Life Insurance Enrollment Form Codes 104, 106, 107 Non-Union

For employees in Codes 104, 106 and 107 Non-Union 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 $20,000 of Life and AD&D coverage at no cost to you.

• You may purchase additional Life and AD&D through payroll deduction. You may purchase additional coverage in increments of $5000 ranging from $5000 to $40,000. 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
• You may change your beneficiary at any time.
• For more information, click here

Completed forms should be sent to the NYU Benefits Office: 7 E St., 2nd Floor, New York, NY 10003-4475 (Campus mail code: 8923)