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Life Enrollment05

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Member Information

Personal Information

First Name: {MemberFirstName}

Last Name: {MemberLastName}

Date of Birth: 1970-01-01

Sex: {MemberGender}

Marital Status: {MemberMaritalStatus}

Social Security Number: * * * - * * -

Spouse Information

First Name: {SpouseFirstName}

Last Name: {SpouseLastName}

Date of Birth: {SpouseBirthDate}

Social Security Number: {SpouseSSNumber}

Child(ren) Information

Child 1: {Child1FirstNameDisplay} {Child1LastNameDisplay}, {Child1BirthDateDisplay}, {Child1GenderDisplay}

Child 2: {Child2FirstNameDisplay} {Child2LastNameDisplay}, {Child2BirthDateDisplay}, {Child2GenderDisplay}

Child 3: {Child3FirstNameDisplay} {Child3LastNameDisplay}, {Child3BirthDateDisplay}, {Child3GenderDisplay}

Child 4: {Child4FirstNameDisplay} {Child4LastNameDisplay}, {Child4BirthDateDisplay}, {Child4GenderDisplay}

Contact Information

Address: {MemberStAddress}, {MemberCity}, {MemberState}, {MemberZipCode}

Phone Number: {MemberPhoneNumber}

Email Address: {MemberEmailAddress}

Employment Information

Agency: {MemberAgency}

Date of Hire: {MemberDateOfHire}

Current Coverage Information

Member Life Term Insurance Policy

Member Coverage:

Spouse Coverage:

Children Coverage: $20,000

Personal Accident Insurance Policy

Coverage Amount:

Coverage for: {PAIApplyingSSO}

Payment Information

Payment Type: {PaymentType}

Frequency: {MemberBillingFrequencySSO}

Keeping your information up-to-date ensures you receive all important communications and benefits.

Click here to update information

Keeping your information up-to-date ensures you receive all important communications and benefits.

Click here to update information

Personal Information

Last Name: {MemberLastName}

First Name: {MemberFirstName}

Date of Birth: 1970-01-01

Gender: {MemberGender}

Marital Status: {MemberMaritalStatus}

Social Security Number: {MemberSSNumber}

Spouse Information

First Name: {SpouseFirstName}

Last Name: {SpouseLastName}

Date of Birth: {SpouseBirthDate}

Social Security Number: {SpouseSSNumber}

Child(ren) Information

Child 1: {Child1FirstName} {Child1LastName}, {Child1BirthDate}, {Child1Gender}

Child 2: {Child2FirstName} {Child2LastName}, {Child2BirthDate}, {Child2Gender}

Child 3: {Child3FirstName} {Child3LastName}, {Child3BirthDate}, {Child3Gender}

Child 4: {Child4FirstName} {Child4LastName}, {Child4BirthDate}, {Child4Gender}

Contact Information

Address: {MemberAddress}, {MemberCity}, {MemberState}, {MemberZipCode}

Phone Number: {MemberPhoneNumber}

Email Address: {MemberEmailAddress}

Employment Information

Agency (Initials): {MemberAgency}

Date of Hire: {MemberDateOfHire}

Current Coverage Information

Member Life Term Policy

Member Coverage: $300,000

Spouse Coverage: $200.00

Children Coverage: $20,000

Personal Accident Insurance Policy

Member/Family Coverage: $250,000

Payment Information

Payment Type: {PaymentType}

Frequency: {PaymentFrequency}

Keeping your information up-to-date ensures you receive all important communications and benefits.

Need to update your information?

Select your Insurance Products

Member Term Life Insurance

Select a plan to continue

Accident Death and Dismemberment

Select a plan to continue

Would you like to add family members to your coverage?

Spouse

Dependent Children

Spouse Information

First Name

Error: Enter your spouse's first name

Middle Initial

Last Name

Error: Enter your spouse's last name

Date of Birth

Error: Date of birth is required

Sex

Male
Female

Error: Please select spouse gender

This coverage is not available to {SpouseFirstName} due to the age requirements of this plan.

Contact SAMBA's Group Plan Department at (800) 638-6589, weekdays from 8:00am - 5:00pm EST or visit us at sambaplans.com.

Children Information

How many children 25 years old or younger are you insuring?

Please Select Number of Children

First Name

Error:First name is required

Last Name

Error:Last name is required

Date of Birth

Error:Please enter a valid date of birth

Sex

Male
Female

Error:Gender is required

First Name

Error:First name is required

Last Name

Error:Last name is required

Date of Birth

Error:Date of birth is required

Sex

Male
Female

Error:Gender is required

First Name

Error:First name is required

Last Name

Error:Last name is required

Date of Birth

Error:Date of birth is required

Sex

Male
Female

Error:Gender is required

First Name

Error:First name is required

Last Name

Error:Last name is required

Date of Birth

Error:Date of birth is required

Sex

Male
Female

Error:Gender is required

Error:First name is required

Error:Last name is required

Error:Date of birth is required

Sex

Male
Female

Error:Gender is required

Error:First name is required

Error:Last name is required

Error:Date of birth is required

Sex

Male
Female

Error:Gender is required

To add children to your policy after this enrollment, contact us at (800) 638-6589

Children must be 25 years or younger.

Please update your list to continue.

Sorry! You don't qualify for this plan, but Group Enhancement Life (GEL) plan is available.

If you have any questions, contact us at 1-202-833-4910, weekdays from 8:30 am - 5:30 pm (EST).

This coverage is not available due to the age requirements of this plan.

Contact SAMBA’s Group Plan Department at (800) 638-6589, weekdays from 8:00 am - 5:00 pm EST or visit us at sambaplans.com.

Testing Info: {SSOInfoFlag}

Overage Member: {MemberOverAgeLimitUsingInPage} Spouse: {SpouseOverAgeLimitUsingInPage}

Session ID: b32rr3ljdu3ulton2cdk4k3a02 | {SpouseTLExisitingCoverageSSO}

Payment: {PaymentType}|{MemberBillingFrequencySSO}

CBene3Info: {CBene3FirstName} | {CBene3LastName} | {CBene3Relationship} | {CBene3BirthDate} | {CBene3Percent}

CBene4Info : {CBene4FirstName} | {CBene4LastName} | {CBene4Relationship} | {CBene4BirthDate} | {CBene4Percent}

Sorry! We're having trouble accessing your information.

Please contact us at 1-800-638-6589, weekdays from 8:00 am - 5:00 pm (EST).

SAMBA Term Life Insurance and Accidental Death and Dismemberment coverages are issued by The Prudential Insurance Company of America, Newark, NJ. The Booklet-Certificate contains all details, including any exclusions, limitations and restrictions, which may apply. CA COA #1179, NAIC #68241, Contract Series 83500.

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