Get placentia form 001.docx

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Underwritten by: Unum Life Insurance Company of America LTC Department 2211 Congress Street, Portland, Maine 04122 PLACENTIA - YORBA LINDA UNIFIED SCHOOL DISTRICT CLASS 001: CERTIFICATED EMPLOYEES WORKING A MINIMUM OF 20 HOURS /WEEK Benefit Election Form Long Term Care - Policy #079752-001 Date of Birth (MM/DD/YYYY) / / Date of Hire (MM/DD/YYYY) / / Work Telephone # ( ) Your Name: (Last Name, First, Middle...
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