* Required Field
Refer to the Member Enrollment Booklet when completing this form. Coverage may be subject to evidence of insurability (satisfactory proof of good health) requirements. If you have questions, please call The Standard's dedicated CTA Customer Service Department at 800.522.0406 or email firstname.lastname@example.org.
Please Note: The amount of Dependents Life Insurance for each dependent may not exceed 50% of your Life Insurance amount under the Group Policy.
I wish to make the choices indicated on this form. I authorize my employer to deduct premiums from my wages to cover my cost of insurance sponsored by California Teachers Association. I understand that my employer may provide updated payroll information to The Standard either periodically or at The Standard's request to ensure proper premium deductions are being made for my coverage. I understand that a copy of this form will be provided to my employer to facilitate payroll deduction for the coverages that I have elected. I understand that my premium deduction amount will change if my coverage or costs change. This authorization will remain in effect until cancelled by me or by The Standard. I certify that I meet the eligibility requirements of the coverage(s) for which I applied and understand that if I am no longer eligible my coverage(s) will end. I also certify that the information I have provided is accurate.
I understand that Disability Insurance coverage will not pay for benefits for disability due to any diagnosed mental or physical condition for which I have received treatment, care, services or taken prescription medication in the 30 calendar days prior to my insurance effective date unless I have worked 10 consecutive regular days of required attendance after my insurance effective date and prior to becoming disabled.
By clicking the box marked "I agree," I acknowledge that I am signing this document electronically. I understand that this electronic signature shall be enforceable under the applicable state or federal law and is equivalent to a manual signature.