Life Insurance Enrollment and Changes
How to enroll or increase supplemental life insurance coverage
Employees must enroll in Supplemental Life within 31 days of eligibility (hire or qualifying life event). In order for employees to enroll or increase their supplemental life coverage outside the period of initial eligibility (PIE), the employee must complete a statement of health and submit it to Prudential for approval.
Once an employee receives an approval from Prudential, the employees will need to complete the UPAY 850 form to elect for supplemental life coverage. The form and the Prudential approval letter must be submitted to the HR department within 31 days of the approval date via fax at 855-251-6438.
Family status changes
Family life events that do not require a statement of health to enroll or increase coverage are:
- Establishing a domestic partnership
- Birth of a child or grandchild
To enroll or increase your coverage, complete and return a UPAY 850 form within 31 days of the life event.
Dependent life insurance
To enroll a spouse or domestic partner in dependent life coverage outside of PIE, the spouse or domestic partner should complete a statement of health and submit it to Prudential.
The spouse can be enrolled by the employee if done within 31 days of the date of marriage.
Employees may enroll their eligible dependent children into coverage at any time by completing a UPAY 850 form ›
How to decrease supplemental life coverage
Supplemental life coverage can be decreased at any time.
To decrease supplemental life coverage, complete the UPAY 850 form and elect to decrease coverage under supplemental life.
Return the form to Human Resources via fax at 855-251-6438, email firstname.lastname@example.org or mail to Route 114.
Life insurance information ›
Prudential statement of health form ›
UPAY 850 form ›