Please complete this form if you are enrolling in the Alliance International Health Plan.

Enrollment is effective on the first day of the month following your hire date.

Changes requested after enrolling must be made within 30 days of a qualifying event.

Enrollment Information

What brings you here today? *

I'm enrolling as a new employee

I want to update my spouse as the primary employee

Employee Information

IM Region *

Field Name

Effective date (please confirm this with your employer) * +

Employee Last Name *

Employee First Name *

MI

Social Security Number *

Date of Birth * +

US Phone

US Email Address *

US Mailing Address *

US Citizen/Citizen Resident: *

Marital Status: *

Gender: *

Spouse Information

Spouse Last Name

Spouse First Name

MI

Social Security Number

Date of Birth +

US Citizen/Citizen Resident:

Marital Status:

Gender:

Covered Dependent Information

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

Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

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: * 🛈

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:

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

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

%

Spouse Beneficiaries

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

%

Declaration and Signatures

I hereby elect coverage under the health plan option for myself and eligible family dependents listed on this form, and I agree that all information provided is correct. I further agree that we shall abide by the selected Plan Document.

I understand that when information changes (e.g. new child, marriage status, leaving employment, or any other change), it is my responsibility to inform Alliance Benefits within 30 days. Failure to provide accurate information or report changes within 30 days may jeopardize my benefits.

I acknowledge that if I do not choose to enroll in Voluntary Life for myself or my dependents within 30 days of my date of hire, transfer, or other specific qualifying event and I choose to enroll in the future, I will be required to satisfy life insurance proof of insurability which will include an Evidence of Insurability medical history form and may require a paramedical exam.

I authorize any physician, medical practitioner, hospital, clinic or other medically related facility, government agency, insurance company, the Medical Information Bureau, or other organization or person that has any records knowledge of me or any family member for whom coverage is requested, to give tothe Alliance Health Plan any such information. A photographic copy of this authorization shall be as valid as the original.

Employees who are not US or Canadian citizens will not be covered by Long Term Disability.

I have read the Privacy Notice made available to me on the Alliance Benefits Website (www.alliancebenefits.org) under the International section.

Employee Signature *

clear

Signature Date * +

Spouse Signature

clear

Signature Date +

Secured by Formsite