• State Employees Association of North Carolina

     

     

    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:

    • Group Voluntary Life Insurance - offers you a valuable opportunity to add extra life insurance protection, ensuring financial security for your future.

    Do you already have life insurance with us?

    If you currently have coverage, you do not need to enroll again. However, we encourage you to:

    • Verify your current coverage through your HR team, or by speaking with a benefit counselor, and
    • Review and update your beneficiary information with your HR team, if needed

    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!

  • Please enter the last five digits of your social security number below. This will allow us to search our database for your coverage details.

  • WELCOME VALUED CUSTOMER!

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

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you work for the Town or the School?
  • Format: (000) 000-0000.

  • Hidden Calculations (Case Level)

  • ORIGINAL EFFECTIVE DATE (DATE FIELD)
     - -
    2 digit month, 2 digit day, 4 digit year
  • EFFECTIVE DATE*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Voluntary Life Insurance

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

  • If you have current coverage on yourself, it will be listed below. You may be eligible to increase your coverage.  

  • How much coverage can I get?

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

    • If you are under age 60, you can elect from $10,000 up to $250,000 in $10,000 increments
    • If you are age 60-69, you can elect from $10,000 up to $80,000 in $10,000 increments

    If you have current coverage on yourself, it will show below in the current coverage column.  If you would like to increase your coverage, or if you are a new applicant, enter the total amount of coverage you would like to apply for in the new total coverage column.

    If you have current Voluntary Term Life and you do not wish to increase but you are applying for spouse and/or child coverage, please enter your current coverage amount in the new total coverage column.

    *Coverage exceeding the guaranteed issue limits will be automatically reduced to that limit.

     

  • *If you are interested in applying for a higher amount, please contact cstephens@SEANC.org 

  • Spouse Coverage Section

  • If you have current coverage on your spouse, it will show below in the current coverage column.

  • How much coverage can I get for my spouse?

  •  

    If you have elected coverage on yourself, you can elect spouse coverage for $25,000.

     

  • If you would like to increase your spouse coverage, or if your spouse is a new applicant, enter the new total amount of coverage you would like to apply for in the new total coverage column.

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

    *If you are interested in applying for a higher amount, please contact cstephens@SEANC.org 

  • Spouse Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • How much coverage can I get for my child?

  • 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: $10,000 (age 25 for full-time students)

    If you have current coverage on your child(ren), it will show below in the current coverage column. 

  • If you would like to increase your child coverage, or if your are applying for first time child coverage, select 'YES'. 

    If you do not wish to apply for child coverage, please select 'NO'

  • Do you want child coverage?*
  • Group Voluntary Term Life Monthly Premium*
    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. 
  • Primary Beneficiary(ies):
    Rows
  • Contingent Beneficiary(ies):
    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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