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This is an enrollment option for you to select additional term life insurance for you and your family. If you would like to complete a hardcopy of the enrollment form, or you have questions or concerns, contact Human Resources at 937/898-2220.

UNUM Term Life Enrollment Form 2010

*Your Email Address:

If you do not have an email address to insert in the previous question, please insert the following email address: employee@cicl.com

Initial Enrollment Application (Y/N): If this is your first time enrolling in this program, select "Yes" for this option. If you are not interested in this coverage, place the letters "NA" for the answer.

   * Annual Enrollment Application. (This is the selection to make if you want to make changes to an existing election and/or information. The election/information you provide will replace your prior election/information on file with Unum.)

   * Employee SS#:

   * Gender:

   * Date of Birth:

   * Hours scheduled to work per week:

   * Employee First Name:

   * Middle Initial:

   * Last Name:

   * Street Address:

   * City:

   * State:

   * Zip Code:

   * Employee date of hire with CICL:

   * Annual Compensation: (To determine this figure, take the scheduled number of hours you are scheduled to work per week and multiple that times 52 week. This will give you the total number of scheduled hours for the year. The next step is to take the total number of scheduled hours for the year and multiple that times your hourly rate. This figure will represent your annual compensation for the purpose of this coverage. This figure does not take into account any overtime or increased hours that you pick up during the year.)

   * Are you a Residential Specialist or a Program Coordinator (Non-Exempt)?:

   * Are you in a Program Administrator, Program Manager, or Program Director (Exempt)?

    Spouse First Name (if coverage is selected):

    Spouse Date of Birth (if coverage is selected):

   * Have any tobacco products been used by you in the last 12 months?

   * Have any tobacco products been used in the last 12 months by your spouse?

    Coverage Election: Please indicate the amount of coverage you would like to select for you, if applible. (If you have chosen life coverage over the guarantee amount of $50,000 for you or $20,000 for your spouse or your child, you will also need to complete an "Evidence of Insurability" form. The amount of life coverage over the gurantee issue amount will be subject to medical underwriting approval and will become effective in accordance with the terms of the policy.)

Please indicate the amount of coverage you would like to select for your spouse.

    Please indicate the amount of coverage you would like to select for your child(s). Dependent life coverage amounts cannot exceed 50% of your life coverage amount.

Beneficiary Information (primary person): Please provide the first, middle, and last name of the individual and the percentage, from (1% - 100%) of the benefit that is to be paid to that individual.

Beneficiary Information (secondary person): Please provide the first, middle, and last name of the individual and the percentage, from (1 - 100%) of the benefit that is to be paid to that individual.

Beneficiary Information (if benficiary is not living): If the beneficiary (ies) named above are not living, then provide the first, middle, and last name of the individual that the benefit is to be paid.

Limitations and Exclusions:

Delayed Effective Date: Employee: Insurance will be delayed for employees not in active employment until the date they return to work. regularly scheduled vacatrion time is considered active employment.

Dependent: coverage for totally disabilited dependents willbe delayed until the date the individual is no longer totally disabled. this delay does not apply to newborn children while dependent insurance is in effect. Totally Disabled means that as a result of sickness or injury, the dependent is unable to perform each of the usual and customary activities of a person of the same age and sex in good health.

Exclusion for Suicide:

Where the cause of death is suicide, no benefit will be paid for a loss occurring within 24 months after the individual's initial effective date of insurance, and no increased or additional insurance will be payable for a loss occurring within 24 months after the day such increased or additional insurance is effective.

Employee Electronic Signature:

I have read and understand the limitations and exclusions and I certify that all statements are true to the best of my knowledge and belief and I understand that a copy of this form willbe made available to me at my request. I authorize CICL to make the necessary deductions from my compensation to pay the premium when my insurance becomes effective. I undertstand that my payroll deduction amount will change if my coveage or costs change.

My employee number and the last four digits of my SS# are: (111111/1111)