Life Insurance: New Hires

Life Insurance

Please answer the questions below so that we may determine the correct enrollment form(s) to send to the email address(es) you provide on this form. Be sure to (1) Complete, (2) Sign and (3) Submit forms electronically to process your enrollment. All three steps are required for your submission to be complete.
Please confirm your benefit eligibility on the benefits webpage before completing this form.

Also be sure to review the plan details on the website prior to enrolling.
First Name
Last Name
Email
Please use your City email address if you have one. example@example.com
Department
Employee Status
Would you like to enroll in life insurance at this time for yourself, your spouse, or your children?

To enroll OVER the $200,000 employee guaranteed issue amount for yourself or OVER the $20,000 spousal guaranteed issue amount additional forms and health questions are required. Would you like to enroll above these amounts for you or your spouse?
Spouse's First Name
Spouse's Last Name
Spouse's Email
example@example.com

Next Steps

After you click the Next button below, complete the captcha, and click the Submit button on the next page, we will send an Enrollment Form to the email address you provided on this form. It will come from "City of Cambridge via Adobe Acrobat Sign".

Once you receive the form, please complete and sign it. It will be sent to Human Resources for eligibility review and processing. You will be given an option to download your completed form.

If you don't see it in your inbox within 10 minutes of submitting this form, please check your spam/junk folders. If you still do not see the form, please contact benefits@cambridgema.gov or call 617-349-1770. 1
Next Steps

After you click the Next button below, complete the captcha, and click the Submit button on the next page, we will send one Enrollment, one Evidence of Insurability (EOI), and one HIPAA form to the email address you provided on this form. Both the EOI and HIPAA forms will also need to be signed by your spouse and will be sent to the email address you provide for them. The forms will come from "City of Cambridge via Adobe Acrobat Sign".

Once you receive the forms, please complete and sign them. They will be sent to Human Resources for eligibility review and processing. You will be given an option to download your completed form.

If you don't see them in your inbox within 10 minutes of submitting this form, please check your spam/junk folders. If you still do not see the forms, please contact benefits@cambridgema.gov or call 617-349-1770. 2
Next Steps

After you click the Next button below, complete the captcha, and click the Submit button on the next page, we will send one Enrollment, one Evidence of Insurability (EOI), and one HIPAA form to the email address you provided on this form. The EOI form will also need to be signed by your spouse and will be sent to the email address you provide for them. The HIPAA form will only need to be signed by your spouse. The forms will come from "City of Cambridge via Adobe Acrobat Sign".

Once you receive the forms, please complete and sign them. They will be sent to Human Resources for eligibility review and processing. You will be given an option to download your completed form.

If you don't see them in your inbox within 10 minutes of submitting this form, please check your spam/junk folders. If you still do not see the forms, please contact benefits@cambridgema.gov or call 617-349-1770. 3
Next Steps

After you click the Next button below, complete the captcha, and click the Submit button on the next page, we will send one Enrollment, one Evidence of Insurability (EOI), and one HIPAA form to the email address you provided on this form. The forms will come from "City of Cambridge Benefits Team via Adobe Acrobat Sign".

Once you complete, sign and submit, your forms will be sent to Human Resources for eligibility review and processing. You will be given an option to download your completed form.

Be sure to also complete your selected deferred compensation vendor’s online enrollment process as defined on the webpage to ensure account creation and make your investment selections.

If you don't see the form in your inbox within 10 minutes of submitting this form, please check your spam/junk folders. If you still do not see the form, please contact benefits@cambridgema.gov or call 617-349-1770. 4
Next Steps

Based on your responses to the questions above, you do not want to enroll in or modify your existing life insurance coverage. No further action is required. You can close this window.

If you would like to enroll in or modify your existing life insurance coverage, please refresh this form by clicking here and change your answers to the previous questions. Do not use the Back button below.

If you have any questions, please contact benefits@cambridgema.gov or call 617-349-1770. none

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