Enrollment Form - Unified Life Insurance Company

Underwritten By:
Unified Life Insurance Company
7201 W 129th Street
Overland Park, KS 66213

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 #
Must be 9 digits. Currently Entered: 0 digits.
Please do not use dashes. Example: 123456789
Social Security Number
Maximum of 9 digits allowed. 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.

Please contact your Human Resources Department to withdraw consent.
Type of Participant
GRP BCS 2013 ENR-AL 12/2013
GRP BCS 2013 ENR-AK 12/2013
GRP BCS 2013 ENR-AZ 12/2013
GRP BCS 2013 ENR-AR 12/2013
GRP BCS 2013 ENR-DC 12/2013
GRP BCS 2013 ENR-DE 12/2013
GRP BCS 2013 ENR 03/2013
GRP BCS 2013 ENR-IN 12/2013
GRP BCS 2013 ENR-KY 12/2013
GRP BCS 2013 ENR-LA 12/2013
GRP BCS 2013 ENR-ME 12/2013
GRP BCS 2013 ENR-NM 03/2013
GRP BCS 2013 ENR-OK 03/2013
GRP BCS 2013 ENR-PA 03/2013
GRP BCS 2013 ENR TX 05/2017
GRP BCS 2013 ENR-VT 03/2013
GRP BCS 2013 ENR-VA 03/2013
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