/depts/,/depts/uwhealth/,/depts/uwhealth/benefits/,/depts/uwhealth/benefits/open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/lifelock-identity-theft-protection/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/lifelock-identity-theft-protection/resources/,

/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/lifelock-identity-theft-protection/resources/Election-Form-09.18.2017.pdf

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UWHC,UWMF,

Departments & Programs,UW Health,Benefits,UW Health Open Enrollment,UWMF Open Enrollment,LifeLock Identity Theft Protection,Resources

Open Enrollment LifeLock Election Form

Open Enrollment LifeLock Election Form - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWMF Open Enrollment, LifeLock Identity Theft Protection, Resources


State Zip
Legal Name
Social Security Number
Address
City
Phone Number (
E-mail
Spouse Name
Dependent Name
Dependent Name
Dependent Name
Birthdate / /- -
SSNSSN - Gender M F DOB / /
- SSN - Gender M F DOB / /
SSNSSN - Gender M F DOB / /
SSN - - Gender M F DOB / /
) -
By signing this form, you represent that you have the authority to enroll those dependents indicated above in LifeLock services and you further agree to
LifeLock’s Terms and Conditions which can be found at www.lifelock.com/terms on behalf of yourself and any other members of your family you are
enrolling. Please see your HR department for the cancellation policy or a copy of LifeLocks Terms and Conditions.
Employee Signature: Date Signed:
Important Message: Without complete information, your enrollment in LifeLock service will be delayed until complete information is received.
Employee ID
MONTHLY PAYROLL DEDUCTIONS LifeLock
Benefit Elite
LifeLock
Ultimate Plus™
$8.49 $25.49
$16.98 $50.98
$14.86 $36.11
Employee Only [18 and over]
Employee + Spouse/Domestic Partner
Employee + Children
**
Employee + Family
**
$23.36 $61.61
BIWEEKLY PAYROLL DEDUCTIONS LifeLock
Benefit Elite
LifeLock
Ultimate Plus™
$4.25 $12.75
$8.49 $25.49
$7.43 $18.06
Employee Only [18 and over]
Employee + Spouse/Domestic Partner
Employee + Children
**
Employee + Family
**
$11.68 $30.81
WAIVER
LifeLock Election Form
I want to waive identity theft protection from LifeLock.
Must agree to terms and conditions at LifeLock.com/terms.
** Children under the age of 18 will receive a product designed specifically for minors, LifeLock Junior service.
Enrollment in LifeLock service is limited to employees and their eligible dependents.
Open Enrollment 2018
Employee ID: _______
Return completed forms to Human Resources by October 27 deadline:
Fax: 608-263-5778 | Ask HR form in ServiceNow