Mail-In Disability Enrollment
How Do I Sign up for the Long Term Disability Plan via the mail?
Please download and fill out one of the following forms based on your payment option:
1199 Payroll Deduction Packet.
Click here to download 1199 payroll deduction form
Authorization for automatic payment a deduction from your personal checking account the 2nd of each month to pay premium for the subsequent month.
Click here to download Bank Authorization deduction form
Employee Express Deduction Packet.
Click here to download Employee Express deduction form
Forms are in Adobe Acrobat. Click here to obtain the reader so you can view/print the documents.
Mail Enrollment Forms to:
Benefits Unlimited Insurance, Inc.
P.O. Box 530820
Henderson, NV 89053-9907
Click here for more detailed instrucitons
LTD Application form
A. Complete Page 1 Up to disability income coverage data and parts A,B, & C.
Complete Page 2 - Part D (details of yes answers below)
B. Sign by the Signature of Primary Insured Line (Page 2 - Bottom by Arrow) and list your city and date of signature on the line above it.
Direct Deposit Form
A Fill in Part I - Lines 1 through 4b.
B. Fill in Line 5b - Establish an Allotment -- Place the ($) amount of the cost of your disability amount in this space.
C. Sign by the X" on Line 6a.
D Fill in your Social Security number on Line 7c -- Follow the BUI with your Social Security number. No dashes or spaces are necessary.
E. Provide us your Postal Ease Number and Employee ID number.
