Life & Accident Insurance Enrollment and Change Form Header Image

Standard Insurance Company Enrollment & Cancellation Form

Please note, enrollment in or cancellation of voluntary life / ADD can only be submitted during one of the following events: 

1. Open Enrollment  (Only applicable from November 1, 2022 - November 10, 2022) 

2. Up to 30 days following a qualified event

3. New Hire Enrollment 

Please review the guidelines for Voluntary Life Insurance by clicking here. 

Employee Full Name*

Birth Date *
Address*
Gender*
Spouse Full Name
Spouse Birth Date

Coverage

Check with your Human Resources Department about coverage options, minimum and maximums available to you and, if applicable, Evidence of Insurability requirements.  If you choose not to elect any coverage below, in future enrollments, you may be required to provide Evidence of Insurability or be subject to a Late Enrollment penalty.  


Please note, enrollment in or cancellation of voluntary life / ADD can only be submitted during one of the following events: 

1. Open Enrollment (Only applicable from November 1, 2022 - November 10, 2022) 

2. Up to 30 days following a qualified event

3. New Hire Enrollment 

Please review the guidelines for Voluntary Life Insurance by clicking here. 


Your employer provides Basic Life with AD&D - please choose from the following options for any additional coverage. 

Are you cancelling or enrolling today?
CANCELLATION:Please select Life and/or Accident Insurance to be cancelled
Life Insurance*
$
If you do not want to request additional paid life insurance, please select "Decline" from the previous question
Spouse Life Insurance*
$
If you do not want to request additional paid life insurance, please select "Decline" from the previous question
Children Life Insurance*
$
If you do not want to request additional paid life insurance, please select "Decline" from the previous question
Voluntary Accidental Death & Dismembernent (AD&D) Insurance (Employee Paid) *
You must choose to elect or decline coverage
$
If you do not want to request additional paid life insurance, please select "Decline" from the previous question

Spousal Beneficiary Information

This designation applies to Spousal Life insurance elected above.   Designations are not valid unless signed, dated, and delivered in accordance with the terms of the Group Policy during your lifetime. 

Name*
Primary or Contingent Beneficiary? *
Contingent will be beneficiary if Primary is deceased
Address*
Name
Primary or Contingent Beneficiary?
Contingent will be beneficiary if Primary is deceased
Address
Name
Primary or Contingent Beneficiary?
Contingent will be beneficiary if Primary is deceased
Address
Name
Primary or Contingent Beneficiary?
Contingent will be beneficiary if Primary is deceased
Address
Name
Primary or Contingent Beneficiary?
Contingent will be beneficiary if Primary is deceased
Address

Signature

I understand that I will need to complete the Evidence of Insurability form directly with Standard Life Insurance who will inform me of my approval/denial of additional coverage. *

Link to Evidence of Insurability Form

http://www.standard.com/mybenefits/mhs_ho.html

Use your mouse or finger to draw your signature above
Date/Time
:  

To Be Completed by Human Resources

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