Group Life Insurance Enrollment Worksheet Minnesota Life
EMPLOYER NAME: Central New Mexico Community College LIFE POLICY NUMBER: 345831. Please complete Group Life Evidence of Insurability for coverage that is not guaranteed.
2. Return completed and signed form to your Benefits Office.
A. EMPLOYEE INFORMATION
Name (First, MI, Last) / CNM ID Number
B. SUPPLEMENTAL LIFE
Employee
Current Amount $ / Increase Decrease
Waive/Cancel / $10,000 or $20,000
Amount $ / Additional Amount
Amount $
Requires EOI Form / Grand
Total $
Spouse
Current Amount $ / Increase Decrease
Waive/Cancel / Additional Amount
Amount $
Requires EOI Form / Grand
Total $
Child
$10,000 / $15,000 / $20,000 / Waive/Cancel
C. SPOUSE/DOMESTIC PARTNER INFORMATION
Name (First, MI, Last) Spouse Domestic Partner
Date of Birth (Month, Day, Year) / Is your spouse also an employee covered under this plan? Yes No / Gender
Male Female
D. CHILDREN INFORMATION – (List names and date of birth for your eligible children)
E. BENEFICIARY INFORMATION
PRIMARY Beneficiary Designation: must equal 100% (attach a separate page if additional space is needed)
1st Primary Beneficiary (Last Name, First Name)
/Benefit %
% /2ndPrimary Beneficiary (Last Name, First Name)
/Benefit %
%Date of Birth
/Social Security #
/Relationship
/Date of Birth
/Social Security #
/Relationship
CONTINGENT Beneficiary Designation: must equal 100% (attach a separate page if additional space is needed)
1st Contingent Beneficiary (Last Name, First Name)
/Benefit %
% /2ndContingentBeneficiary (Last Name, First Name)
/Benefit %
%Date of Birth
/Social Security #
/Relationship
/Date of Birth
/Social Security #
/Relationship
F. AUTHORIZATIONI authorize my employer to make these change(s) and to withdraw any premiums from my salary to pay for supplemental insurance coverage.
Employee Signature / Evening Telephone Number / Date Signed
HR USE ONLY
EE SL / SP SL / DP SL / CH SL / DEDN 12/23/17 / BCOV 01/01/18 / BN Initials: