed:__________

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