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Complete this form to enroll in or change your voluntary benefits for this upcoming year.

For Open Enrollment Only

Effective June 1, 2026

Benefit Options

Enroll in Allstate Accident Policy? *

Yes

No

Keep Existing Coverage

Who would you like to enroll in Allstate's Accident Policy?

Employee Only

Employee + Spouse/Domestic Partner

Employee + Child

Family

None

Which Allstate Accident Policy?

Plan 1

Plan 2

Accident Policy Info

Enroll in Allstate Cancer Policy? *

Yes

No

Keep Existing Coverage

Who would you like to enroll in Allstate's Cancer Policy?

Employee Only

Employee + Spouse/Domestic Partner

Employee + Child

Family

None

Which Allstate Cancer Policy?

Plan 1 - Low

Plan 2 - Mid

Plan 3 - High

Cancer Policy Info

Who would you like to enroll in Allstate Universal Life Coverage?

Employee

Spouse / Domestic Partner

Child(ren)/Grandchild(ren)

Employee Universal Life Coverage Amount:

Spouse/Domestic Partner Universal Life Coverage Amount:

Child/Grandchild 1 First & Last Name

Child 1 Gender

Male

Female

Child/Grandchild 2 First & Last Name

Child 2 Gender

Male

Female

Child/Grandchild 3 First & Last Name

Child 3 Gender

Male

Female

Child/Grandchild 4 First & Last Name

Child 4 Gender

Male

Female

Universal Life Info

Child 1 Date of Birth

Child 1 Universal Life Coverage Amount:

Child 2 Date of Birth

Child 2 Universal Life Coverage Amount:

Child 3 Date of Birth

Child 3 Universal Life Coverage Amount:

Child 4 Date of Birth

Child 4 Universal Life Coverage Amount:

Universal Life Rates

Enroll in Short Term Disability Policy? *

Yes

No

Keep Existing Coverage

Employee Job Title

Short Term Disabililty Info

Approximate Premium

Determine Your Short Term Rates

Employee First Name

Employee Last Name

Employee Date of Birth * required

Employee Gender *

Male

Female

Employee Hire Date * required

Employee Personal Email

Employee SS#

Phone Number

Height

Weight

Select an Address

Employee Annual Salary

Primary Beneficiary

Relationship to Employee

Contingent Beneficiary(s) and Relationship

Spouse/Domestic Partner SS#

Date of Marriage

Spouse/Domestic Partner First Name

Spouse/Domestic Partner Last Name

Child 1 First Name

Child 1 Last Name

Child 2 First Name

Child 2 Last Name

Child 3 First Name

Child 3 Last Name

Child 4 First Name

Child 4 Last Name

Spouse/Domestic Partne Gender

Male

Female

Spouse/Domestic Partner Date of Birth

Child 1 Gender

Male

Female

Child 1 Date of Birth

Child 2 Gender

Male

Female

Child 2 Date of Birth

Child 3 Gender

Male

Female

Child 3 Date of Birth

Child 4 Gender

Male

Female

Child 4 Date of Birth

Additional Questions or Notes for Rick or Johnny

Thanks for submitting! If we have any additional questions, we will contact you directly!

Eastern Select Services

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