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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
1 . Action taken on this form (choose
Enroll in this plan; or
Change my enrollment to the following; or
Stop participation in this Plan. (If this
action has been selected, move on to #4.)
Coverage Option (choose one):
Guranteed issue or Maximum Coverage
Amount of Insurance:
I understand that if I am applying for coverage after 60 days of becoming
eligible to participate in this Plan, or if I elect the Maximum Coverage
option, I must also submit a completed Standard Company’s Medical
History Statement form and be approved by The Standard Company.
I authorize deductions from my salary based on the amount of coverage
I elected and the current premium rate, until revoked by me.