INSURANCE QUESTIONNAIRE
1. NAME (Last) (First) (Middle) THIS DATE
[Handwritten Name] [Handwritten Date]
2. THE FOLLOWING GROUP INSURANCE PROGRAMS HAVE BEEN ESTABLISHED FOR EMPLOYEES OF THIS COMPANY THROUGH EMPLOYEE INSURANCE ASSOCIATIONS (MEBA) WITH THE ASSISTANCE OF THE COMPANY:
[Checkbox] GROUP LIFE INSURANCE PROGRAM
[Checkbox] GROUP HEALTH INSURANCE PROGRAM
3. IF AN INSURANCE FORM IS REQUIRED FOR THE INDIVIDUAL NAMED APPLICATION FOR ANY TYPE INSURANCE:
[Handwritten Note]
4. I AM NOW PARTICIPATING, OR WOULD LIKE TO PARTICIPATE IN THE FOLLOWING INSURANCE PROGRAMS:
TYPE OF POLICY DESIRED POLICY NUMBER DEDUCTION AUTHORIZED CASH PAID
[Handwritten Details]
5. I DO NOT ELECT TO PARTICIPATE IN ANY OF THE STATED INSURANCE PROGRAMS:
[Signature Section]
EMPLOYEE INTERVIEWED: [Signature] [Signature]
FORM NO. 37-190