Clear Form ENROLLMENT FORM P.O. Box 269, Oceanside, CA 92049 800.942.3646 Fax 760.966.1093 lnwia.com Accidental Death & Dismemberment Group Insurance Program ENROLLMENT REQUIREMENTS  Account number must be supplied for Free Basic and Additional coverage enrollment  Only 1 member per account is eligible for the free basic coverage  Must be 18 years of age or older to enroll  Must be signed: o For free basic coverage, please sign in Box 2 o For Additional coverage, please sign in Box 1. Be sure to indicate the amount of coverage desired, as well as whether or not you require family protection. Member Information PLEASE PRINT OR TYPE Name of Sponsoring Credit Union: __________________________________________ Member's Full Name: Member Account#: Member's Address: Member's Date of Birth:  Please send me a billing reminder via e-mail Member's Email: Beneficiary Information Primary Beneficiary - The Person(s) who will receive the insurance benefits if living upon death of insured. Primary Beneficiary Date of Birth Relationship Primary Beneficiary Date of Birth Relationship Contingent Beneficiary - The Person(s) who will receive the insurance benefits only if no Primary Beneficiary(ies) is/are living upon death of insured. Contingent Beneficiary Date of Birth Relationship Contingent Beneficiary Date of Birth Relationship Box 1 - Additional Amount of Accident Insurance Desired ( See chart in brochure)  $10,000  $40,000  $100,000  $175,000  $20,000  $50,000  $125,000  $200,000  $30,000  $75,000  $150,000  $250,000 Family Protection? Yes No If yes, please indicate:  Spouse Only  Spouse + Children  Children Only I herby authorize and direct my Credit Union and LNW Insurance Administrators, Inc. to retain my account information to initiate periodic deductions for the additional amount of accidental insurance selected above from my �Savings �Checking Account (requires a voided check). If no choice is indicated or there is no voided check attached, premiums will be drawn from the savings account. This authorization remains valid until LNW Insurance Administrators Inc., has received written notice from me of it's termination. Member Signature Required for processing Date of Signature Box 2 - Free Basic Insurance coverage only  I do not wish to enroll for Additional coverage at this time. Member Signature Required for processing Date of Signature