Enrollment Form - Church Mate Plus Plan

Sagicor Church Mate Plus Plan Enrollment Form

Affordable Group Life and Health Insurance for Church Members
Group Policy Name: Church Mate Plus

Group Policy Number: 63025

Member Information
Member Information

Please share your information with us. Eligible age for coverage is 18-70 years
What is your Name*

First NameMiddle InitialLast Name
What is your Date of Birth*

MonthDayYear
Gender*

MaleFemale
Email Address*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityParish

Postal / Zip CodeCountry
Tax Registration Number (TRN)

Dependents Details
Eligible dependents are Spouse (married or unmarried maximum age of entry 70 years, in the case of marriage a copy of the marriage certificate is required) and children, step-children or legally adopted children (up to age 26, a copy of the birth certificate and proof of Adoption is required). The listed dependent(s) can be covered under the member’s Group Health and Life Policy.
I would like to add my First Name Last Name who was born on Date as a dependent on my policy.
I would like to add my First Name Last Name who was born on Date as a dependent on my policy.
I would like to add my First Name Last Name who was born on Date as a dependent on my policy.
I would like to add my First Name Last Name who was born on Date as a dependent on my policy.

Beneficiary Information
Beneficiaries refer to any party/person to whom the benefits of the Group Life and Health Insurance proceeds are assigned, by the member.

* If a Child under 19 years is named, a Trustee must be assigned

**If more than one beneficiary is designated, proceeds will be divided equally unless you indicate a share.

***The Total percentage allocation for all beneficiaries combined should not exceed 100%
I would like to assign Percentage (%) percent of the benefits awarded under this policy to my First Name Last Name who was born on Date . Trustee name First Name Last Name
I would like to assign Percentage (%) percent of the benefits awarded under this policy to my First Name Last Name who was born on Date . Trustee name First Name Last Name
I would like to assign Percentage (%) percent of the benefits awarded under this policy to my First Name Last Name who was born on Date . Trustee name First Name Last Name
I would like to assign Percentage (%) percent of the benefits awarded under this policy to my First Name Last Name who was born on Date . Trustee name First Name Last Name
I would like to assign Percentage (%) percent of the benefits awarded under this policy to my First Name Last Name who was born on Date . Trustee name First Name Last Name
I would like to assign Percentage (%) percent of the benefits awarded under this policy to my First Name Last Name who was born on Date . Trustee name First Name Last Name

Total Premium*
I elect coverage for myself/child and agree to remit annually, the sum outlined above in respect of the premium for the benefits selected. I declare that the answers shown above are complete and true and I understand they form the basis upon which insurance will be made effective and coverage under this plan is restricted to the maximum amount allowable per life insured. I authorize my physician, hospital or other medically related facility to disclose to Sagicor Life Jamaica Limited any additional information about my health habits or my medical history.
E-Signature*
Type your name
Card Delivery Option
Deliver your health card to

Your mailing addressSagicor Life, Head OfficeYour Church address
Church address

Street Address

Street Address Line 2

CityParish

Postal / Zip Code
Advisor Information
Please tell us which Sagicor Advisor (if any) encouraged you to sign up:

Advisor's First NameAdvisor's Last Name
To complete your Sagicor Church Mate Plus enrollment, pay your premium at any Sagicor Life or Paymaster location using Group/Account Number 63025 and your TRN. This represents your Policy Number.

Please share your proof of payment to slj_groupinsuranceoffers@sagicor.com
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Sagicor Church Mate Plus Plan Enrollment Form