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Life Insurance Information

Parsippany-Troy Hills, New Jersey, United States
1 million dollars
June 19, 2019

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Enrollment Form

United of Omaha Life Insurance Company

**** ****** ** ***** *****, Omaha, Nebraska 68175

Employer Section (To be completed by the employer. Required fields are marked with an asterisk *Employer Name: Altech Services, Inc. Effective Date: Group ID: Sub Group ID: Location Code: Class: Occupation:

*Salary: o Hourly

o Monthly

o Weekly

o Semi-Monthly

o Bi-Weekly

o Annually

*Date of Hire: Hours Worked Per Week:

Employee Section (Please print clearly. Required fields are marked with an asterisk *Last Name: *First Name: MI:

*SSN/ID Number: *Birth Date (MM/DD/YYYY): *Gender: *Marital Status:

*Street Address:

*City: *State: *Zip Code:

Voluntary Short-Term Disability Coverage Election

Employee Coverage Only Enroll Decline Benefit Amount Weekly Premium Amount

(Per Paycheck - 52/Year)

Voluntary Short-Term Disability o o per Week $ Enrollment Information

Enrollment must occur within 31 days from the date the employee becomes eligible (or as otherwise stated in the applicable policy). If you are required to pay premiums for any coverage, the enrollment form MUST be signed and dated to authorize payroll deductions. The premium amounts indicated on this form are estimates, and are subject to change based on the final terms and conditions of the applicable policy as well as your age and/or salary on the effective date of the coverage. Agreement and Signature

I represent that the information I have provided in this enrollment form is complete, true and accurate to the best of my knowledge. I understand that payment of premium does not guarantee eligibility for coverage. I understand and agree that I must satisfy all active work or active eligibility requirements that pertain to the policy to be eligible for coverage. Should I apply for waived coverage in the future, I understand that evidence of insurability may be required, acceptable to the underwriting company, at my own expense. I understand that if coverage is applied for in the future, it must be during an enrollment period approved by the underwriting company or due to a life change event as defined or allowed by the applicable policy, and that a waiting period may apply. By signing below, I acknowledge that I understand and agree to the above statements, and that I have read and understand the benefit summary or outline of coverage provided to me for each type of coverage. The above requirements will apply unless otherwise stated in the applicable policy, or unless prohibited by any applicable state or federal law. SIGNATURE OF EMPLOYEE DATE / / Additional Information

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. (Note: This fraud warning does not apply to residents of AL, AR, CA, CO, DC, FL, KS, KY, LA, ME, MD, NJ, NM, NY, OH, OR, PR, RI, TN, VT and VA. Please review the specific fraud warning for your state of residence if provided below, or view it online at New Jersey Fraud Warning: Any person who includes any false or misleading information on an application for insurance is subject to criminal and civil penalties.

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