Forms All forms are in Adobe® Acrobat® format. Click on the form you need and you should see the form appear in a new window. Print, complete and sign the form before submitting it to your employer or Boston Mutual Life Insurance Company.

GROUP ENROLLMENT A Group Enrollment Form must be completed for each participant enrolling in a Boston Mutual group insurance plan. The Employer/Plan Administrator should complete the following information: Group Number, Division Number, Policyholder Name Date of Hire State (state abbreviation for the legal address of the group) Class (stated in the Group Policy) Occupation or Job Title Salary Type and Earnings Average Hours Worked (during a normal work week), Effective date and Department ID (if applicable)

The Employee should provide the following information and return the form to the Plan Administrator:

• Social Security Number
• Name
• Sex
• Name of Beneficiary
• Date of Birth (month/day/year in numerals)
• Coverages Elected (if dependent coverage is offered and elected, the spouse name and birth date must also be indicated on the form)
• Date of Signature

When the enrollment form has been completed in its entirety and signed, copies should be made and maintained by both the Employer and the Employee while the original is sent to Boston Mutual for processing.

*Additional copies may need to be taken should multiple coverages exist. These would be forwarded to the appropriate administrator.

REFUSAL OF INSURANCE

It is the plan administrator's responsibility to inform all prospective participants of the coverages provided under the group plan. In addition, participants must be told that if they do not wish to take a coverage for which they are eligible, evidence of insurability will be required if they choose the insurance at a later date. The plan administrator should fill in the Policyholder and Group Number portions of the form. The individual who is declining the coverage must complete the balance of the card including signature and date. If your plan offers several types of coverage and an individual declines some but not all of the insurance available, be sure to include a copy of the form along with the individual's enrollment card. Any eligible individual who declines any coverage must complete the REFUSAL OF INSURANCE. The employer should maintain the original form in their file as well as send a copy to the Home Office of Boston Mutual.