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