M E M O R A N D U M

 

 

To:                    State Employees Assurance Department

                         Two Northside 75

                         Suite 300

                         Atlanta, Georgia 30318-7778

 

FROM:         _____________________________________

                                             Name

                      _______________________________________

                                   Address

                       _________________________________________

                    (____)________________________________________

                                           Daytime Phone

                    SS #_____________/________/_____________

                

I choose to continue Group Term Life Insurance (GTLI) coverage for any period during which I am on Leave Without Pay.  I understand that the following conditions apply:

 One (1) year of continuous membership is necessary

Premiums of one percent (1%) of my monthly salary will accrue for each month of a LWOP period

At termination of state employment and on application for a refund, premiums are deducted from the proceeds

At retirement, premiums due are deducted from the monthly benefit

At death, premiums are deducted from the life insurance payment to beneficiaries

 

                   ______________________________________________

                                                   Signature

 

 

                                      _________________________

                                                     Date