Village Ford Life Insurance Form

Employee First Name(*)
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M.I.(*)
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Last Name(*)
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Date of Birth(*)
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Gender(*)
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Home Address(*)
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City(*)
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State(*)
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Zip(*)
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Social Security #(*)
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Phone #(*)
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Employer Portion - Village Ford to Complete
Date of Hire:
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Occupation:
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Salary $
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LIFE & AD&D COVERAGE

Company Paid Benefits-Insured by Mutual of Omaha
Life/AD&D
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VOLUNTARY LIFE OPTIONS-Mutual of Omaha

Type of Coverage
Voluntary Employee Life Election
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Amount of Coverage $
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Bi-Weekly Cost (26 Pays) $
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Voluntary Spouse Life Election
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Amount of Coverage $
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Bi-Weekly Cost (26 Pays) $
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Voluntary Dependent Child Election
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Amount of Coverage $
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Bi-Weekly Cost (26 Pays) $
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See Page 13 & 14 of the Benefit Newsletter for Plan Specifics and Cost
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VOLUNTARY LONG TERM & CONTRIBUTORY SHORT TERM DISABILITY

Type of Coverage
Voluntary Long Term Disability
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Amount of Coverage $
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Bi-Weekly Cost (26 Pays) $
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Contributory Short Term Disability
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Amount of Coverage $
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Bi-Weekly Cost (26 Pays) $
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See Page 13 & 14 of the Benefit Newsletter for Plan Specifics and Cost
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BENEFICIARY INFORMATION
Primary Beneficiary Last Name(*)
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First Name(*)
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M.I.(*)
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Relationship of Beneficiary(*)
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Social Security #(*)
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Primary Street Address(*)
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City(*)
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State(*)
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Zip(*)
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Contingent Beneficiary's Last Name
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First Name
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M.I.
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Relationship of Beneficiary
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Social Security #
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Contingent Street Address
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City
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State
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Zip
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NOTE: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper.
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ACKNOWLEDGEMENT OF COVERAGE

I authorize Village Ford to make payroll deductions based on the coverage election(s) indicated above. I understand that all of the foregoing elections will be made post-tax in accordance with my plan elections for the 2018 plan year. I further understand that if the required contributions for the elected benefit(s) change while this agreement is in effect, my payroll deductions may be automatically adjusted to reflect the change. I will receive notice of such a change.

I understand that the above election(s) are irrevocable until the next open enrollment period, unless I have a change in family status. A change in family status will include the following: a) marriage or legal separation/divorce/death, b) spouse terminating or obtaining employment, c) transfer to a different employment status (full-time to part-time or vice versa), d) significant change in spouse’s health coverage, and e) loss of dependent status or birth or adoption of a child.

Only benefit changes consistent with the above will be permitted and must be made within 30 days of the change in family status. I understand that I am responsible for notifying Village Ford of any change in family status and for completing the necessary forms within those 30 days.
Employee Name:(*)
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Date:(*)
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Employee Signature:(*)
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