Tuesday, April 25, 2006

FIS Short Term Disability, Long Term Disability and upplemental Life Insurance Enrollment Form


IS

Short Term Disability, Long Term Disability and

Supplemental Life Insurance Enrollment Form

HARTFORD LIFE AND ACCIDENT INSURANCE
COMPANY


Confirmation Statement

This statement confirms the benefits enrollment for
Richard Shide:

You have elected:

If you have elected coverage, the costs reflected below are your
maximum 24 (Semi-Monthly) deductions. This information is not a guarantee of
coverage, your elections are subject to the terms of the policy.

Disability Insurance

  • Voluntary Short Term Disability (STD) Insurance
    Election:     Up to 60% of my regular pay at the cost of $16.62
  • Voluntary Long Term Disability (LTD) Insurance
    Election:     Declined

Life Insurance

  • Employee Supplemental Life Election: Declined
  • Spouse Supplemental Life Election: Declined
  • Child(ren) Supplemental Life Election: Declined

Some amounts elected may be subject to Evidence of
Insurability before the excess can become effective. The Hartford will mail you
a Personal Health Application after the enrollment closes if you are required to
provide one.

You may return to the site anytime before the end of
your enrollment period to make changes. If you log in again and make any
election changes, your previous elections will be overwritten.


 

 
To ensure the
privacy of your election(s),
please print this page for your records,
then
close this browser
window.

posted by rickdog at 4:43 PM 0 comments