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As you're enrolling in supplemental life insurance (using the supplemental life form), please note the following:
Enrollment or Change Form
If you are electing coverage in this plan for the first time, check the ENROLLMENT box.
If you are already enrolled in this plan and are requesting a change of some type, check the CHANGE box.
Besides checking the CHANGE box, you should also check whichever change or changes you are requesting from the list provided:
- Change Employee Coverage
- Add Spouse Coverage Only
- Drop Spouse Coverage
- Add Child(ren) Coverage
- Drop Child(ren) Coverage
- Change Smoker Status
- Other Name/Address Change etc.
Employee's Complete Address
This should be your home address: Street or P.O. Box number, City and Zip Code.
Employee Insurance Amount
This is the TOTAL amount of insurance that you wish for yourself. Dependent coverage is not included in this amount.
If you are requesting a change to your amount of coverage, the amount shown should represent the TOTAL amount to be carried. For example, an employee who is currently covered for $100,000 and is requesting an increase of an additional $50,000 would show $150,000 in this box. Likewise, if an employee is requesting to decrease coverage from $100,000 to $50,000, he or she would show $50,000 in this box.
Basic Annual Earning
This is the total of your regular payment from the State of Ohio during a 12-month period but not any commissions, bonuses, overtime or fringe benefits.
Dependent Child Insurance Amount
The benefit amount is currently 5,000 per eligible, enrolled child, but the amount will increase to $7,000 per eligible, enrolled child as of July 1, 2008.
Employee's Beneficiary
You may choose to have an individual or individuals as your beneficiary. If the space provided on the back of the form is not sufficient to show all the beneficiaries chosen, you may attach a separate sheet.
Signature and Date
After you've completed the form, mail it to:
The Prudential Insurance Company of America
PO Box 5072
Millville, NJ, 08332-9931
For those who have been laid off.
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