ENROLLMENT FORMS - DEPENDENT GROUP TERM LIFE
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Click
on the appropriate link below to download a printable PDF file
of the selected form.
The
forms below function as either Screen Viewable forms,
indicated by the symbol: 
or
Screen Fillable forms, which are labeled with the button:
(Screen
Fillable forms require you use Adobe Acrobat 5.0, or
higher.)
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Dependent
Group Term Life (DGTL) forms:
NOTE:
Employees of FBI, USSS, DEA, ATF, CBP, CIS,
and ICE must complete the SAMBA Payroll Allotment
Form 299. All other agencies must
complete the Direct
Debit application.
*Current members updating coverage, contact
SAMBA regarding the short form health
statement. |
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| Form
Description |
PDF
Type |
Premium |
| DGTL
Member Enrollment Form |
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| DGTL
Dependent Enrollment Form |
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| Short
Form Health Statement |
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| Beneficiary
Form |
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| Allotment
Form 299 |
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| Direct
Debit Application Form |
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