CTA-endorsed Disability and Life Insurance

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.