Transcription of Reliance Standard Life Insurance Company Enrollment and ...
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Reliance Standard Life Insurance Company Enrollment and ...
Reliance Standard life Insurance Company Reset Enrollment and Statement of Health Name of Employer Location/Division Bill Group AFLAC Incorporated 000001. Policy # and Class # Policy # and Class # Policy # and Class # Policy # and Class # Policy # and Class #. GL157254 / 1. Application Type: Initial Eligibility/New Hire Late Applicant Other Increase Approved Annual Enrollment Change in Status: Nature of Change(s): Date of Change: If marriage, divorce or birth of a child, please provide copy of document. Employee/Member Information Always Complete Submit completed Enrollment Name Social Security Number and Statement of Health form to: Gender Date of Birth Age State of Birth Date of Hire or Address City State Zip Reliance Standard Box 7818 Phone Number Occupation Annual Compensation Hours Worked Per Week Philadelphia, PA 19101-7818. Email Address We do not accept faxed forms. Are you actively performing all the duties of your occupation or profession? Yes No If No, explain: Spouse Information Complete Only If Applying for Spouse Coverage Spouse Name Gender Date of Birth Age State of Birth Address City State Zip Coverage Elected and Amounts Enroll or Current Increase or Monthly Coverage Total Amount Applied For Decline1 Amount Decrease Premium 1 Times Earnings 2 Times Earnings 3 Times Earnings Group Term Supplemental life Enroll 4 Times Earnings See Premium Table Employee2 Decline 5 Times Earnings 6 Times Earnings 7 Times E
Reliance Standard Life Insurance Company Enrollment and Statement of Health LRS-9457-0111 Home Office: Schaumburg, Illinois/Administrative Office: Philadelphia, PA Page 1 of 3 Name of Employer AFLAC Incorporated Location/Division
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