Life Insurance Enrollment Form Codes 100, 102, 103

For employees in Codes 100, 102 and 103 only.

This form is used for:

• enrollment in the basic plan; and/or
• electing supplemental group life insurance; and/or
• designating beneficiaries.

Instructions

NYU provides you with free group term life insurance. The amount of coverage provided is based on your age as of the January 1st coinciding with or following your birthday. To view the life insurance schedule, click here

• You may purchase additional coverage if you wish. If you earn less than $150,000 per year there are six options to choose from ranging from one half times your salary to 3 times your salary, to a maximum of $300,000. If you earn over $150,000 per year, the limit is 2 times your salary up to a maximum of $450,000. The monthly cost is determined by the amount you elect and your attained age as of the January 1 coincident with or following your birthday. To view the rate schedule for supplemental life insurance coverage, click here
• If you wish to purchase additional coverage after your initial enrollment period expires you may do so, however, you will be required to provide the insurance carrier with proof of good health unless you apply for coverage within 31 days of a Qualified Status Change, click here.
• For more information: click here.
• Completed forms should be sent to the NYU Benefits Office: 7 E 12 St., 2F, New York, NY 10003 (Campus mail code: 8923).