Life Insurance Benefits Enrollment Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email Address
Social Security Number
Employment Information
Employee ID
Department
Position/Title
Date of Hire
Coverage Selection
Select Coverage Amount
$50,000
$100,000
$150,000
$200,000
Other
If Other, specify amount
Beneficiary Information
Primary Beneficiary Name
Relationship
Percentage (%)
Contingent Beneficiary Name
Relationship
Percentage (%)
Authorization
Signature
Date