International Health Plan Enrollment Form

COMPLETE THIS FORM IF YOU ARE ENROLLING IN THE INTERNATIONAL HEALTH PLAN
All changes must be made within 30 days of the qualifying event. New enrollment is effective on the first day of the month following hire date.
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Employee Information

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Spouse Information

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Covered Dependent Information

  List spouse and/or children to be covered (eligible children are those under the age of 26)
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Life Insurance

  • Basic Life Insurance for $30,000 coverage is included in the Health Plan for each employee
  • Additional Life Insurance may be purchased for the employee, spouse and children (refer to rate chart in summary guide for details)
  • Up to the maximum amount is guaranteed provided you apply within 30 days of certain eligible events. To begin or increase additional insurance after the 30-day window, you must complete and Evidence of Insurability (EOI) medical history form
Employee Voluntary Life Insurance: * 🛈
Spouse Voluntary Life Insurance: * 🛈
Child Voluntary Life Insurance: * 🛈

Beneficiary Designations

  • This applies to Life and AD&D Insurance. Designations are not valid unless signed, dated and submitted to Alliance Benefits
  • Dependent’s insurance, if any, is payable to the employee if living.
  • Benefits are only payable to secondary beneficiaries if primary beneficiaries are deceased.
  • If you name two or more beneficiaries:
    • Two or more surviving beneficiaries will share equally, unless you provide specified unequal shares.
    • If only one beneficiary survives, we will pay the total death benefit to that beneficiary.
  • If a minor or your estate is the beneficiary, if may be necessary to have a guardian or legal representative appointed by the court before any death benefit can be paid. If the beneficiary is a trust or trustee, the written trust must be identified in the beneficiary designation.
  • A power of attorney must grant specified authority by the terms of the document or applicable law to make or change a beneficiary designation.  If you have any questions, please consult your legal advisor.

Employee Beneficiaries

Spouse Beneficiaries

Declaration and Signatures

Employee Signature *
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Spouse Signature
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