FIND A CHURCH

REQUEST FOR INSURANCE COVERAGE

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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:
MM slash DD slash YYYY
Address
Address of Congregation:
(if applicable)
MM slash DD slash YYYY
MM slash DD slash YYYY

Type of coverage requested

Insurance
Health Insurance
Disability Insurance

AUTHORIZED person completing this form. This should not be the person being enrolled.

Name
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