Town of East Windsor and Board of Education 

Employee 
Enrollment & 

–

Account & Unit Number 

Waiver -CT 

Employee Information 

(Last) (First) (MI) Social Security NumberYour 
Name 
(Street) Date(Month, Day, Year)

Mailing

 
Employed

Address

 Full-Time 
(City) (State) (ZIP) (Month, Day, Year)


Birth

 
Date 


Hrs Wrkd Per Wk Salary Amount Salary Mode 


Job Occupation/Class

Male 


Yr

 Wk 

Hr 
Mo 

Bi-wkly 

Female 

$ 


Location What is your payroll mode?

Do you have an eligible spouse or child? 
Yes No Mnthly Bi-mnthly Wkly Bi-wkly 
Benefit Options 

Coverage 
Long Term DisabilityGroup Term LifeVoluntary Term LifeEmployee 
Elect 
Elect * 
Elect$ 
Decline 
DeclineSpouse 
Elect$ 
DeclineChildren 
Elect$ 
Decline 
Have you used nicotine products in the past 12 months?
Has your spouse used nicotine products in the past 12 months?
Important! If declining any coverage for yourself or any dependent, give reason: 
* You can not decline any coverage paid in full by your employer. 
Yes 
Yes 
No 
No 

Beneficiary Designation (Complete if life coverages are elected.) 

Full Name Relationship 

If two or more beneficiaries are named, proceeds shall be paid in equal shares to the surviving beneficiaries, unless specified 
otherwise. If no beneficiary has been named, any proceeds will be payable as provided by the group policy. 

Eligible Dependent Information (Complete if you have elected benefits for your spouse and/or children.) 

Spouse’s Name Birth Date Social Security Number 
Male 
Female 
Do you have foster children? Yes No 
If yes, do you provide principal support and does the child(ren) live with you at least 50% of the time? Yes No 
IMPORTANT -Complete 
both sides of this form ==>> 
EGP 43375 07/20/2006 

Principal Life Insurance Company 


Employee Signature (Read and sign below.) 

I understand and agree with the following statements: 

• 
My dependents, including step and foster children and those over the maximum age, are eligible for coverage 
based on plan provisions. Eligibility for my dependents, over the maximum age, will be verified when claims are 
submitted. 
• 
If I decline any coverage, I may apply at a later date. However, I must provide proof of good health at my own 
expense and coverage will only become effective subject to approval from Principal Life. 
• 
Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits 
an application or files a claim containing a false or deceptive statement, may be guilty of insurance fraud. 
• 
If the group policy requires that I make contributions, I authorize my employer to deduct them from my pay. 
I declare that the information I have completed on this enrollment form is complete and true. I understand an agent or 
broker cannot guarantee coverage, revise rates, benefits, or provisions without written approval from Principal Life. 

Your Signature X 
Date Signed

 Instructions 

After this form is completed and signed, make two copies and send the original to Principal Life Insurance Company: 

· One for the employer · One for the employee 
Underwritten by: Mailing Address: 
Principal Life Insurance Company Des Moines IA 50392-0002 
07/20/2006