Benefit Selector

Benefits Selection Tool

Use the form below to see what the available benefits cost and allocate your employer's monthly contribution to obtain the best benefit mix for you and your family. If the total cost of the benefits you select exceeds your employer's monthly contribution, you can pay the difference by payroll deduction. The calculator on the right side of the screen will update your selections and keep track of the costs. You can keep changing your selections until you get the best mix of coverage and cost. Once you have decided on the benefits you want, click the "Sign Up" button to complete the enrollment form. If you would like to change your selections at any time before completing your enrollment, you will always have the option to return to this page.

Plan Information
Employer Plan ID Number		48
Eligibility Waiting Period		30 Days
Eligibility Waiting Period Waived For Initial Enrollment		Yes
Employer Monthly Contribution		$75.00
Basic Life and AD&D		$25,000
Basic Life and AD&D Cost		$6.25
Short Term Disability		Yes
Your Remainder Left To Spend:		$68.75

Choose Your Benefits
Employee Voluntary Life Insurance		Date of Birth:
Spouse Voluntary Life Insurance		Date of Birth:
Child(ren) Voluntary Life Insurance
Dental Coverage
Vision Coverage (not be available in NC).
Short Term Disability Insurance, Enter Average Weekly Income; (Maximum Income: $2,083.33). Note: this benefit not eligible for employer contribution. (See Disability Details).	$

Employee Information

Last Name

This is a required question

First Name

This is a required question

M.I.

This is a required question

Sex

Male Female

This is a required question

Social Security Number

Numbers only - no dashes

Must be 9 digits

This is a required question

Date Of Birth

This is a required question

Date Employed Full-Time

Date cannot be in the future.

This is a required question

Hours Worked Per Week

Minimum required 30 hours

This is a required question

Occupation

This is a required question

Beneficiary

Name the person to whom life your life insurance benefits are to be paid. You are the beneficiary for your insured family members' life insurance.

This is a required question

Beneficiary Relationship

What is your beneficiary's relationship to you?

Spouse
Child(ren)
Sibling
Parent
Other:

This is a required question

Contact Information

E-Mail Address

Must contain @

This is a required question

Street Address

This is a required question

City

This is a required question

State

This is a required question

Zip Code

Must be a number

This is a required question

Telephone

Numbers only - no dashes

Must be a number

This is a required question

Confirming Your Benefit Selections

Enroll Me For The Following Coverages:

(Note: Basic Life and AD&D coverage is provided by the employer for all eligible employees. You do not have to enroll for any of the voluntary coverages to be insured for Basic Life and AD&D.

Voluntary Life
Dental
Vision
Short Term Disability

This is a required question

Employee Voluntary Life Coverage Amount

This is a required question

For Disability Insurance, Enter Average Weekly Income; Leave Blank For No Coverage (Maximum Income: $2,083.33)

This is a required question

Spouse Coverage

Do You Wish To Insure Your Spouse?

Yes
No or Not Applicable

This is a required question

Spouse Information (If Applying for Coverage)

Enroll My Spouse For:

Voluntary Life
Dental
Vision

This is a required question

Spouse Voluntary Life Coverage Amount

Note: Spouse coverage amount may not exceed 50% of employee coverage.

This is a required question

Last Name:

This is a required question

First Name:

This is a required question

M.I.

This is a required question

Sex

Male
Female

This is a required question

Social Security Number

Numbers only - no dashes

Must be 9 digits

This is a required question

Date Of Birth

This is a required question

Does Your Spouse Have Any Other Dental Coverage?

This is a required question

If Yes, What Is The Name Of The Insurance Carrier?

This is a required question

Child(ren) Coverage

Do You Wish To Insure Your Child(ren)?

Yes
No or Not Applicable

This is a required question

Child(ren) Information (If Applying for Coverage)

Enroll My Child(ren) For:

Voluntary Life
Dental
Vision

This is a required question

Child(ren) Voluntary Life Amount

Amount selected applies to each child

This is a required question

Number of children

This is a required question

Notices And Signature

Authorization For Electronic Communication

If you check the Email box below, future information will be sent to you electronically using the e-mail address provided on this application form. You may withdraw this authorization at any time.
If you authorize electronic communication, email will be used to:

confirm your coverage,
deliver your certificate of insurance, and
communicate with you about policy administration.

Please Communicate With Me By:

Email

Regular Mail

This is a required question

Confirmation Of Enrollment

By my signature below, I confirm that I have been offered insurance and have elected to enroll for one or more coverages as indicated above. Further, I authorize my employer to make payroll deductions (if applicable) for insurance coverage for which I have applied.

Confirmation Of Declination Of Coverage

By my signature below, I confirm that I have been offered insurance and have elected to decline to purchase any insurance. I understand that in the event I wish to enroll at a later date, I will be required to furnish evidence of insurability at my own expense and the insurance company will have the right to refuse any request.

ELECTRONIC TRANSACTIONS, SIGNATURES AND RECORDS CONSENT STATEMENT IT IS CRITICAL THAT YOU READ AND AGREE TO THIS CONSENT STATEMENT BEFORE SUBMITTING THIS ELECTRONIC APPLICATION. IF YOU DO NOT ACCEPT THESE TERMS AND CONDITIONS OF THIS CONSENT STATEMENT, YOU ARE NOT AUTHORIZED TO SUBMIT THIS APPLICATION ELECTRONICALLY AND WILL NEED TO CONTACT YOUR HUMAN RESOURCES ADMINISTRATOR FOR FURTHER INSTRUCTIONS FOR APPLICATION PROCESS.

