Group Enrollment Form for Accidental Death Policy at a glance
What it is: This is the Group Enrollment Form for Accidental Death Policy of Globe Life And Accident Insurance Company, Administrative Office: Globe Life Center, Oklahoma City, Oklahoma 73184.
Who signs: The Proposed Insured/Applicant signs under Signature of Proposed Insured/Applicant.
A filled-in Group Enrollment Form for Accidental Death Policy example: an applicant enrolls with a beneficiary
How to fill out Group Enrollment Form for Accidental Death Policy, box by box
Proposed Insured/Applicant
Under Proposed Insured/Applicant, enter First, Middle and Last.
Mailing Address, Date of Birth and Social Security Number
Enter the Mailing Address (Street, City, State, Zip), the Date of Birth, the Home Telephone and Work Telephone (Area Code, Number), the Social Security Number and the Email Address.
Replacement of coverage
Is the insurance applied for intended to replace or change any coverage now in force with this or any other company? Mark Yes or No. If Yes, comply with the application Replacement Regulation or Rule.
Date, Application State, Agents' Signature and Agents' Writing Number
The form prints Date, Application State, Agents' Signature and Agents' Writing Number.
More rules for Group Enrollment Form for Accidental Death Policy
The form prints Benefit Amount $3,000 ($3,000 spouse, $1,000 each child), Annual Mode of Premium, Send Premium Notice and Automatic Payment Plan (checked November 11, 2026).
Enter the Day of the Month to Draft Bank.
Common questions about Group Enrollment Form for Accidental Death Policy
Who signs it?
The Proposed Insured/Applicant signs under Signature of Proposed Insured/Applicant.
What am I certifying when I sign?
The applicant declares the statements recorded are true and complete to the best of the applicant's knowledge and belief with respect to any proposed insured. The applicant agrees that: (1) no policy will be binding upon the Company unless upon its date of issue and delivery each proposed insured is alive; (2) no agent has authority to accept risks or make or change contracts or waive the Company's rights or requirements. Except with respect to a minor child of mine, this application is made with the knowledge and consent of the proposed insured.
Sources
[1] Group Enrollment Form for Accidental Death Policy (01-28), Globe Life And Accident Insurance Company (the Official source link on this page).
