Upcoming Events

Jul
06
Wed
Emergency Membership Meeting
Jul 06, 2022
Big Sky
Jul
13
Wed
General Membership Meeting
Jul 13, 2022
Big Sky Conference Room
Aug
10
Wed
E-Board Meeting
Aug 10, 2022
REACT Center
Sep
14
Wed
General Membership Meeting
Sep 14, 2022
Big Sky Conference Room
Oct
12
Wed
E-Board Meeting
Oct 12, 2022
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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