Employee Benefit Interest Form
for Voluntary Benefits
Yes, I’m interested in learning more about:
F Universal Life Insurance
o
This type of individual life insurance policy is designed to provide coverage for your
working years and beyond. Unlike your current group life insurance policy, these rates
and coverage amounts are designed NOT TO CHANGE as you age. In addition, this
insurance holds a permanent cash-value and can be taken with you if you change jobs or
retire. Coverage is available for you, your spouse and children.
o
Employee coverage starts as low as $3.00 a week.
F Critical Illness Insurance
o
Pays an immediate, one-time, lump-sum benefit following the diagnosis of one of several
specified diseases such as heart attack, stroke, major organ transplant, paralysis, coma,
renal (kidney) failure, and coronary bypass surgery. Coverage is available for you, your
spouse and children.
o
Employee coverage starts as low as $1.00 a week.
With either of the selected coverage’s you can:
F Choose benefits that meet your individual needs
F Participate through convenient payroll deductions
F Take your coverage with you if you change jobs or retire
To Enroll or Ask Questions
Call Toll-Free 877-826-3364
If you are interested in learning more about these products, please complete this
form and fax it to 949-716-2999 or call 877-826-3364. If you reach voice mail, please
leave a message. A licensed Benefit Counselor will contact you to provide you with your
personal costs and coverage options.
PLEASE COMPLETE THIS SECTION IF YOU ARE FAXING THIS FORM TO 949-716-2999:
Name ____________________________________________________________________
Daytime Phone Number (______) ______________________
Date of Birth ______/______/________
Date of Hire ______/______/________