Plan year July 1, 2023 through June 30, 2024
Use this form to enroll in additional life insurance coverage for yourself, spouse/sponsored dependent, or children. Qualifying dependent children may be covered to age 26. This form also allows you to enroll in separate accidental death & dismemberment insurance.
Revision date: 04/13/2023
Submit paper form to Benefits Office, 112 Scovell Hall, Lexington KY 40506-0064