THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA Group Insurance Enroment Form Page 1 of 6 Guardian Life, P.O. Box 14319, Lexington, KY 40512 Pease print ceary and mark carefuy. Empoyer Name: Cinton Essex Warren Washington BOCES Group Pan Number: 00475527 Benefits Effective: PLEASE CHECK APPROPRIATE BOX q Initia Enroment q Re-Enroment q Add Empoyee/Dependents q Drop/Refuse Coverage q Information Change q Increase Amount q Famiy Status Change Cass: 20 Pay Periods Division: Subtota Code: (Pease obtain this from your Empoyer) About You: First, MI, Last Name: Socia Security Number - - Address City State Zip Gender: Date of Birth(mm-dd-yy): - - Phone:( ) - Emai Address: Are you married or do you have a spouse? q Yes q No Date of marriage/union:_ Do you have chidren or other dependents? q Yes q No Pacement date of adopted chid:_ About Your Job: Hours worked per week: Job Tite: Work Status: q Active q Retired q Cobra/State Continuation Date of fu time hire: Annua Saary: $ About Your Famiy: Pease incude the names of the dependents you wish to enro for coverage. A dependent is a person who reies on you for financia support. Additiona information may be required for non-standard dependents such as a grandchid, a niece or a nephew. Spouse (First, MI, Last Name) Chid/Dependent 1: Gender Socia Security Number Socia Security Number Status (check a that appy) q Student (post high schoo) q Disabed Chid/Dependent 2: Socia Security Number Status (check a that appy) q Student (post high schoo) q Disabed CEF2014-NY Questions? Ca the Guardian Hepine (888) 600-1600 www.guardianife.com DATE FORM PUBLISHED: Apr 29, 2015 1
Chid/Dependent 3: Socia Security Number Status (check a that appy) q Student (post high schoo) q Disabed Chid/Dependent 4: Socia Security Number Status (check a that appy) q Student (post high schoo) q Disabed Drop Coverage: q Drop Empoyee q Drop Dependents The date of withdrawa cannot be prior to the date this form is competed and signed. Last Day of Coverage: q Termination of Empoyment q Retirement Last Day Worked: q Other Event: Date of Event: Loss Of Other Coverage: I and/or my dependents were previousy covered under another insurance pan. Loss of coverage was due to: q Termination of Empoyment: q Divorce q Death of Spouse q Termination/Expiration of Coverage Coverage Lost q Denta q Vision Coverage Being Dropped: q Denta q Vision q Basic Life q Empoyee q Spouse q Chid(ren) q Empoyee q Spouse q Chid(ren) I have been offered the above coverage(s) and wish to drop enroment for the foowing reasons: q Covered under another insurance pan q Other (additiona information may be required) Denta Coverage: You must be enroed to cover your dependents. Check ony one box. Your premium Empoyee Ony EE, Spouse & Dependent/Chid(ren) Option 1: Base Pan q $16.20 q $44.61 Option 2: Buy-Up Pan q $25.97 q $70.79 q I do not want this coverage. If you do not want this Denta Coverage, pease mark a that appy: q I am covered under another Denta pan q My spouse is covered under another Denta pan q My dependents are covered under another Denta pan Vision Coverage: You must be enroed to cover your dependents. Check ony one box. Your Premium Empoyee Ony EE, Spouse & Dependent/Chid(ren) Exam Pus Aowance q $3.36 q $7.20 q I do not want this coverage. If you do not want this Vision Coverage, pease mark a that appy: q I am covered under another Vision pan q My spouse is covered under another Vision pan q My dependents are covered under another Vision pan 2
Guardian Group Pan Number: 00475527 Pease print empoyee name: Basic Life Coverage with Accidenta Death and Dismemberment (AD&D): Benefit reductions appy. Pease see pan administrator. Poicy Amount Empoyee Ony q $15,000 The Guarantee Issue Amount is $15,000. q I do not want this coverage. Name your beneficiaries: (Primary beneficiary percentages must tota 100%) Primary Beneficiaries: Name: Socia Security Number: % Date of Birth (mm-dd-yy): - - Reationship to Empoyee:_ Name: Socia Security Number: % Date of Birth (mm-dd-yy): - - Reationship to Empoyee:_ Contingent Beneficiary: Socia Security Number: Date of Birth (mm-dd-yy): - - Reationship to Empoyee:_ (In the event the primary beneficiaries are deceased, the contingent beneficiary wi receive the benefit. Empoyer maintains beneficiary information.) If this Basic Life poicy is intended to repace your existing ife insurance poicy under your current empoyer, provide the amount of the previous poicy $ Important Notes: Based on your pan benefits and age, you may be required to compete an evidence of insurabiity form for Basic Life. Signature An empoyee's decision to eect Vision or not eect Vision must be retained unti the next pan's Open Enroment period. If the empoyee eects not to enro in vision coverage, they are not eigibe to enro unti the pan's next Open Enroment period. I understand that my dependent(s) cannot be enroed for a coverage if I am not enroed for that