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    Benefit Activation Form

    Uploaded by

    ambercausey02
    Benefit

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Benefit Activation Form

    Uploaded by

    ambercausey02
    16 views1 page
    Benefit

    Original Title

    BenefitActivationForm

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Benefit

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    16 views1 page

    Benefit Activation Form

    Uploaded by

    ambercausey02
    Benefit

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    First PREMIER® Bank

    P.O. Box 5506


    3820 N. Louise Ave.
    Sioux Falls, SD 57117-5506

    Please complete this form and return to:


    Benefit Administrator
    PO Box 5506
    PREMIER Credit Protection Sioux Falls, SD 57117-5506
    Benefit Activation Request Fax: 605-235-5403
    Email: [email protected]
    *Do Not Include Sensitive Information such as your
    Social Security Number or Account Number*
    Personal Information

    Primary Cardholder Name: ______________________________ Phone Number: _________________________________

    Address: ____________________________________________ City/State/Zip: ___________________________________

    If you wish to activate benefits on more than one account, please list the last four numbers of each account: _____________

    Email Address: _______________________________________ Today’s Date: ___________________________________

    Event TYPE REQUIRED DOCUMENTATION

    □ Loss of Life Representative must provide death certificate indicating cause of death.

    □ Disability Disability Statement and Employment Statement below must be


    completed. In addition, please provide proof of your disability (such as a
    statement or letter including the date(s) and cause of Disability on a
    medical professional’s letterhead).

    □ Involuntary Unemployment The Employment Statement below must be completed. In addition, please provide
    evidence, including the date(s), of your Involuntary Unemployment (such as a letter
    from employer, proof you have filed for unemployment, or a copy of your
    unemployment check and/or stub). If Strike or Lockout, evidence of Involuntary
    Unemployment may include a statement signed by an officer of your union.

    □ Unpaid Family Leave The Employment Statement below must be completed. In addition, please provide
    evidence, including the date(s), that your employer has approved the Unpaid Family
    Leave.

    Employment Statement

    Last Date Worked: ____/____/________ Return to Work Date (if know): ____/____/________

    Is your interruption of employment the result of willful misconduct, criminal acts, voluntary resignation, or retirement?
    YES ____ NO ____

    Company Name: __________________________ City/State/Zip: _____________________________________

    Disability Statement

    Cause of Disability: ___________________________________________________________________________________

    Date You First Became Disabled: ____/____/________ Date You Will Be Returned to Work: ____/____/________

    Have you been deemed to be totally and permanently disabled? YES____ NO ____ If yes, provide date: ____/____/_______

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