________________________
(Employee)_______________________________________ is being notified pursuant to Internal Revenue Code Section 101(j) that (Employer) ___________________________:
1. Employer is applying for life insurance on employee's life
2. The maximum face amount for which employee could be insured at the time the policy is issued is $_________________ (the actual face amount may be less)
3. Employer will be a direct or indirect beneficiary of proceeds payable on death of employee.
Employee acknowledges receipt of the above notice and agrees that:
1. I consent to being insured by employer
2. I consent to the policy being continued after I terminate employment with employer
3. I understand that employer will be a direct or indirect beneficiary of any death proceeds payable.
_______________________________ ________________________
Employee Signature 
Date
Copyright 
2016, Pentera Group, Inc., 921 East 86th Street, Suite 100, Indianapolis, Indiana 46240. All rights reserved.
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