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Completing the Enrollment Form
The Supplemental Life Insurance Enrollment Form is available for download. The document is an Acrobat Reader PDF file, and requires Adobe's free Adobe Reader software to display and print. Follow this link to download, display and print the Enrollment Form. The downloaded document is about 10K in size.

This enrollment form should only be used by exempt employees. Union-represented employees should consult the Union Benefits Trust at 800-228-5088 for information.

As you are enrolling in supplemental life insurance, please note the following:

  1. ENROLLMENT OR CHANGE

    If you are electing coverage in this plan for the first time, check the ENROLLMENT box. If you are already enrolled in this plan and are requesting a change of some type, check the CHANGE box.

    Besides checking the CHANGE box, you should also check whichever change or changes you are requesting from the list provided:

    • Change Employee Coverage
    • Add Spouse Coverage Only
    • Drop Spouse Coverage
    • Add Child(ren) Coverage
    • Drop Child(ren) Coverage
    • Change Smoker Status
    • Other Name/Address Change, etc.
  2. EMPLOYEE’S COMPLETE ADDRESS

    This should be your home address: Street or PO Box Number, City, State and ZIP Code.

  3. EMPLOYEE INSURANCE AMOUNT

    This is the TOTAL amount of insurance that you wish for yourself. Dependents are not included in this amount. If you are requesting a change to your amount of coverage, the amount shown should represent the TOTAL amount to be carried. For example, an employee who is currently covered for $100,000, and is requesting an increase of an additional $50,000 would show $150,000 in this box. Likewise, if an employee is requesting to decrease coverage from $100,000 to $50,000, he or she would show $50,000 in this box.

  4. BASIC ANNUAL EARNINGS

    This is the total of your regular payment from the State of Ohio during a 12-month period. This does not include any commissions, bonuses, overtime or fringe benefits. You will need to round your basic annual earnings up to the next highest $1,000 before reporting on the form. (If you are eligible for group life insurance, this is the same amount that is listed on your Payroll Earning Statement in the Group Life Insurance box.)

  5. EMPLOYEE’S BENEFICIARY

    You may choose to have one or more individuals as your beneficiaries. Please see the back of the Enrollment Form and Your Beneficiary for more information. If the space provided is not sufficient to show all the beneficiaries chosen, you may attach a separate sheet to this form.

    After you’ve completed the Enrollment form, make a copy for your records, and mail the form to:

    Prudential Insurance Company of America
    PO Box 5072
    Millville, NJ 08332-9931