PIA Insurance Trust
Accidental Death & Dismemberment Census Form
Individual Census Form
This is not an application for insurance.
Please submit a separate census form for each person requesting a proposal.
Name
Gender Male     Female
Agency Name
Address
City State Zip Code
Phone Number
Fax Number
Number of hours worked per week
Date of Birth
Coverage is being requested on: Member/Employee Only
Member/Employee & Family

If dependent coverage is being requested:

Spouse's Name
Date of Birth
Dependent 1 Child's Name
Date of Birth
Dependent 2 Child's Name
Date of Birth
Dependent 3 Child's Name
Date of Birth
Dependent 4 Child's Name
Date of Birth

Benefit Amount: ($30,000 - $400,000 in increments of $10,000):

Spouse's benefit amount cannot exceed Member's/Employee's benefit amount. Children's benefit amount cannot exceed 50% of Member's/Employee's benefit amount.
Member/Employee Only:
Member/Employee & Family