Group Insurance Enrolment Card

POLICYHOLDER NAME *

ASSOCIATION EMPLOYER CREDIT UNION UNION

APPLICANT'S SURNAME *

DATE OF BIRTH *

SEX *

M F

APPLICANT'S FIRST NAME *

Email *

MARITAL STATUS *

SINGLE MARRIED

BENEFICIARY'S NAME (SURNAME FIRST) *

Applicable to health/life

BENEFICIARY'S RELATIONSHIP TO APPLICANT *

APPLICANT'S OCCUPATION *

HOW ARE EARNINGS PAYABLE *

Hourly Weekly Monthly Annually

AMOUNT OF LIFE INSURANCE *

AMOUNT OF AD & D INSURANCE *

HEALTH INSURANCE *

YES NO

DEPENDENTS TO BE COVERED?* *

YES NO

EMPLOYEE CATEGORY:

EMPLOYEE ONLY EMPLOYEE & ONE EMPLOYEE & FAMILY

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