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Life Insurance Enrollment Form (2024 Update, Nov 24)

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1Application

2Allotment

3Review and Submit

Authorization to Start, Stop, or Change an Allotment

Privacy Act Statement

AUTHORITY: 37 U.S.C. Section 701, E.O. 9397.

PRINCIPAL PURPOSE:To permit starts, changes, or stops to allotments. To maintain a record of allotments and ensure starts,changes, and stops are in keeping with member’s desires.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. Section 552a(b) of the Privacy Act, these records of information contained therein may specifically be disclosed outside the DoD as a routine use to the Federal Reserve banks to distribute payments made through the direct deposit system to financial organizations or their processing agents authorized by individuals to receive and deposit payments in their accounts. It may also be disclosed to the Treasury Department, Internal Revenue Service, Social Security Administration, Department of Veterans Affairs, Federal,state and local agencies for civil or criminal law enforcement. In addition it can be released for any of the blanket routine uses published at the beginning of the DFAS compilation of system of record notices.

DISCLOSURE: Voluntary; however, failure to provide the requested information as well as the Social Security number may result in the member not being able to start, change, or stop allotments.

Branch of Service*

Air Force

Army

Marine Corps

Navy

Name of Allotter*

First Middle Initial Last

Social Security Number*

Pay Grade*

Address of Allotter*

Street Address or P.O. Box Address Line 2 City State ZIP Code

Phone*

Daytime Telephone Number

Statement of Understanding

I understand that this allotment is legal and that by voluntarily completing this form,I am responsible for:

Ensuring that the information is correct;
Reviewing my Leave and Earnings Statement to ensure the allotment stops, starts, or changes as directed including amount and payee;
Collecting overpayments from the receiver (payee) of the allotment, if I do not change or stop the allotment after a loan is repaid;
Contacting the receiver (payee) of the allotment, at my expense, to obtain monthly statements for my personal records.

I also understand that any problems once the allotment is delivered to the receiver (payee) are beyond the control of the Defense Finance and Accounting Service (DFAS) and that DFAS is only responsible for ensuring proper delivery of any voluntary allotment for the period directed. I further understand that pursuant to conditions listed in the DoD 7000.14-R, Volume 7A, changes can be made by DFAS to an allottee’s name, address, or account number.

Under penalty of the Uniform Code of Military Justice, I certify that this allotment is NOT for the purchase, lease, or rental of personal property or payment toward personal property.

Signature of Allotter*

Date*

I authorize the National Guard Association of Mississippi to process a debit against my bank account in payment of my life insurance. Until this authorization is revoked in writing and received by my bank at least l0 working days prior to the scheduled debiting of my account, my bank is authorized to process these debits against my account. In addition, I agree to also notify the National Guard Association of Mississippi in writing if I withdraw this authority.

Life Insurance Enrollment Form (2024 Update, Nov 24)

Guard Member Information

Spouse Information

Type of Coverage

Basic SSLI Coverage

Enhanced SSLI Coverage

Beneficiary(ies)

Statement of Health

In the last 10 years, has any Applicant under this application for coverage:

Been diagnosed or treated by a physician for any of the following:

Has the spouse been diagnosed or treated by a physician for any of the following:

In the past 5 years, has any Applicant:

Conditions Relating to this Enrollment Form

Authorization to Start, Stop, or Change an Allotment

Privacy Act Statement

Statement of Understanding