Upcoming Events

Dec
14
Wed
E-Board Meeting
Dec 14, 2022
REACT Center
Jan
11
Wed
General Membership Meeting
Jan 11, 2023
Big Sky Conference Room
Feb
08
Wed
E-Board Meeting
Feb 08, 2023
REACT Center
Mar
08
Wed
General Membership Meeting
Mar 08, 2023
Big Sky Conference Room
Apr
12
Wed
E-Board Meeting
Apr 12, 2023
REACT Center

General Participation & Group Insurance Enrollment Form


Last Name *
First Name *
Middle Initial
Marital Status *
Home Address *
City *
State *
Zip *
Sex *
Date of Birth *
SSN *
Home Phone Number *
Date of Employment (if known)
IBM Number
Date of Retirement
YES NO Coverage Description Benefit Effective Date
X
Membership Life and AD&D $50,000

Beneficiary Designation

Primary Beneficiary Name *
Relationship *
Date of Birth *
Contingent Beneficiary Name
Relationship
Date of Birth

If no Beneficiary is designated, or if the designated Beneficiary does not survive the insured person, any life insurance benefit will be paid as described under the Beneficiary provisions of the Master Policy for the applicable life insurance benefit. Copies of the Master Policies for the life insurance benefits are available at the Stanislaus County DSA offices. If you designate a minor (a person not of legal age) it may be necessary to have a guardian or legal representative appointed before any death benefit can be paid. This means legal expense for the beneficiary and delay in the payment of insurance. Please consider this when naming your beneficiary. 

I hereby elect to participate in the above group insurance plans and authorize the necessary payroll deductions for the contributions required of me for the various insurance plans. If I elect not to participate in the above group plans at the present time, I understand that in the event that I should desire to participate at a later date I will be required to furnish at my own expense satisfactory evidence of good health.

Attention! Beneficiary Designation is NOT valid unless this form is signed AND dated.

Signature *

Use your mouse, finger, or touch device to write your signature.
Date *






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