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Oklahoma state and education employees group insurance board life insurance application

OKLAHOMA STATE AND EDUCATION EMPLOYEES GROUP INSURANCE BOARD
LIFE INSURANCE APPLICATION
COORDINATOR MUST COMPLETE THIS SECTION BEFORE IT IS RETURNED TO OSEEGIB FOR PROCESSING
Please Note: All information including entity/agency name and address must be completed.
NEW HIRE'S ANNUAL SALARY $ (SALARY MUST BE COMPLETED FOR NEW HIRES) ANNUAL SALARY Information Must Be Included for New Hires (Life Summary Sheet May Be Attached) SECTION 1. EMPLOYEE INFORMATION ONLY -- PLEASE PRINT NEATLY AND CLEARLY
SECTION 2. EMPLOYEE COVERAGE BEING REQUESTED (IN EVEN $20,000 UNITS ONLY)
DO NOT TURN IN THIS FORM IF EITHER OF THESE TWO ITEMS PERTAINS TO YOU: (1) You are a new hire and want only Basic Life and
the Guaranteed Issue amount of Supplemental Life Insurance (Guaranteed Issue equals 2 times your annual salary at time of employment) or (2)
You terminated and are being rehired within 24 months and want only the same amount of life insurance you had when you left.
NEW HIRE/REHIRE EMPLOYEE
OPTION PERIOD/MIDYEAR COVERAGE CHANGE
COMPLETE THIS SECTION
COMPLETE THIS SECTION
Amounts should be listed in even $20,000 units.
Amounts should be listed in even $20,000 units.
DO NOT LIST premium cost.
DO NOT LIST premium cost.
TOTAL COVERAGE DESIRED
TOTAL COVERAGE DESIRED
SECTION 3. AUTHORIZATION (READ BEFORE SIGNING THIS FORM).
It is understood and agreed that all statements and answers given on this form are true and complete, and they are the basis on which the group
life insurance requested by me is issued. I authorize OSEEGIB to request any additional information from any source as may be deemed
necessary. I agree OSEEGIB may request that I submit to an examination by a physician selected by OSEEGIB, at my expense, if OSEEGIB
deems it necessary. It is further understood and agreed that failure to provide complete and accurate information might affect my insurability and
may constitute grounds for retroactive termination of coverage. If member coverage is retroactively terminated and dependents are enrolled with
life coverage, the dependent life coverage will also be terminated. The member must be enrolled in Basic Life coverage in order for dependents to
have Dependent Life coverage. *** SEE PAGE 2 FOR MEDICAL INFORMATION ***
FOR HCMD REVIEW ONLY ----- DO NOT WRITE IN THIS SECTION LIFE INSURANCE APPLICATION -- PAGE 2 -- MEDICAL INFORMATION. PLEASE PRINT CLEARLY.
This form must be completed by the member who is requesting Employee Life coverage. If you need to list additional information you feel is
pertinent to the consideration of this application, please use a separate sheet of paper. Both pages of this form must be returned to: OSEEGIB,
HCMD, P O BOX 57830, Oklahoma City, OK 73157-7830. Fax # 1-405-717-8997

MEMBER ID or SSN
MEMBER'S NAME
Tobacco Use? Yes No Packs/Cigars per Day Alcohol Use? Yes No Cans/Drinks per week
Please CIRCLE all conditions below that you have received any type of treatment for. On the line in front of the condition, list the LAST
YEAR
in which you received treatment. Treatment includes but is not limited to office visit, surgery, lab, and medication.
Year
List any conditions or surgeries you have had that are not already given on this form.
Include the last year you were treated for the Diabetes
List any medications you take on a regular basis. Include the strength of the medication Heart Disease / Disorder
Transplants

Source: http://www.norman.k12.ok.us/assets/files/LifeInsuranceApplication.pdf

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