The following table shows forms that may be used when changes in life insurance coverage will be made.

Form Title Use

LI$1$ Life Insurance Election New and continuing employees use this form to sign up for, modify, or cancel their life insurance coverage.

LI$2$ Life Insurance Continuation Employees who are retiring fill out this form to choose their options for continuing their life insurance coverage.

LI$3$ Life Insurance Conversion Agencies use this form to inform employees about their rights to convert to an individual policy when employees separate or resign.

LI$4$ Life Insurance Request Employees who are eligible for insurance but waived coverage may use this form to obtain life insurance by providing medical information.

LI$5$ Beneficiary Form Employees use this form to indicate who should receive the death benefits from their life insurance. This form is optional. If the standard order of beneficiaries is acceptable, the form does not need to be filed.

An employee is retiring and wishes to continue her life insurance coverage. What form will she need to complete?

LI$1$

LI$2$

LI$3$

LI$4$

LI$5$