2027 USAble Enrollment Form

This enrollment is for:

Date of Qualifying Event

Date

Name

First NameLast Name

Date of Birth

Date

Gender

E-mail

Social Security Number

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

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

City/State

Postal / Zip Code

Marital Status

How many hours per month do you work in your SEIU Local 503 represented position?

Section 2 - Term Life Insurance
(you must work at least 40 hours per month to enroll in voluntary life insurance)

Member and spouse term life benefit levels are $10,000, $20,000, $30,000, $40,000, $50,000, $60,000, $70,000, $80,000, $90,000, $100,000, $110,000, $120,000, $130,000, $140,000, $150,000, $160,000, $170,000, $180,000, $190,000 or $200,000

New Member (within 90 days of new membership) -

You are guaranteed up to $100,000 in Member Term Life insurance.
Your spouse is guaranteed up to $40,000 of Spouse Term Life insurance. You must have voluntary member insurance to purchase spouse insurance.
Your unmarried, dependent children under age 26 are guaranteed up to $10,000 of Child Term Life insurance.

Open Enrollment -

If you are currently enrolled you can step-up to the next benefit level of Member Term Life insurance up to a maximum of $100,000.
Children are guaranteed up to $10,000 of Child Term Life insurance.

All other coverage requires approval through Evidence of Insurability

You cannot be enrolled as a member and as a dependent on another member's voluntary term life policy.
You must be enrolled in voluntary member term life to apply for spouse/partner or child term life.
If you request more than the guaranteed issue you (or your spouse/partner) will be required to submit an evidence of insurability and be approved by USAble Life. Please note, that we will issue any guaranteed amount and if your Evidence of Insurability is approved your coverage will be increased. Contact Membership Advantages for the Evidence of Insurability form.

Member Voluntary Life

Spouse/Partner Voluntary Term Life

Spouse Name and Date of Birth

Child Voluntary Term Life

1. Child Name and Date of Birth

2. Child Name and Date of Birth

3. Child Name and Date of Birth

4. Child Name and Date of Birth

5. Child Name and Date of Birth

6. Child Name and Date of Birth

Please attach a sheet to enroll additional children. The list can be uploaded using the upload button below. The following information is required to add dependent children:

Name
Date of Birth
Relationship

Short Term Disability Insurance

DUO Accident Insurance

Section 4 - Beneficiary Designation

You may choose a beneficiary(s) to receive life benefits. If no beneficiary survives, payment will be made in accordance with the terms of the policy. Unless designated otherwise, beneficiary designations for all life coverage will be the same. If multiple beneficiaries are listed you must include the percentage (%) for each beneficiary. All primary beneficiaries must equal 100%. All contingent beneficiaries must equal 100%.

Additional beneficiaries can be added by uploading an additional sheet of paper. The sheet must list if primary or contingent, the name name of beneficiary, social security #, date of birth, phone number, address and relationship. The link to upload is located at the bottom of this form.

For Spouse/Partner and Child Term Life, you are the beneficiary.

1. Primary Beneficiary (Name, social security number, date of birth, phone number, address, and relationship.)

2. Primary Beneficiary (Name, social security number, date of birth, phone number, address, and relationship.)

1. Contingent Beneficiary (Name, social security number, date of birth, phone number, address, and relationship.)

2. Contingent Beneficiary (Name, social security number, date of birth, phone number, address, and relationship.)

Upload additional dependent and beneficiary information.

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.

Eligibility Requirements

Maintain SEIU Local 503 membership.
Work at least 40 hours per month in an SEIU-represented position for life, accident, or short-term disability coverage.
Be actively working and scheduled for the minimum required hours when coverage begins.

Eligible Dependents

Spouse or domestic partner.
Unmarried dependent children under age 26.
Domestic partners require appropriate documentation (Affidavit or Registered Domestic Partnership certificate).
A dependent who is unable to perform normal age-appropriate activities when coverage would start must wait until they are able to do so before coverage begins.

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 ends if:

Required premiums are not paid.
Eligibility requirements are no longer met.
You are no longer a member of SEIU Local 503.

Conversion at Retirement
You retire at any age or terminate age 65+:

Coverage continues at no cost for 31 days.
During that period, you may convert your voluntary term life insurance to an individual permanent policy.
You must contact Membership Advantages to request a conversion application.
Conversion application must be submitted within 31 days.

Portability at Termination
If you leave employment before age 65:

You may port (continue) your voluntary term life insurance as an individual policy.
You must contact Membership Advantages to request a conversion application.
Application must be made within 31 days of employment termination.

Accident Insurance

If employment terminates before age 79, you may port your accident insurance coverage to an individual policy.
Application must be submitted within 31 days of termination.

Short-Term Disability Insurance

Coverage ends upon retirement or termination of employment.
No portability or conversion option available.

Benefit eligibility and termination provisions are detailed in the USAble Life Benefit Booklet. The booklet is located on the SEIU Local 503 website at seiu503.org click on the Membership Advantages page. You can obtain a printed copy of the booklet by contacting the SEIU Local 503 Membership Advantages office at the number below.

The plan may be amended from time to time or terminated in its entirety at any time by SEIU Local 503.

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 USABle Enrollment Form

Section 1 - Member Information

Section 3 - Short Term Disability Insurance

Section 4 - DUO Accident Insurance