KCL Group Benefits

Please complete and submit the appropriate elements for plan termination or reporting change. If you need assistance with your KCLGB ID# or do not know your ID#, please call:
877-266-6767 (producers enter ext. 8200, employers enter ext. 8302)

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All fields are required.

Your KCLGB ID

Group Policy Number

Employer/Group Name

Enrollee SSN

Employee First Name

Employee Last Name

Reason for Add/Termination/Change (Please indicate marriage, divorce, new hire, other.)

Successfully Received.

USAGE: Please click on the date textboxes in order to bring up a calendar.

Termination

Last Day Worked

Add

It is the Employer's Responsibility to maintain a copy of the Employee Enrollment Card.

Contact(for individual completing request)

Email Address

Verify Email Address

Employee Information

Full-time employment date

Location

Hours worked/week

Annual earnings

Coverage Class

Rehire date

This enrollment is: (check or fill in all that apply)

Initial enrollment

Late entrant

New hire

Change

Other

Employee Information

Home Address

City

State

Zip

Sex

Status

Date of Birth (M/D/Y)

Employee Coverage(s)

Basic Life & AD&D

Short-Term Disability

Long-Term Disability

Vision

Dental

If Applicable:

Low Plan

High Plan

Voluntary/Supplemental Life Amount:

Voluntary STD If Applicable: Amount:

Voluntary LTD If Applicable: Amount:

Dependent Coverage(s): Employee Coverage Required

Dependent Life

Spouse Voluntary/Supplemental Life Amount:

Child/ren Voluntary/Supplemental Life Amount:

Spouse Dental

Child/ren Dental

Spouse Vision:

Child/ren Vision:

Change of Name

New First Name

New Last Name

Effective Date

Change of Insured Benefits

Class From

Class To

Change Annual Salary From

Change Annual Salary To

Effective date

Change of Spouse

Terminate Spouse

First Name

Last Name

SSN

Sex

DOB

Add Spouse

First Name

Last Name

SSN

Sex

DOB

Effective date

Note: If coverage is contributory, evidence of insurability must be submitted when adding dependent(s) more than 31 days after the dependent is eligible.

* In order to ADD a dependent, an employee signature will be required on a change of information form (G129).

Change for dependent child

Terminate Child Coverage

First Name

Last Name

SSN

Sex

DOB

Add Child Coverage

First Name

Last Name

SSN

Sex

DOB

Effective date

Note: If coverage is contributory, evidence of insurability must be submitted when adding dependent(s) more than 31 days after the dependent is eligible.

* In order to ADD a dependent, an employee signature will be required on a change of information form (G129).

Change of Address (complete only if enrolled for Dental coverage)

Street Address 1

Street Address 2

City

State

Zip Code

Effective date

SERVICE CENTER

Plan Eligibility Change Form