Enrollment Form – The University of Tennessee The Prudential

Enrollment Form – The University of Tennessee
The Prudential Insurance Company of America
Employee General Information
Last Name
751 Broad Street, Newark, New Jersey 07102
1-877-232-3619
Effective Date of Coverage (for office use only)
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First Name
Middle Initial
Address
City
Social Security Number
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–
 Single
 Divorced
Date Employed
Month Day
Year
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/
Email
Phone
State
Marital Status
 Married
 Widowed
Your Annual Earnings
$
Zip Code
Date of Birth
Month Day Year
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/
(For Prudential Use Only)
Control # 50973
Voluntary Long Term Disability
I wish to enroll for the Long Term Disability insurance coverage.
I authorize my employer to deduct contributions for the cost of the plan from my earnings.
Payroll Deduction: $
I would like to enroll in Plan 0
I would like to enroll in Plan 1
I would like to enroll in Plan 2
I would like to enroll in Plan 3
I would like to enroll in Plan 4
No Long Term Disability insurance coverage chosen.
I understand that in the event I desire such insurance at a later date, I will be required to furnish medical evidence of
insurability at my own expense, and the insurance company will have the right to refuse my request.

Long-Term Disability Insurance coverage is issued by The Prudential Insurance Company of America, 751 Broad Street, Newark, NJ
07102. Disability Support 1-800-842-1718. The Booklet-Certificate contains all details, including any policy exclusions, limitations,
and restrictions, which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group Contract
issued by Prudential, the terms of the Group Contract will govern. Contract provisions may vary by state. California COA #1179,
NAIC#68241. Contract Series: 83500.
©2015 Prudential Financial, Inc. and its related entities.
Prudential, the Prudential logo and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities,
registered in many jurisdictions worldwide.
GL.2014.192
Ed. 08/2015
Page 1 of 3
Enrollment Form – The University of Tennessee
Employee General Information
Last Name
First Name
Middle Initial
Last 4 digits of Social Security No.
XXX – XX –
Acceptance or Waiver of Coverage
I am enrolling for coverage and I authorize my employer to deduct from my earnings until further notice my contributions
for insurance under a contract issued by The Prudential Insurance Company of America. I understand that if I desire to increase
the amount of my insurance or add dependent coverage hereafter, I may be required to furnish evidence of insurability for
myself and/or my dependents. To the best of my knowledge and belief, I declare the statement above is true and understand it is
the basis for determining the contribution for coverage. I also understand that for coverage to become effective, I must be
actively at work during the enrollment period and on the effective date of the plan. If I apply for an amount that requires
evidence of insurability satisfactory to The Prudential Insurance Company of America, I must be actively at work on the date of
approval for the amount requiring satisfactory evidence of insurability.
I do not wish to enroll for any of the above optional coverages. I certify that I have been given the opportunity by my above
named employer to enroll for coverage. I understand that if I desire to enroll hereafter, I may be required to furnish satisfactory
evidence of insurability to The Prudential Insurance Company of America for myself and/or my dependents.
FLORIDA RESIDENTS—Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement
of claim or an application containing false, incomplete, or misleading information is guilty of a felony of the third degree.
NEW YORK RESIDENTS—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 shall
also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
This warning ONLY applies to accident and disability coverage.
I have read and understand the terms and requirements of the fraud warnings included as part of this form.
Employee Signature:
GL.2014.192
Date (Month/Day/Year)
Ed. 08/2015
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/
Page 2 of 3
Enrollment Form – The University of Tennessee
Employee General Information
Last Name
First Name
Middle Initial
Last 4 digits of Social Security No.
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XXX – XX – _
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For residents of all states except Alabama, Arkansas, the District of Columbia, Florida, Kentucky, Louisiana, Maine,
Maryland, New Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island, Utah, Vermont, Virginia and Washington;
WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person,
or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or
information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent
insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil
damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of
misleading, information concerning any fact material thereto
ALABAMA RESIDENTS - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines
or confinement in prison, or any combination thereof.
ARKANSAS, DISTRICT OF COLUMBIA, LOUISIANA and RHODE ISLAND RESIDENTS – Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance
is guilty of a crime and may be subject to fines and confinement in prison.
KENTUCKY RESIDENTS - Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance 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.
MAINE AND WASHINGTON RESIDENTS - Any person who knowingly provides false, incomplete, or misleading
information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include
imprisonment, fines, and denial of insurance benefits.
MARYLAND RESIDENTS - Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
NEW JERSEY RESIDENTS - Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
PENNSYLVANIA and UTAH RESIDENTS - 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 material fact thereto commits a fraudulent insurance act, which is a
crime and subjects such person to criminal and civil penalties.
PUERTO RICO RESIDENTS: Any person who knowingly and with the intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other
benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be
sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars
($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present,
the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may
be reduced to a minimum of two (2) years.
VERMONT RESIDENTS – Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly
makes a false statement in an application for insurance may be guilty of a criminal offense under state law.
VIRGINIA RESIDENTS - Any person who, with the intent to defraud or knowing that he/she is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.
If you have any questions, please see Human Resources for details.
GL.2014.192
Ed. 08/2015
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