Life Insurance Enrollment Form Code 107 Local 810

For employees in Codes 107 Local 810 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 $12,500 of Life and AD&D coverage at no cost to you, with a Total and Permanent Disability (T & PD) insurance benefit.

• You may purchase additional Life, AD&D and T & PD 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.