USC Benefits

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Forms | Life and Accident Insurance

Life and Accidental Death and Dismemberment Insurance

The following forms are available to be downloaded to your printer. Once completed, please return them to the Office of Benefits Administration. Please note that additional documentation is often required to accompany some forms. If you do not have Adobe Acrobat on your computer, you may down-load it from the ITS Web site.

Life Insurance Short Form Health Statement
If you wish to Increase your Supplemental Life Insurance or enroll your spouse in Dependent Life Insurance at the $50,000 level you are required to complete and submit the Short Form Health Statement directly to Prudential. If more medical information is required Prudential will send you a Long Form Statement of Evidence of Insurability which once completed must also be submitted directly to Prudential.

Voluntary Accidental Death and Dismemberment (AD&D)
This brochure describes our voluntary AD&D insurance

AXA Travel Assistance Program
This brochure describes the travel assistance program which is part of our AD&D insurance

Life and AD&D Beneficiary Form PDF fillable form
Use this form to designate a beneficiary(s) for your life insurance and/or AD&D plans

Life Insurance—State Specific Requirements Notice

Employee Benefit Programs · Health Benefits at USC · Retirement Programs
Financial Security · Educational Benefits · Work/Life Balance
Forms · Coming Events · Directory and Links · Resources
Print Your Own Booklets · Contact Us · Orientation · Site Map · eTrac
USC Benefits Home

Benefits programs are subject to change at anytime by the university, at its discretion, without prior notice or liability, to the extent permitted under applicable law. The benefits described in this Web site are available to staff and faculty employed by the University of Southern California subject to certain eligibility requirements. In the event of a discrepancy between the benefits and limitations described in this Web site and a plan document or a collective bargaining agreement, the terms of the plan document or collective bargaining agreement will govern. Employees of other entities that have entered into agreements with the University of Southern California to provide payrolling service are subject to the policies and procedures adopted by their employer.