Group Insurance Enrolment CardCompany websiteGroup Insurance Enrolment CardGROUP INSURANCE ENROLMENT CARDPLEASE COMPLETE FORM IN BLOCK LETTERSPOLICYHOLDER NAME *ASSOCIATIONEMPLOYERCREDIT UNIONUNIONAPPLICANT'S SURNAME *DATE OF BIRTH *SEX *MFAPPLICANT'S FIRST NAME *Email *MARITAL STATUS *SINGLEMARRIEDDO YOU HAVE ANY OTHER FORM OF INSURANCE? TICK √MOTORFIREBURGLARYMARINELIFEMEDICALIF YES, SPECIFYBENEFICIARY'S NAME (SURNAME FIRST) *Applicable to health/lifeBENEFICIARY'S RELATIONSHIP TO APPLICANT *APPLICANT'S OCCUPATION *HOW ARE EARNINGS PAYABLE *HourlyWeeklyMonthlyAnnuallyAMOUNT OF LIFE INSURANCE *AMOUNT OF AD & D INSURANCE *HEALTH INSURANCE *YESNODEPENDENTS TO BE COVERED?* *YESNOEMPLOYEE CATEGORY:EMPLOYEE ONLYEMPLOYEE & ONEEMPLOYEE & FAMILYSubmit Request