coverage. I understand that the premium amounts shown above are estimations and are for iustrative purposes ony. Submission of this form does not guarantee coverage. Among other things, coverage is contingent upon underwriting approva and meeting the appicabe eigibiity requirements as set forth in the appicabe benefit booket. I understand that I must be activey at work or my eected coverage wi not take effect unti I have met the eigibiity requirements (as defined in the benefit booket.) This does not appy to eigibe retirees. If coverage is waived and you ater decide to enro, ate entrant penaties may appy. You may aso have to provide, at your own expense, proof of each person's insurabiity. Guardian or its designee has the right to reject your request. Pan design imitations and excusions may appy. For compete detais of coverage, pease refer to your benefit booket. State imitations may appy. Your coverage wi not be effective unti approved by a Guardian or its designated underwriter. I hereby appy for the group benefit(s) that I have chosen above. I understand that I must meet eigibiity requirements for a coverages that I have chosen above. I agree that my empoyer may deduct premiums from my pay if they are required for the coverage I have chosen above. I acknowedge and consent to receiving eectronic copies of insurance reated documents, in ieu of paper copies, to the extent permitted by appicabe aw q I vountariy agree to that arrangement. q I do not agree to that arrangement. I understand that I may change my eection by providing Guardian 30 day prior written notice. I state that the information provided above is true and correct to the best of my knowedge. Any person who with intent to defraud any insurance company or other person fies an appication for insurance or statement of caim containing any materiay, fase information, or conceas for purpose of miseading information concerning any fact materia hereto, commits a frauduent insurance act, which is a crime, and may aso be subject to civi Penaties, or denia of insurance benefits (Does not appy to Life Insurance). Receipt of acceerated death benefits may affect eigibiity for pubic assistance programs and may be taxabe. A discount is associated with the acceerated death benefits. A fee of up to $250.00 wi be required for the administrative cost of evauating and processing Your appication for this benefit. Questions? Ca the Guardian Hepine (888) 600-1600 www.guardianife.com 3
The Poicy permits the group Poicyhoder to change, reduce, restrict or terminate Your rights or benefits under the Poicy without Your consent; and b) such change, reduction, restriction or termination may occur at a time when Your heath status has changed and may affect Your abiity to procure individua coverage. The state in which you reside may have a specific state fraud warning. Pease refer to the attached Fraud Warning Statements page. The aws of New York require the foowing statement appear: Any person who knowingy and with intent to defraud any insurance company or other person fies an appication for insurance or statement of caim containing any materiay fase information, or conceas for the purpose of miseading, information concerning any fact materia thereto, commits a frauduent insurance act, which is a crime, and sha aso be subject to a civi penaty not to exceed five thousand doars and the stated vaue of the caim for each such vioation. (Does not appy to Life Insurance.) SIGNATURE OF EMPLOYEE X DATE Enroment Kit 00475527, 0001, EN Fraud Warning Statements The aws of severa states require the foowing statements to appear on the enroment form: Aabama: Any person who knowingy presents a fase or frauduent caim for payment of a oss or benefit or who knowingy presents fase information in an appication for insurance is guity of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Arizona: For your protection Arizona aw requires the foowing statement to appear on this form. Any person who knowingy presents a fase or frauduent caim for payment of a oss is subject to crimina and civi penaties. Caifornia: For your protection Caifornia aw requires the foowing to appear on this form: The fasity of any statement in the appication sha not bar the right to recovery under the poicy uness such fase statement was made with actua intent to deceive or uness it materiay affected either the acceptance of the risk or the hazard assumed by the insurer. Coorado: It is unawfu to knowingy provide fase, incompete, or miseading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penaties may incude imprisonment, fines, denia of insurance, and civi damages. Any insurance company or agent of an insurance company who knowingy provides fase, incompete, or miseading facts or information to a poicy hoder or caimant for the purpose of defrauding or attempting to defraud the poicy hoder or caimant with regard to a settement or award payabe