Gallagher Benefit Services - The Northwestern University Non-Employee Postdoctoral Scholar Benefit Program

Fields marked with are required to submit this form.

1. Personal Information

First Name

Last Name

Gender

Date of Birth
MM/DD/YYYY
/ /

Marital Status

Social Security #
No dashes

Home or Cell Phone

Home Address
(Please provide your U.S. home address including number, street, city, state, zip)

Postdoc Email Address

Total Monthly Salary/Stipend

Appointment Start Date
MM/DD/YYYY

Appointment End Date
MM/DD/YYYY

2. Department Information

Department Name

Department Contact Name

Department Contact Phone

Department Contact Email

Department Contact FAX

3. Opt-Out of Coverage (Waiver): I understand if I opt out of any, or all, of the Northwestern University Non-Employee Postdoctoral Scholar Benefit Program-sponsored plans, the University will not provide me, or my eligible dependents, with any medical, dental, vision, short-term disability, additional life and/or long-term disability insurance or coverage and I am responsible for all costs related to any services provided.
When declining for yourself or your dependents, you must provide a reason. Any waived coverage will automatically uncheck any of your benefit selections made below in Section 5a-c.
*This is not an open enrollment field.

I wish to decline coverage for myself in the following plans:

	Medical
	Dental
	Vision

I am waiving this coverage because (check one):

Covered by another plan

Other (please specify)

I am declining coverage for the following dependents:

Spouse/Partner

Child(ren)

I am waiving this coverage because (check one):

Covered by another plan

Other (please specify)

4. Type of Action or Qualifying (Life) Event: Please provide date of event, if applicable.

Open enrollment [?]

New Hire enrollment [?]

Change in appointment status

Date: MM/DD/YYYY

I wish to enroll my Civil Union Partner and meet the required conditions.

Add eligible family member
(Provide details below in Section 6 and select Enroll by their name(s).
Date: MM/DD/YYYY

Please select a reason for adding family member:

If Other, please specify:

Change personal data for eligible family member
(Please provide details below in Section 6.)
Date: MM/DD/YYYY

Delete plan member
(Specify family member in Section 6 and select Delete by their name.)
Date: MM/DD/YYYY

Select Reason:

If Other, please specify:

Cancel previous waiver due to loss of spouse/partner coverage

Date: MM/DD/YYYY

Please provide a letter from the employer certifying that you and your family member(s) were enrolled in the plans(s) and specifying the date coverage ends.

5. Benefit Coverage Options:

5d. Standard Life and Accidental Death and Dismemberment Insurance:

You are automatically enrolled in this plan. J1 and J2 Visa requirements are satisfied with this insurance. Details are provided on the Life Insurance page of this web site.

5e. Standard Voluntary Additional Life Insurance Coverage - Self: Please click Yes on the voluntary additional life purchase option you desire or click on the statement below the choices to indicate you do not wish to purchase this insurance. You may purchase up to 5 times your annual earnings, not to exceed $500,000. Your purchase is calculated in multiples of $10,000 and rounded up to the nearest $10,000 increment. Failure to purchase this coverage at initial enrollment will disallow the guarantee issue amount of $150,000, and your approval for this program will be subject to medical underwriting.

I wish to purchase the following multiple of my annual earnings in voluntary additional life insurance:

Amount of Insurance:

Actual Amount:

Monthly Premium:

I wish to purchase this insurance:

1x Annual Earnings

Yes

2x Annual Earnings

Yes

3x Annual Earnings

Yes

4x Annual Earnings

Yes

5x Annual Earnings

Yes

None

$ 0.00

5f. Standard Voluntary Additional Life Insurance Coverage - Spouse/Children: You may purchase this insurance for your spouse and children as well. Please click the appropriate space below and call our office for details at 1-800-319-9557. Rate information.

	I wish to purchase this coverage for my spouse
	I wish to purchase this coverage for my child(ren)
	I do not wish to purchase this coverage
	I wish to cancel this coverage

5g. Standard ‘50/50’ Long-Term Disability Insurance Coverage: Please click Yes below to display your monthly cost for this coverage: $____
The University pays the exact monthly amount you pay for this coverage to assist you in covering the cost of this valuable program. Please note: This coverage is only available for purchase at initial enrollment. Please call our office if you wish to purchase this coverage at a later date.

	Yes, I wish to purchase this coverage
	No, I do not wish to purchase this coverage
	I wish to cancel this coverage

6. Eligible Family Members to be covered - List individuals whom you are enrolling or deleting from coverage.
You must provide the 6-digit PCP number below for anyone enrolling in the Aetna HMO plan, including yourself.
You must provide the 6-digit dental office number below for anyone enrolling in the First Commonwealth Dental HMO plan, including yourself.

Check Action Desired

Enroll

Delete

Last Name

First Name

Birthdate
MM/DD/YYYY

Gender

Social Security #

Coverage Elected

Medical

Dental

Vision

PCD Office Number [?]
(Medical HMO)

PCD Office Number [?]
(Dental HMO)

Currently Disabled

Self

SAME AS ABOVE

Spouse/
Partner

Child

7. Beneficiary Information:

Standard Life Insurance Company
Subject to the terms of the Group Contract(s), between Standard Life Insurance Company and said policyholder, I request that the following Beneficiary (beneficiaries) be substituted under said contract(s) as my designated Beneficiary (beneficiaries), in lieu of any and all beneficiaries previously named by me:

Primary Beneficiary Designation
Name of Beneficiary (First, MI, Last Name)	Related To Me As:	Date of Birth MM/DD/YYYY	Address of Beneficiary (Address, City, State, Zip)	Percentage
				%
				%
				%
			Percentage Total:	100%

Contingent Secondary Beneficiary Designation
Name of Contingent Beneficiary (First, MI, Last Name)	Related To Me As:	Date of Birth MM/DD/YYYY	Address of Beneficiary (Address, City, State, Zip)	Percentage
				%
				%
				%
			Percentage Total:	100%

*If more than one named, the beneficiaries shall share equally unless otherwise stated above.
Benefits are only payable to a contingent Beneficiary if you are not survived by one or more primary Beneficiary(ies).

Unless otherwise above expressly provided, if any Beneficiary listed above designated predeceases me, the share which such Beneficiary would have received if such Beneficiary had survived me shall be payable equally to the remaining designated Beneficiary or beneficiaries, if any, who survived me, but if no designated Beneficiary survives me, the Beneficiary shall be determined as prescribed in said Group Contract(s). If a minor (a person not of legal age), or your estate, is the Beneficiary, It may be necessary to have a guardian or a legal representative appointed by the court before any death benefit can be paid. If the Beneficiary is a trust or trustee, the written trust must be identified in the Beneficiary designation. A power of attorney must grant specific authority, by the terms of the document or applicable law, to make or change a beneficiary designation.

This Designation of Beneficiary refers only to a Group Life Insurance contract.

This Designation of Beneficiary is subject to change as provided in said Group Contract(s).

I agree and understand the Terms and Conditions.

Yes	No

I have read the General Notice of COBRA Continuation Rights.

Yes	No

I have read the Insurance Carrier Privacy Notice.

Yes	No

I have read the required Notice of the Health Insurance Marketplace.

Yes	No

I have read the Gallagher Benefit Services Notice of Privacy Policy and Insurance Practices

Yes	No

When you click "Submit & Create Printable Form" below to submit your completed enrollment form, you are providing your electronic signature. You will be submitting your enrollment form to the secure GPA database. Please print and keep a copy of the enrollment form for your records in the event eligibility verification is required.

Date: