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Optional Life

Dependent Life

Voluntary Accidental Death and Dismemberment (VAD&D)

Optional Life Summary

• Complete the Medical History Statement provided to you by Human Resources

  • Sign and date the form
    
  • Mail the form to CIGNA Insurance at the address provided on the form. Please do not send a copy of the form to the Human Resources. Due to privacy regulations, we do not maintain medical history in our office. CIGNA will contact both you and the Human Resources regarding declination or approval.
    
    
    
• Complete the Life Insurance Enrollment form. You must indicate the amount you are applying for - one to five times your annual salary. Remember to complete the beneficiary information section.
  
  • Sign and date the form
    
  • Return the form to the Human Resources. The request will be processed once the approval is received from CIGNA.

If you are currently enrolled and wish to increase the amount of your coverage, please follow the instructions below:

• Complete the Medical History Statement provided to you by Human Resources

  • Sign and date the form
    
  • Mail the form to CIGNA Insurance at the address provided on the form. Please do not send a copy of the form to the Human Resources. Due to privacy regulations, we do not maintain medical history in our office. CIGNA will contact both you and the Human Resources regarding declination or approval.
    
    
• Complete the Life Insurance Enrollment form. You must indicate the amount you are applying for - i.e., one to five times your annual salary. Remember to complete the beneficiary information section.
  
  • Sign and date the form
    
  • Return the form to the Human Resources. The request will be processed once the approval is received from CIGNA.

• Complete the Life Insurance Enrollment form. You will only need to indicate your name, ID, and birth date
  
  • In the optional life section, check the "cancel" box
    
  • Sign and date the form
    
  • Return the form to the Human Resources

Dependent Life Summary

• Complete the Medical History Statement to add your spouse / same sex domestic partner. You do not need to indicate the amount of coverage you are requesting on the form. Children do not need to complete a Medical History Statement, they are automatically covered.
  
  • Sign and date the form
    
  • Mail the form to CIGNA Insurance at the address provided on the form. Please do not send a copy of the form to the Human Resources. Due to privacy regulations, we do not maintain medical history in our office. CIGNA will contact both you and the Human Resources regarding declination or approval.
    
    
    
• Complete the Life Insurance Enrollment form. You will need to indicate the plan you are applying for (example: Spouse $25,000/Children $10,000, etc.). You will automatically be the beneficiary for the dependent(s) you are covering.
  
  • Sign and date the form
    
  • Return the form to the Human Resources. The request will be processed once the approval is received from CIGNA.

• Complete the Life Insurance Enrollment form. You will only need to indicate your name, ID, and birth date.
  
  • In the Dependent Life Section, check the "cancel" box
    
  • Sign and date the form
    
  • Return the form to the Human Resources
    

Voluntary Accidental Death and Dismemberment (VAD&D)

VAD&D Summary

• Complete the VAD&D section of the Life Insurance Enrollment form. You will need to indicate the amount for which you are enrolling in increments of $10,000 (up to the lesser of 10 times your salary or $500,000 maximum).
  
  • Indicate your election of Employee Only or Family coverage
    
  • Complete the Beneficiary section
    
  • Sign and date the form
    
  • Return the form to the Human Resources

If you are currently enrolled and wish to change your plan (to employee only or family), or increase your coverage, please follow the instructions below:

• Complete the VAD&D section of the Life Insurance Enrollment form. You will need to indicate the amount for which you are enrolling in increments of $10,000 (up to the lesser of 10 times your salary or $500,000 maximum).
  
  • Indicate your election of Employee Only or Family coverage
    
  • Complete the Beneficiary section
    
  • Sign and date the form
    
  • Return the form to the Human Resources

• Complete the Life Insurance Enrollment form. You will only need to indicate your name, ID, and birth date
  
  • In the VAD&D section, check the "cancel" box
    
  • Sign and date the form
    
  • Return the form to the Human Resources