Get Mutual Of Omaha Ltd Enrollment Form - Filice Insurance

Filling out the Mutual Of Omaha LTD Enrollment Form is a crucial step in securing long-term disability coverage. This guide will walk you through the process of completing the form online, ensuring that you provide accurate and complete information.

Follow the steps to successfully complete the enrollment form.

1. Click the 'Get Form' button to access the enrollment form and open it in your preferred document editor.
2. In the employer section, fill in the necessary details, including the employer's name, group ID, sub group ID, class, location code, full-time employment date, hours worked per week, effective date, and salary. Be sure to indicate if your salary is hourly, weekly, monthly, or semi-monthly.
3. In the employee section, print clearly your last name, social security number, occupation, birth date (MM/DD/YYYY format), and your age. Indicate whether you are opting for employee-only coverage or long-term disability coverage, and choose between bi-weekly or annual premium payments.
4. Provide your first name, middle initial, and gender. If you wish to decline coverage, please indicate this by checking the appropriate box.
5. In the dependent information section, if applicable, list all dependents you are enrolling. For each dependent, provide their name, gender, relationship, birth date, and social security number. Ensure you clearly indicate if a dependent is over the limiting age specified in your plan but is a full-time student.
6. Read the enrollment information carefully. Remember that enrollment must occur within 31 days of eligibility, and you must sign and date the form to authorize payroll deductions for any premiums.
7. Complete the agreement and signature section. Read the statements carefully and sign. Ensure that the signed date is included in the designated format.
8. Once all sections are complete, you can save your changes, download the form, print it, or share it as required.

Complete your enrollment form online today to secure your long-term disability coverage.