Group Long Term Disability (LTD) Insurance Plan
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Complete the following to enroll in the Group Long Term Disability Insurance Plan.
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.
Evidence of Insurability is required if:
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.
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:__________________________________
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