Transcription of Underwritten by 5Star Life Insurance Company (a Baton ...
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Underwritten by 5Star Life Insurance Company (a Baton ...
Last NameFirst Name Male Female Height ft in Weight lbsHome Address:Street Line 1 Street Line 2 City State ZipEmailDaytime Phone NumberFull-Time Employment Date Coverage Effective DateUse black or blue ink and print using all upper case Life Insurance Enrollment FormUnderwritten by 5 Star Life Insurance Company (a Baton Rouge, Louisiana Company )Admin Office: PO Box 83043, Lincoln, NE 68501 1-866-863-9753 R1208 2/14 Employee/Applicant Information//Month Day Year //Month Day Year//Month Day YearEmployee Insurance CoverageBasic Group Basic Group Life Amount AD&D AmountAmounts requiring Evidence of Insurability are subject to Statement of Optional/Voluntary Group Life Amount AD&D Amount Annual VoluntaryEarnings Premium Amount$,$,(If coverage is earnings based)$,(Statement of Health must be completed.)
Beneficiary Information I designate my beneficiary(ies) to receive benefits as indicated below. The employee is the beneficiary for all dependent
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