Universal Life Insurance Application for Payroll Deduction
Please complete Part I of the form completely. The left side of the form is
for the employee; the right side is for spouse/dependent coverage, if
applicable. Everyone must complete side one of the application, answering all
the questions and signing and dating for the proposed insured. If the proposed
insured is not a new hire, he/she must complete Part II - Medical Questions on
side two of the application as well, and answer all questions, including
question 13 a thru n, and sign and date the bottom of the form. Call
1-866-533-2357 for assistance. Mailing the application:
After completing and signing the application, please mail to:
NC Mutual Life Insurance Company
411 W. Chapel Hill Street
Durham, NC 27701
Attention: Bernard Obie, Group Sales Manager Upon receipt at NC Mutual, the
application will be reviewed for completeness and signed by the agent, copied,
and a copy mailed to the proposed insured.
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* Some Duke HR forms may require you to list your Duke Unique ID. If you do
not know or are unsure of your Duke Unique ID, you can look it up
here.
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