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  • Life Insurance and AD&D Enrollment Form 2023-24
  • Click to view (pdf or doc)
  • 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
  • Email form back to