Assurant Employee Benefits

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Employee Application and Instructions

When you have a new applicant for your Assurant Employee Benefits Insurance Policy, please have the individual complete this form.

For other policy administration forms and claim forms, please visit the Forms section.

Instructions for Employee Application

  1. From the list in the Employee Application section below, select the state where the employee resides.  

  2. Receive the Voluntary Employee Application.
    Or
    If an application is unavailable for the state selected, you will receive information to call your group sales representative or our customer service number (800) 733-7879.  

  3. Print the application and type or print your information.  

  4. To avoid any delay in your request for coverage, the following fields on the application must be completed.

    • Employee name

    • Policy/Participation number (if applicable) and Account number (if applicable)

    • Sex

    • Basic annual earnings

    • Employee date of birth

    • Employee Social Security number

    • Spouse's date of birth (if applying for spouse coverage)

    • Coverages requested and the desired amount of coverage (if electing Life, Long Term Disability or Short Term Disability)

  5. Note: All dates should be in mm/dd/yyyy format.

  6. The Group Health Questions only need to be completed if an employee is a "late" applicant* or applying for any amount of Life coverage in excess of the Maximum Amount without Proof of Good Health*.
    *Refer to your Group Policy for specific information regarding these terms.  

  7. The employee must sign and date the application.  

  8. If the application is not completed online, print the Employer name and Employee name in each page of the application and staple the pages together.  

  9. Mail the completed application to the address listed at the bottom left-hand side of the form.

If you have any questions or need more information, please contact your Assurant Employee Benefits group sales representative or call Customer Service at (800) 733-7879 and select option 3 to speak with a Voluntary representative.

Employee Application (Voluntary Life)

When you have a new applicant for your Assurant Employee Benefits Voluntary Life Policy, please have the individual complete this form.

Please select the applicant's state of residence from the list below and an employee voluntary life application will appear.

Print this employee application. After it is completed, you may fax it to us toll free at 1-888-208-2323.

Arizona

Michigan

New Mexico

California

Montana

New York

Connecticut

North Dakota

Pennsylvania

Florida

New Hampshire

Virginia

Indiana

New Jersey

Wisconsin

Maryland

 

 

All Other States

Employee Application (Voluntary LTD)

When you have a new applicant for your Assurant Employee Benefits Voluntary LTD Policy, please have the individual complete this form.

Please select the applicant's state of residence from the list below and an employee voluntary LTD application will appear.

Print this employee application. After it is completed, you may fax it to us toll free at 1-888-208-2323.

Maryland

New Jersey

Pennsylvania

New Hampshire

New York

 

All Other States