2023 Optional Life Insurance Election

Black man hands filling out form on a desk

Optional Life Election Form

During our recent open enrollment, the maximum amount of optional life coverage you were allowed to elect was $40,000 for yourself and $5,000 for your spouse or domestic partner. You should have had the opportunity to purchase up to $500,000 for yourself and up to $30,000 for your spouse or domestic partner. Elected amounts over $40,000 for you or $5,000 for your spouse or domestic partner are subject to evidence of insurability (EOI); you or your spouse/domestic partner must answer health questions and receive approval before the additional amounts take effect.

Using this form, you can elect a higher amount for yourself and your spouse/domestic partner. Remember that amounts above $40,000 for you and $5,000 for your spouse require EOI before the full coverage amount takes effect. You can review the biweekly costs for coverage here.

Life Insurance Insurance Form

Who Is Electing Coverage?

Self

Spouse/Domestic Partner

Both

Team Member First Name

Team Member Last Name

Team Member ID Number

Spouse/Domestic Partner First Name

Spouse/Domestic Partner Last Name

Employee Life Insurance Election *

Spouse/Domestic Partner Life Insurance Election *

Type your name in the box as your authorization to purchase additional optional Team Member and/or spouse/domestic partner life insurance coverage.