Group Enrollment Form American United Life Insurance Company a company ® ® ONEAMERICA One American Square, P.O. Box 6123 Indianapolis, IN 46206-6123 (800) 553-5318 www.employeebenefits.aul.com Active Retired Applicant's Social Security Number: Gender: Employed Full-Time: Yes No Marital Status: Single Married Applicant's State of Residence: Are you authorized to work and reside in the US? Yes No COVERAGE BEING APPLIED FOR: Apply for or decline each coverage listed below. Not checking a box or boxes will be considered a declination of that coverage. Employment Status: I hereby apply for the requested group life and/or disability insurance coverage for which I and my dependents, if any, are eligible and available under AUL’s policy. I understand receipt of any coverage greater than the guaranteed issue amount or application for coverage after the approved enrollment period first requires medical underwriting and written approval by AUL. Signature of Applicant: _____________________________________________________________ Date: _________________________ • • • • I authorize my employer to deduct from my wages the amount of premium required for the amount of coverage approved by AUL, including any premium increases due to age bracket or salary changes when applicable. Premium payments greater than the amount of premium owed will not result in additional coverage under AUL’s policy. The undersigned represents any information or documents provided to AUL by the undersigned prior to and after the date of the application for insurance and the facts and other matters contained in the foregoing are true and accurate to the best of the undersigned’s knowledge and belief. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. Male Female The undersigned understands and agrees 1. any insurance coverage or benefit are contingent upon any statements made to AUL as being complete and correct and 2. benefits under any group life or disability insurance policy will be paid only if AUL or its third party administrator decides in its discretion the applicant is entitled to them. The undersigned have read, understand, and retained the notices, limitations, and exclusions for his/her records. Applicant's Telephone Number: Applicant's E-mail Address: ( ) - (normal business hours): Applicant's Full Legal Name: Date of Birth: Employer: Peter Corporation Employer: Peter Corporation Employer's State: OH MUST BE COMPLETED BY THE EMPLOYER Group Policy #: Class # : Occupation: Salary: Mode: [ ] Hourly [ ] Weekly [ ] Bi-Weekly [ ] Semi-Monthly [ ] Monthly [ ] Annually Date Hired Full Time: F/T Requirements (hours, days, weeks, etc.): Applicant's Residential Zip Code: Benefit Amount / Option Requested Name of Primary Beneficiary: Relationship: SSN/Date of Birth: Name of Contingent Beneficiary: Relationship: SSN/Date of Birth: For AUL Term Life Coverages, identify your Beneficiary Designation to ensure proceeds can be paid according to your wishes. Percentage: Percentage: Decline   Employee Voluntary Term Life & AD&D $_________ ENROLL A(2006) Page 1 G-13416 7/10/15