Town of Brookline Group Life Insurance Form

  • Town of Brookline

     

    Boston Mutual Life Insurance Enrollment Form
    120 Royall Street • Canton, MA 02021

  • Welcome to Your Boston Mutual Life Insurance Enrollment!

    Today, we’ll guide you through your options to sign up for:

    • Basic Life Insurance - in the event the employee passes away, this benefit helps the beneficiary with everyday expenses like the mortgage, bills and keeping the household running. 
    • Group Voluntary Life Insurance - offers you a valuable opportunity to add extra life insurance protection, ensuring financial security for your future.

    Our goal is to make this process simple, informative, and tailored to help you make the best choice based on your current phase of life.

  • LOCATE ME!

  • WELCOME VALUED CUSTOMER!

  • If you are a current customer and there is information populated in the fields below that needs to be updated, please email nicole.girard@bostonmutual.com

  • Let's get to know you a little bit better...

  • Do you work for the City or the School?*
  • Format: (000) 000-0000.

  • Hidden Calculations (Case Level)

  • ORIGINAL EFFECTIVE DATE (DATE FIELD)
     - -
  • EFFECTIVE DATE*
     - -

  • Basic Life Insurance

    The Town of Brookline offers a $5,000 Basic Life Insurance policy. The cost of the policy is split between you and the Town. Your cost for this coverage is $1.59 a month.

  • Great news! You are already covered under this benefit.

  • Basic Life Insurance

    The Town of Brookline offers a $5,000 Basic Life Insurance policy. The cost of the policy is split between you and the Town. Your cost for this coverage is $1.59 a month.
  • Would you like to sign up for Basic Life Insurance?*
  • Just to confirm — if you don’t enroll in Basic Life, you won’t be eligible for Voluntary Term Life coverage (which also allows you to cover your spouse and/or children). Do you want to continue without enrolling?*
  • Date of Birth*
     - -

  • Voluntary Life Insurance

    Group Voluntary Life Insurance is coverage in addition to Basic Life Insurance. This line of coverage is paid entirely by you. This insurance offers the opportunity to lock in your age for the duration of the policy.

  • How much coverage can I get?

    As part of this Special Open Enrollment, you can elect coverage with no medical questions!*

    • If you are under age 60, you can elect from $10,000 up to $150,000 in $10,000 increments
    • If you are age 60-69, you can elect from $10,000 up to $50,000 in $10,000 increments
    • Those age 70 and above can elect up to $20,000

    If you would like to apply for coverage, enter the amount of coverage you would like to apply for in the total new coverage column below.

    *If you are interested in applying for a higher amount, please contact Brian Fitzgerald at brf@mosseandmosse.com.

     

  • Rows

  • If you have elected coverage on yourself, you can elect spouse coverage.

    Spouses are eligible for up to a maximum of 50% of whatever you, the employee, elects, subject to the amounts shown below - with no medical questions!*

    • If the spouse is under age 60, they can elect from $5,000 up to $30,000 in $5,000 increments
    • If the spouse is age 60-69, they can elect from $5,000 up to $20,000 in $5,000 increments

    If you would like to apply for coverage on your spouse, enter the amount of coverage you would like to apply for in the total new coverage column below.

    If you do not wish to apply for spouse coverage, please enter a zero (0) in the total new coverage column below.

    *If you are interested in applying for a higher amount, please contact Brian Fitzgerald at brf@mosseandmosse.com.

     

  • Spouse Date of Birth
     - -
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  • If you have elected coverage on yourself, you can elect child coverage.

    Child coverage is flat rate per month and covers all existing or future children. Please note that this coverage is only valid until the youngest child turns 26.

    • Age 14 days - 1 year: $500

    • Age 1-19 years: $5,000 (age 25 for full-time students)

    If you would like to apply for coverage on your child(ren), enter the amount of coverage you would like to apply for in the total new coverage column below.

    If you do not wish to apply for child coverage, please enter a zero (0) in the total new coverage column below.

  • Rows
  • Rows
  • Would you like to update or apply for Group Voluntary Life coverage shown above?*
  • Would you like to update the beneficiary information on your Basic Life coverage?*
  • Are you interested in learning more about the additional permanent life insurance options?*

  • BENEFICIARY INFORMATION:

    Name your beneficiary(ies) for Life benefits. List additional beneficiaries on a separate sheet and provide them to your HR team. The total percentage of benefit must equal 100%. If you do not designate a percentage payable for each beneficiary, the total proceeds payable will be divided equally among each beneficiary. For Voluntary Life, if an insured dependent dies, we will pay the proceeds to you. 
  • Rows
  • Rows

  • ACCEPTANCE OF INSURANCE

  • I apply for the insurance for which I am now eligible (or for which I may become eligible) under the provisions of the Group Policy or Group Policies issued to my employer by the Boston Mutual Life Insurance Company and authorize deductions, if any, from my earnings of the required premium contribution toward the cost of the insurance. I understand that if I am disabled on the date my insurance would otherwise become effective, I shall only become insured on the date I return to active full-time work. I further understand that if I decline insurance coverage for which I am now eligible and I desire to participate in the plan at a later date, I must furnish, at my own expense, evidence of insurability satisfactory to Boston Mutual Life Insurance Company.

  • REFUSAL OF INSURANCE

  • I hereby certify that I have been given an opportunity to participate in the Group Insurance Plan offered by my Employer (or the Association with whom I am affiliated) and insured by Boston Mutual Life Insurance Company and that I have declined to do so with respect to:

  • I further understand that if I desire to participate in the Plan at a later date with respect to the coverage checked, I must furnish, at my own expense, evidence of insurability satisfactory to Boston Mutual Life Insurance Company.

  • Finalize Your Enrollment

  • Please take a moment to review your answers and make any necessary corrections before submitting. Once you click "Submit," your enrollment selections will be submitted to Boston Mutual Life Insurance Company.

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