Enrollment Form - Pan-American Life Insurance Company

601 Poydras Street
New Orleans, LA 70130

If you have any questions during the enrollment process, please call us at 866-797-3343.

1Participant Information > 2Dependent Information > 3Review Your Entry
State
Group #
Name of Employer
Employment Date Employment Date / MM / DD YYYY
Effective Date Effective Date / MM / DD YYYY
Annual Maximum
Name of Insured Name of Insured First Last
Name Name First Middle Last
Date of Birth Date of Birth / MM / DD YYYY
Sex
Social Security Number
Must be 9 characters. Currently Entered: 0 characters.
Please only enter numbers. Do NOT enter dashes. Ex: 123456789
Social Security Number
Must be 9 digits. Currently Entered: 0 digits.
Do not use dashes. Example: 123456789
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone Phone - ### - ### ####
Email
Email Consent

Email Consent I authorize email communications between myself and BeniComp regarding BeniComp policies such as application, enrollment, and claims communications. I also understand that I may withdraw my consent to communicate via email at any time.
Type of Participant
BCS-ENR-07-CA 11/2007
BCS-ENR-07 11/2007
BCS-ENR-07-ID 11/2007
BCS-ENR-07-KY 11/2007
BCS-ENR-07-LA 11/2007
BCS-ENR-07-MN 11/2007
BCS-ENR-07-NM 11/2007
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