Click on the "I Agree" button at the end of the online enrollment form only if you agree to:

Enter into any electronic transactions on the Affinity Choice Web Site, in connection with online enrollment, beneficiary designations and similar transactions ("Transactions");
Provide electronic signatures ("Signatures") on the Affinity Choice Web Site, in connection with agreeing to, consenting with and entering into any such Transactions; and
Receive electronic delivery of records generated in connection with your Transactions and Signatures on the Affinity Choice Web Site ("Records"). These Records will also include electronic delivery of written consumer information and notifications to which you are legally entitled.

Your consent is required before submitting any information through the Affinity Choice Web Site and utilizing any of the Transactions, Signatures and Records functions incorporated within the Affinity Choice Web Site. Your consent is applicable to all Records provided to you through the Affinity Choice Web Site, including in connection with a Transaction. Your consent is also applicable to entering into Transactions and executing Signatures on the Affinity Choice Web Site. Your employer and/or employee benefit plan may also involve the use of Records, Transactions and Signatures. At any time after you have provided your consent, you may revoke 95206 E-Enroll or modify your consent by calling Customer Service at 1-804-273-9797 and following the directions you are given (in which case the revocation or modification of consent will not apply until after proper written notification is received by Affinity Choice Web Site). If you do not provide your consent or decide later to revoke your consent, you will not be able to enter into Transactions or receive Records through this Affinity Choice Web Site. In such event, alternatives are available to you, including the use of paper enrollment forms, which may be obtained by calling Customer Service. Upon your request, a paper copy of any Record, such as an enrollment form, will be provided to you through the following means: (a) By printing such Record, as provided through the Affinity Choice Web Site; and (b) If such Record cannot be printed or you want to ensure you have a duplicate copy of such Record, you will be able to call Customer Service and order such copy. A nominal fee may be charged for ordering such Record.

Insurance Company	NAIC Identification Number	Principal Address and Telephone	List of Jurisdictions Authorized to do Business	State of Domicile
Companion Life Insurance Company	77828	7909 Parklane Road Suite 200 Columbia, SC 29223 800-753-0404	AK, AL, AR, AZ, CO, DC, DE, FL, GA, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NV, NH, NM, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, and WY	SC
To reach Companion Life Customer Service with regard to any questions about this Consent Statement and the consent process please call 1-800-753-0404.

FRAUD WARNING (Not applicable in AZ, FL, GA, MD, OR, VA): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits (in TX, may be committing) a fraudulent insurance act, which is a crime and subjects (in KS, which may be determined by a court of law to be a crime which subjects) such person to criminal and civil penalties.

FRAUD WARNING (FL ONLY): Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
95206 E-Enroll

NOTICE TO PROPOSED INSURED. In connection with your application for insurance as part of our normal underwriting procedure, an investigative consumer report may be obtained, including, if applicable, information as to character, general reputation, personal characteristics and mode of living. This information is obtained through personal interviews with your friends, neighbors and associates. Upon written request, received within a reasonable time, additional, detailed information concerning the nature and scope of this investigation will be provided.

Employee SSN:
Employee DOB:

Signature

Type your full name.

This is a required question

Declination of Optional Insurance

I, , wish to decline all optional insurance. I understand that I will be covered for the basic life insurance amount of $25,000 provided by my employer. I further understand that by declining optional insurance, I am forgoing my employer’s contribution and cannot receive it in cash or any other form of payment. If I decide to apply at a later date, I will be considered a Late Applicant and may be required to submit evidence of good health satisfactory to Companion Life Insurance Company in order to become insured.

Beneficiary - for your Employer Paid Life Insurance

Name the person to whom life your employer paid life insurance benefits are to be paid.

This is a required question

Beneficiary Relationship

What is your beneficiary's relationship to you?

Spouse
Child(ren)
Sibling
Parent
Other:

This is a required question

Please provide the following information to confirm your identity for Electronic Signature.

Social Security Number

Numbers only - no dashes

Must be 9 digits

This is a required question

Date Of Birth

This is a required question

Type your full name.

Date: 05/06/2024

Thank You

Your enrollment choices have been received.

Summary of Benefits

You have completed the enrollment process, please print a copy of this for your records.

Previous Back to Calculator Sign Up Complete

IF YOU DO NOT WANT TO PARTICIPATE, TYPE YOUR FULL NAME, DATE OF BIRTH AND CLICK THE DECLINE BUTTON:

I, - , wish to decline all optional insurance.I understand that I will be covered for the basic life insurance amount provided by my employer. I further understand that by declining optional insurance, I am forgoing my employer’s contribution and cannot receive it in cash or any other form of payment. If I decide to apply at a later date, I will be considered a Late Applicant and may be required to submit evidence of good health satisfactory to Companion Life Insurance Company in order to become insured.

Short Term Disability And Your Taxes

IMPORTANT: You cannot use your employer's money to pay for this benefit. You must pay the entire disability premium yourself through payroll deduction.

Your disability benefit payment amount under this plan is 60% of your normal earnings to a maximum of $65,000 annually. To ensure that you will not have to pay income taxes on your benefits, should you ever need them, you pay the entire disability premium yourself through payroll deduction.

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Questions??
804 247 9856
Arranged by: Benetix

Benefits Selection Tool

Plan Information

Choose Your Benefits

Employee Information

Contact Information

Confirming Your Benefit Selections

Spouse Coverage

Spouse Information (If Applying for Coverage)

Child(ren) Coverage

Child(ren) Information (If Applying for Coverage)

Notices And Signature

Authorization For Electronic Communication

Confirmation Of Enrollment

Confirmation Of Declination Of Coverage

Declination of Optional Insurance

Thank You

Summary of Benefits

Benefits & Monthly Costs

Short Term Disability And Your Taxes