Term Life and AD&D Insurance Enrollment Form

Underwritten by:
Unum Life Insurance Company of America
2211 Congress Street, Portand, ME 04122

Policy Number 851664 011
This is NOT an application for insurance. This is an enrollment form.
Please complete the entire form. Blank fields may delay processing.
NOTE: If you DO NOT wish to make changes, do not complete this form.
Please email Jenn Williams or contact Jenn on Microsoft Teams if you have questions.

Unum Voluntary Life Insurance and AD&D Enrollment Form

Unum Voluntary Life Insurance and AD&D Enrollment Form
  • Enrollment Type * Required
    Choose Initial Enrollment if this is your first time enrolling in Voluntary Life & AD&D. OR Choose Annual Enrollment to make changes to existing elections and/or information. The elections/information you indicate will replace your prior elections/information on file with Unum.
  • Gender * Required
  • Name * Required
  • Address * Required
  • Employment Type * Required
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
    (if applicable)
  • Spouse/Partner's Name
    (if they are electing coverage)
  • Have you used tobacco products of any nicotine delivery system in the past 12 months? * Required
    (such as cigarettes, cigars, snuff, chew or pipe)
  • Has your spouse/partner used tobacco products of any nicotine delivery system in the past 12 months?
    (such as cigarettes, cigars, snuff, chew or pipe)
  • Choose from $10,000 to $500,000 in $10,000 increments, up to 5 times your earnings. You can get up to $200,000 with no health questions. This is your guaranteed issue amount.
  • Get up to $500,000 of AD&D coverage for yourself in $10,000 increments to a maximum of 5 times your earnings.
  • Get up to $500,000 of coverage in $5,000 increments. Spouse coverage cannot exceed 100% of the coverage amount you purchase for yourself. Your spouse can get up to $25,000 with no health questions, if eligible (see delayed effective date). This is their guaranteed issue amount.
  • Get up to $500,000 of AD&D coverage for your spouse in $5,000 increments, if eligible (see delayed effective date).
  • Your children - Get up to $10,000 of coverage in $2,000 increments if eligible (see delayed effective date). One policy covers all of your children until their 19th birthday − or until their 26th birthday if they are full-time students. The maximum benefit for children live birth to 6 months is $1,000.
  • Get up to $10,000 of coverage for your children in $2,000 increments if eligible (see delayed effective date).
  • Date Format: MM slash DD slash YYYY
  • Beneficiary Name * Required
  • Please enter a number from 1 to 100.
  • Beneficiary Name
  • Please enter a number from 1 to 100.
  • Contingent Beneficiary Name
    If the beneficary(ies) named above are not living, then pay this person named here.
  • Please enter a number from 1 to 100.
  • Contingent Beneficiary Name
    If the beneficary(ies) named above are not living, then pay this person named here.
  • Please enter a number from 1 to 100.

Limitations, Exclusions, Reductions and Terminations

Effective Dates: Delayed Effective Date: The plan effective date is provided in your certificate. Your effective date may be later than the plan effective date. Coverage for employees who are not in active employment because of an injury, sickness, temporary layoff, or leave of absence is not effective until they have returned to active employment with the employer.

Spouse and Dependent Coverage: If your spouse or child has a serious injury, sickness, or disorder, or is confined, their coverage may not take effect. Payment of premium does not guarantee coverage. Please refer to your policy contract or see your plan administrator fro an explanation of the delayed effective date provision that applies to your plan.

Benefit Reduction: Coverage amounts reduce as you age in accordance with your plan. Coverage may not be increased after a reduction. This is a sample reduction schedule:
Age: Insurance Amount Reduces to:
70 65% of original amount
75 50% of original amount
If your plan has a different age reduction it will be on your certificate.

Exclusion for Suicide Life: Life insurance benefits will not be paid for deaths caused by suicide in the first 24 months after your effective date of coverage or after any increased coverage. If your plan has a different exclusion period for suicide it will be on your certificate.

AD&D Benefit Exclusions if AD&D coverage is included in your plan:
Accidental death and dismemberment benefits are paid for loss of:

  • Life
  • Both hands or both feet or sight of both eyes
  • One hand and one foot
  • One hand and the sight of one eye
  • Speech and hearing

AD&D Exclusions and Limitations, if AD&D is included in your plan*: Accidental death and dismemberment benefits are not paid for losses caused by, contributed to by, or resulting from:

  • disease of the body; diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM);
  • suicide, self-destruction while sane, intentionally self-inflicted injury while sane or self-inflicted injury while insane;
  • war, declared or undeclared, or any act of war;
  • active participation in a riot;
  • committing or attempting to commit a crime under state or federal law;
  • operating any motorized vehicle while intoxicated: and
  • the voluntary use of any prescription or non-prescription drug, poison, fume, or other chemical substance unless used according to the prescription or direction of your physician.

Some exclusions and limitations may not apply. Your certificate has details.

Termination of Coverage:

Your coverage and any spouse and dependent coverage will end of the earliest of:

  • the date the policy or plan is cancelled;
  • the date you are no longer in an eligible group;
  • the date your eligible group is no longer covered;
  • the last day of the period for which you have made any required contributions; or
  • the last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate.

In addition, coverage for any spouse or dependent will end on the earliest of:

  • the date your coverage under a plan ends;
  • the date your dependent ceases to be an eligible dependent;
  • for a spouse, the date of divorce or annulment;
  • the date of your death.

Unum will provide coverage for a payable claim that occurs while you, your spouse, or dependents are coverage under the plan.


*The suicide exclusion does not apply in Washington and is limited to 12 months in Missouri and North Dakota. In New York accidental losses due to drug addiction may be excluded.

Certificate issued under policy form controls: This information is not a complete description of the insurance coverage offered. The policy or its provision may vary or be unavailable in some states. For complete details of coverage please refer to policy form C.FP-1, except in MD please refer to C.FP-1D. Your certificate of coverage controls your benefits and rights.