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Except for address or beneficiary changes, Alliance Benefits must be notified within 30 days of a qualifying event (new hire, marriage, newborn, etc.) to enroll or make changes to your plan. If Alliance Benefits is not notified within a 30-day window, you must wait until the next open enrollment period to enroll or make changes to your plan.
Approved changes will be effective on the first day of the month following the qualifying date (except for births or deaths which will be effective on the actual event day). If the change occurs on the first day of the month, this will be the effective date.
Voluntary Life Insurance changes may be possible with certain qualifying events. In the absence of a qualifying event, any changes must be first approved and may require evidence of insurability.
Requested Change Type
Qualifying event date
*
+
Note: There must be a qualifying event to add a dependent such as marriage, birth, etc.)
*
Add Dependent
Drop Dependent
Name Change
Voluntary Life Amount Change
Beneficiary Change
Other (please describe)
Other (please describe)
General Information
Employer Name
*
Employer Location or Church Code
Employee Last Name
*
Employee First Name
*
MI
Date of Birth
+
SSN (last four digits)
*
Home Phone
Work Phone
Cell Phone
Email Address
*
Home Address
City
State
Zip Code
County
Add Dependents
List spouse and/or children to be covered (e
ligible children are those under the age of 26)
Qualifying event:
Marriage
Birth/Adoption
Loss of Coverage
Other
Other
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Relationship
Spouse
Daughter
Son
Disabled
Y
N
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Relationship
Spouse
Daughter
Son
Disabled
Y
N
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Relationship
Spouse
Daughter
Son
Disabled
Y
N
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Relationship
Spouse
Daughter
Son
Disabled
Y
N
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Relationship
Spouse
Daughter
Son
Disabled
Y
N
Are you or any of your dependents (including spouse) covered under another health plan or Medicare?
Yes
No
If yes, please explain:
Remove Dependents
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Relationship
Spouse
Daughter
Son
Disabled
Y
N
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Relationship
Spouse
Daughter
Son
Disabled
Y
N
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Relationship
Spouse
Daughter
Son
Disabled
Y
N
Life Insurance Beneficiary Designee Change
Basic Life Insurance is for $30,000 and is automatically included in your health plan package. Voluntary Life Insurance is elected. Please designate beneficiaries below:
Primary Beneficiary Name and Address
%
SSN
Relationship
Primary Beneficiary Name and Address
%
SSN
Relationship
Primary Beneficiary Name and Address
%
SSN
Relationship
Secondary Beneficiary Name and Address
%
SSN
Relationship
Secondary Beneficiary Name and Address
%
SSN
Relationship
Secondary Beneficiary Name and Address
%
SSN
Relationship
Voluntary Life Insurance (if eligible)
Additional life insurance coverage may be purchased for employee, spouse and children (through age 25) if the employee is enrolled in the health plan package. Please refer to the Alliance Health Plan Summary Guide located on the Alliance Benefits website (
www.alliancebenefits.org
) for requirements and rates.
Employee Voluntary Life Insurance:
🛈
Yes
No
Spouse Voluntary Life Insurance:
🛈
Yes
No
Child Voluntary Life Insurance:
🛈
Yes
No
If yes, employee amount requested:
If yes, spouse amount requested:
If yes, child amount requested:
Required Signature
Printed Signature Name
*
Signature Date
*
+
By signing, I authorize to be covered under the terms of the plan I have chosen.
*
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