Apply Online

First, please provide your information:

If you are married, please provide your spouse’s information:

Please select the type of coverage you desire:

Complete Enhanced section if beneficiary(ies) differ from the Basic. Spouse’s beneficiary is the Guard Member unless otherwise designated. If you want to make more than one person your beneficiary please add the additional beneficiary or beneficiaries by hitting the + sign to the right of the entry boxes. Please note the percentage (%) must ultimately equal 100%. For example, if you only list one person then that person gets 100%. However, you could split between two people 50/50 or 60/40 or 75/25 or between three people 50/25/25 or whatever. The percentages for multiple beneficiaries must equal 100% when everyone’s percentage is added together.

Answer each question and initial below to acknowledge you’ve read and, TO THE BEST OF YOUR KNOWLEDGE AND BELIEF, understood each question.

Give full details to any “yes” answers in the space below the questionnaire. Please include name, DOB and question number the answer references.

Form Eligibility: I am eligible to apply for this group life insurance as a Guard Member as defined in the Master Group Policy. Agreement: I, as Guard Member, have the appropriate knowledge to answer the health questions for my spouse and children. I represent that all statements and answers in this enrollment form are complete, true and correctly recorded TO THE BEST OF MY KNOWLEDGE AND BELIEF. I agree that: 1) upon approval of this enrollment form by 5Star Life Insurance Company, it and the Certificate of insurance coverage issued to me will describe the benefits and terms of coverage provided under the Master Group policy; and 2) if within 180 days of receipt of all required documentation this enrollment form is not approved, it will become void and any contributions paid will be refunded; I will be so notified. Authorization: I hereby authorize any licensed physician; medical practitioner; hospital; clinic; insurance company; employer; Medical Information Bureau (MIB, Inc.); or Motor Vehicle Administration that may have records of my health condition to give 5Star Life Insurance Company, its authorized representative, and its reinsurers any such information. I authorize 5Star Life Insurance Company, or its reinsurers, to make a brief report of health information to MIB, Inc. I understand that this information will be used to determine my eligibility for coverage and that I may revoke this authorization and enrollment form at any time by providing written notice. A photocopy of this authorization shall be as valid as the original. This authorization shall be valid for 24 months from the date below. I (or my authorized representative) am entitled to receive a copy of this authorization. Signature must be personal.

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.

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.