from insurance proceeds sha be reported to the Coorado Division of Insurance within the Department of Reguatory Agencies. Connecticut, Iowa, Nebraska, and Oregon: Any person who knowingy, and with intent to defraud any insurance company or other person, fies an appication of insurance or statement of caim containing any materiay fase information or conceas, for the purpose of miseading, information concerning any fact materia thereto, may be guity of a frauduent insurance act, which may be a crime, and may aso be subject to civi penaties. Deaware, Indiana and Okahoma: WARNING: Any person who knowingy, and with intent to injure, defraud or deceive any insurer, makes any caim for the proceeds of an insurance poicy containing any fase, incompete or miseading information is guity of a feony. District of Coumbia: WARNING: It is a crime to provide fase or miseading information to an insurer for the purpose of defrauding the insurer or any other person. Penaties incude imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if fase information materiay reated to a caim was provided by the appicant. Forida: Any person who knowingy and with intent to injure, defraud, or deceive any insurer fies a statement of caim or an appication containing any fase, incompete, or miseading information is guity of a feony of the third degree. Kansas: Any person who knowingy, and with intent to defraud any insurance company or other person, fies an appication of insurance or statement of caim containing any materiay fase information or conceas, for the purpose of miseading, information concerning any fact materia thereto, may be guity of insurance fraud as determined by a court of aw. Kentucky: Any person who knowingy and with intent to defraud any insurance company or other person fies a statement of caim containing any materiay fase information or conceas, for the purpose of miseading, information concerning any fact materia thereto commits a frauduent insurance act, which is a crime. Louisiana and Texas: Any person who knowingy presents a fase or frauduent caim for payment of a oss or benefit is guity of a crime and may be subject to fines and confinements in state prison. Maine, Tennessee and Washington: It is a crime to knowingy provide fase, incompete or miseading information to an insurance company for the purpose of defrauding the company. Penaties may incude imprisonment, fines or a denia of insurance benefits. Maryand : Any person who knowingy or wifuy presents a fase or frauduent caim for payment of a oss or benefit or knowingy or wifuy presents fase information in an appication for insurance is guity of a crime and may be subject to fines and confinement in prison. Rhode Isand: Any person who knowingy and wifuy presents a fase or frauduent caim for payment of a oss or benefit or knowingy and wifuy presents fase information in an appication for insurance is guity of a crime and may be subject to fines and confinement in prison. Minnesota: A person who fies a caim with intent to defraud or heps commit a fraud against an insurer is guity of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, fies a statement of caim containing any fase, incompete or miseading information is subject to prosecution and punishment for insurance fraud, as provided in N.H. Rev. Stat. Ann. 638:20 New Jersey: Any person who knowingy fies a statement of caim containing any fase or miseading information is subject to crimina and civi penaties. 4
Guardian Group Pan Number: 00475527 Pease print empoyee name: New Mexico: Any person who knowingy presents a fase or frauduent caim for payment or a oss or benefit or knowingy presents fase information in an appication for insurance is guity of a crime and may be subject to civi fines and crimina penaties or denia of insurance benefits. Ohio: Any person who with intent to defraud or knowing that he/she is faciitating a fraud against an insurer, submits an appication or fies a caim containing a fase or deceptive statement is guity of insurance fraud. Pennsyvania: Any person who knowingy and with intent to defraud any insurance company or other person fies an appication for insurance or statement of caim containing any materiay fase information or conceas for the purpose of miseading, information concerning any fact materia thereto commits a frauduent insurance act, which is a crime and subjects such person to crimina and civi penaties. Vermont: Any person who knowingy presents a fase statement in an appication for insurance may be guity of a crimina offense and subject to penaties under state aw. Virginia: Any person who with intent to defraud or knowing that he/she is faciitating a fraud against an insurer, submits an appication or fies a caim containing a fase or deceptive statement may have vioated state aw. Questions? Ca the Guardian Hepine (888) 600-1600 www.guardianife.com 5
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