REQUEST FOR INSURANCE COVERAGE Date MM slash DD slash YYYY Please complete this form to request insurance coverage. This gives parish leader’s authorization to extend benefits enrollment to newly hired or called employees. Enrollment in benefits plans is required within 30 days of employment. After 30 days of employment, medical underwriting may apply. IMPORTANT INFORMATION:Name of person to be insured: First Last Date of Birth MM slash DD slash YYYY Social Security NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail Name of Congregation: Address of Congregation: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employment position:(if applicable) Date of Employment MM slash DD slash YYYY SalaryBenefits Effective Date: MM slash DD slash YYYY Type of coverage requestedInsurance Health Insurance Disability Insurance: Clergy receive STD and LTD as part of the enhanced benefit plan Group Life Insurance - $50,000 Employer Paid (Lay employees only.) Health Insurance Single Two person Family Disability Insurance STD Employer Paid (Income Replacement Plan-Short-Term) for Lay employee only -Employee Paid? LTD Employer Paid (Long-Term) for Lay employee only -Employer Paid? -Employee Paid? -25% Income Replacement? -50% Income Replacement? AUTHORIZED person completing this form. This should not be the person being enrolled.Name First Last Signature Reset signature Signature locked. Reset to sign again Position PhoneEmail Δ