2027 Legal Insurance Enrollment Form

Important notice: This form replaces all other legal insurance enrollment forms on file and must be signed and dated to be valid. Legal insurance is underwritten by ARAG Legal.

This enrollment is for:

Date of Change

Date

Name

First NameLast Name

Date of Birth

Date

Gender

E-mail

example@example.com

Agency Employed (if your agency is not listed, please enter your agency name below)

Agency not listed - enter your agency name below.

If your agency is not listed above, enter your agency name here.

Home/Cell Phone

Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

City/State

Postal / Zip Code

Work Phone

Format: (000) 000-0000.

Marital Status

If enrolling a domestic partner attach a completed SEIU Local 503 Affidavit of Domestic Partnership form.

Coverage Requested

Spouse/Domestic Partner Name and Date of Birth

Child 1 - Name and Date of Birth

Child 2 - Name and Date of Birth

Child 3 - Name and Date of Birth

Child 4 - Name and Date of Birth

If any of the dependent children listed above is a child with a disability, please indicate so below.

See eligibility information on the bottom of this form for a dependent child with a disability who is age 26 and over. New members enrolling a dependent child over the age of 26 with a disability must include a copy of the Guardianship papers with their completed enrollment form.

Dependent child with a disability?*

*Disability guardianship papers can be uploaded here. See eligibility information on the page two of this form for a dependent child with a disability who is age 26 and over. New members enrolling a dependent child over the age of 26 with a disability must include a copy of the Guardianship papers with their completed enrollment form.

I hereby apply for benefits under the SEIU Local 503 Group Insurance Plan issued by ARAG Insurance Company and agree to pay the required monthly premium. The amount of insurance coverage and the applicable premium are subject to change in accordance with the terms of the master policy agreement between SEIU Local 503 and ARAG Insurance Company. Please see the reverse side for information regarding termination of coverage.

Member Signature

Date

Insurance Effective Date

The insurance effective date is determined by when the enrollment form is received, processed, and the applicable premium payment or payroll deduction is received. Coverage becomes effective according to the plan’s eligibility and effective-date provisions. If payroll deduction is unavailable through your employer, you must pay premiums directly.

Eligible Dependents

Spouse or domestic partner.
Unmarried dependent children under age 26.*
Domestic partners require appropriate documentation (Affidavit or Registered Domestic Partnership certificate).

*Coverage for an unmarried dependent child with a disability may continue beyond age 26 if you or your spouse/partner become the child’s court-appointed legal guardian before the child reaches age 26. To maintain coverage, copies of the court-issued guardianship documents must be submitted to the SEIU Local 503 Membership AdvantagesOffice no later than 31 days after the child’s 26th birthday. Failure to provide the required documentation within this time frame may result in termination of the child’s coverage under the plan.

Enrollment Changes

Coverage elections can generally only be:

Canceled or changed during Open Enrollment, or;
Changed following a qualified status event.
You must notify the SEIU Local 503 Membership Advantages office within 31 days of a qualifying event.

Termination of Coverage
Coverage under the Legal Plan will terminate if the participant fails to pay the required monthly premium or is no longer a member of SEIU Local 503.

Pre-Existing Legal Matters
Any legal matter that occurs or is initiated before the effective date of coverage is excluded from the plan and no benefits will be provided. For purposes of determining eligibility for coverage, ARAG® defines “initiated” as the date:

Written notice of a legal dispute is sent by you or received by you;
A ticket or citation is issued; or
An attorney is retained or hired.

Continuation of Coverage for Existing Claims
Any legal matter for which coverage has been approved prior to termination of coverage will continue to be covered under the plan until that specific legal matter has been completed, subject to the terms, conditions, and limitations of the plan.

Please remember that only the insurance policy can give the actual terms, coverages, amounts, conditions and exclusions.

SEIU Local 503 reserves the right to amend the plan from time to time or to terminate the plan in its entirety at any time.

SEIU Local 503
PO Box 12159
Salem, Oregon 97309-0159

Membership Advantages Office - 503.772.6569
SEIU Member Assistance Center - 844.503.SEIU (7348)

2027 Legal Insurance Enrollment Form

Section 1 Member Information

Section 2 Coverage Requested (check one-if selecting family coverage please complete Section 3)

Section 3 Family Plan Designation (please list family members to be insured)

Section 4 Signature for Enrollment and Authorization for Payroll Deduction/Change