RETURN COMPLETED FORM TO:Benefits Group
P.O. Box 8816
Reston, VA 20195-9912
RETURN COMPLETED FORM TO:
Benefits Group
P.O. Box 8816
Reston, VA 20195-9912
Mutal of Omaha Insurance Company
Long-Term Disability Insurance
Enrollee's Name (First, Middle, Last) __________________________________________________
(please print)
Telephone No._____________________ E-Mail Address__________________________________
Street Address ____________________________________________________________________
City ________________________________State _______________ Zip Code __________________
Date of Birth _________________________SSN___________________Agency_________________
Full-Time Employee (30 or more hours per wk) Yes_____ No _____ Annual Salary: _____________
Benefits are subject to salary requirements.*
Annual Salary |
Monthly Benefit |
Benefit Selection |
Under $42,500 |
$500 |
|
$42,500 - $64,999 |
$1,000 |
|
$65,000 - $87,499 |
$1,500 |
|
$87,500 - $124,999 |
$2,000 |
|
$125,000 - up |
$2,500 |
*You may elect a coverage level lower than your salary, but not a coverage level above your salary.
Signature of Applicant ________________________________________Date _____________________
*Full Name of Beneficiary __________________________________________Relationship ___________
Address_______________________________________City, State, Zip__________________________
*For refund or prepaid premiums in the event of the insured's death.