Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin by indicating the type of application you are submitting: initial application, change in coverage, or total cancellation.
3. Complete the applicant section carefully. Fill in your name, initial, surname, date of birth, and sex. Ensure the details are correct as they verify your identity.
4. Provide your complete mailing address for communication purposes.
5. Indicate the name of the beneficiary and their relationship to you. You have the option to reserve the right to revoke this appointment for initial applications.
6. Select your preferred coverage options. For employee coverage, indicate whether you are applying for basic life insurance and the optional coverage indicated below.
7. If applicable, specify the number of units for accidental death and dismemberment insurance, noting the maximum allowed.
8. Mark whether you are insured under an employee organization group insurance plan and provide the date of last coverage.
9. Authorize the appropriate Pay Agency to deduct necessary premiums from your pay by confirming this selection.
10. If you are canceling your insurance, ensure to check the cancellation option and provide your signature.
11. Review all provided information for accuracy.
12. Finally, save your changes. You can download, print, or share the completed form as necessary.

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