Election Form Backup First Name Last Name Email Phone Beneficiary Accident Plan Individual $26.80 Individual + Children $36.80 Individual + Spouse $36.80 Family $48.40 Hospital Plan Individual $26.80 Individual + Children $36.80 Individual + Spouse $36.80 Family $48.40 Critical Illness Individual $26.80 Individual + Spouse $36.80 Family $48.40
