BENEFITS Personal
Accident Insurance Enrollment Form
Complete this form to enroll in the Personal Accident Insurance
Plan.
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)
Life Insurance Company of North America Policy Holder: INDIANA UNIVERSITY
Policy No. OK-980032
Complete the following to enroll: Name:Campus:
Last
First
M.I.
Social Security #:
-
-
Date of
Birth:
/
/
Address:
Number, Street,
Apt. #
City
State Zip
Select Coverage Option and Benefit Amount (select
one):
Employee Only -- Benefit Amount:
Employee and Family* -- Benefit Amount:
*For Employee and Family coverage, benefits for
family members will be a percentage of the Benefit Amount selected.
Primary Beneficiary(ies):
Name
DOB:
/
/
SSN:
-
-
Address
Relationship:
Percentage:
%
Name
DOB:
/
/
SSN:
-
-
Address
Relationship:
Percentage:
%
Name
DOB:
/
/
SSN:
-
-
Address
Relationship:
Percentage:
%
Contingent Beneficiary(ies):
Name
DOB:
/
/
SSN:
-
-
Address
Relationship:
Percentage:
%
Name
DOB:
/
/
SSN:
-
-
Address
Relationship:
Percentage:
%
The employee will
be the family member's beneficiary unless otherwise indicated in
writing.
I enroll and authorize my employer to deduct
the premiums from my earnings. I understand that the insurance selected
will begin on the effective date as described in the brochure. If I am
not actively at work, the effective date of coverage will be delayed until
I return to work.
