Voluntary Life Insurance Coverage paid by you

Transcription

1 Voluntary Life Insurance Coverage paid by you Employee All active, full-time U.S. Employees regularly working a minimum of 30 hours per week. Benefit Amount Units of $10,000 to $500,000, not to exceed 5 times annual compensation Guaranteed Coverage Amount $150,000 Benefit Reduction Schedule Benefits will reduce to age 65, age 70, age 75, age 80 Your Spouse Provided that you apply for and are approved for coverage for yourself. Benefit Amount Units of $5,000 to the lesser of $300,000 or 100% of employee s voluntary life insurance amount Guaranteed Coverage Amount $40,000 Benefit Reduction Schedule Benefits will reduce to age 65, age 70, age 75, age 80 Your Unmarried, Dependent Children birth to age 26, as long as you apply for and are approved for coverage for yourself. Benefit Amount birth to 6 months $500, 6 months to 26 years - units of $2,000 to the lesser of $10,000 or 100% of the employee s voluntary life insurance amount All Guaranteed Coverage Ongoing Enrollment Events Annual enrollment event is only available for current participants. You may elect to increase your voluntary life coverage up to the guaranteed issue at each annual enrollment. Guaranteed Coverage for Voluntary Term Life Insurance Coverage Guaranteed Coverage Amount is the amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed Coverage is only available during Initial Enrollment and other times as approved. If you apply for coverage that is above the Guaranteed Coverage Amount, or if you are applying for coverage after 31 days after you become eligible, you must fill out a Medical Evidence of Insurability form. All dependent child benefits are guaranteed issue.

2 Other Coverage Features Accelerated Death Benefit Terminal Illness If you or your spouse is diagnosed by two unaffiliated physicians as terminally ill with a life expectancy of 24 months or less, the benefit for terminal illness provides for up to 80% of the Term Life Insurance coverage amount inforce to a maximum of $400,000 of voluntary life benefits to be paid to the insured. This benefit is payable only once in the insured's lifetime, and will reduce the life insurance death benefit. Continuation for Disability for Employees Age 60 or over If your active service ends due to disability, at age 60 or over, your coverage will continue while you are disabled. Benefits will remain in force until the earliest of: the date you are no longer disabled, the date the policy terminates, the date you are Disabled for 12 consecutive months, or the day after the last period for which premiums are paid. You are considered disabled if, because of injury or sickness, you are unable to perform all the material duties of your Regular Occupation, or you are receiving disability benefits under your Employer s plan. Portability This plan allows you to continue all of your voluntary coverage if you leave your employer. Premiums may change at this time. Just pay your premiums directly to the insurance company. Coverage may be continued for you and your spouse until age 70. Coverage may also be continued for your children. Exclusions Voluntary life insurance will not be paid if loss of life is the result of suicide that occurs within the first two years of coverage. Extended Death Benefit The extended death benefit ensures that if you become disabled prior to age 60, and die before it is determined if you qualify for Waiver of Premium, we will pay the life insurance benefit if you remain disabled during that period. If you qualify for this benefit and have insured your spouse or children, their coverage is also extended. No additional premium payment is required for the extended coverage. Waiver of Premium If you are totally disabled prior to age 60 and can't work for at least 9 months, you won't need to pay premiums for your coverage while you are disabled, provided the insurance company approves you for this benefit. You are considered totally disabled when you are completely unable to engage in any occupation for wage or profit because of injury or sickness. This benefit will remain in force until age 65, subject to proof of continuing disability each year. If you qualify and have insured your spouse or children, their premium is also waived.

3 Voluntary Accidental Death & Dismemberment Insurance Coverage paid by you Employee All active, full-time U.S. Employees regularly working a minimum of 30 hours per week. Benefit Amount Units of $10,000 to $500,000, not to exceed 5 times annual compensation Benefit Reduction Schedule Benefits will reduce to age 65, age 70, age 75, age 80 Your Spouse Provided that you apply for and are approved for coverage for yourself. Benefit Amount Units of $5,000 to the lesser of $300,000 or 100% of employee s voluntary ad&d insurance amount Benefit Reduction Schedule Benefits will reduce to age 65, age 70, age 75, age 80 Your Unmarried, Dependent Children Birth to age 26, as long as you apply for and are approved for coverage for yourself. Benefit Amount Units of $2,000 to the lesser of $10,000 or 100% of the employee s voluntary ad&d insurance amount You may need to request changes to your existing coverage if, in the future, you no longer have dependents who qualify for coverage. We will refund premium if you do not notify us of this and it is determined at the time of a claim that premium has been overpaid. A Valuable Combination of Benefits To help survivors of severe accidents adjust to new living circumstances, we will pay benefits according to the chart below. If, within 365 days of a covered accident, bodily injuries result in: We will pay this % of the benefit amount: Loss of life 100% Total paralysis of upper and lower limbs, or Loss of any combination of two: hands, feet or eyesight, or 100% Loss of speech and hearing in both ears Total paralysis of both lower or upper limbs 75% Total paralysis of upper and lower limbs on one side of the body, or Loss of hand, foot or sight in one eye, or 50% Loss of speech or loss of hearing in both ears, or Severance and Reattachment of one hand or foot Total paralysis of one upper or lower limb, or Loss of all four fingers of the same hand, or 25% Loss of thumb and index finger of the same hand Loss of all toes of the same foot 20% Only one benefit (the largest) will be paid for losses from the same accident.

4 Additional Benefits of Voluntary Accidental Death & Dismemberment Insurance For Child Care Expenses If you die as a result of a covered accident, we will pay a benefit for a surviving child under 13 who is enrolled in a licensed child care center at the time of the accident or within 90 days afterwards. This benefit is 5% of your benefit amount per year, but not more than $5,000 per year for 4 years or until the child turns 13, whichever occurs first, for each covered child.. For Wearing a Seatbelt & Protection by an Airbag Additional 10% benefit but not more than $25,000 if the covered person dies in an automobile accident while wearing a seatbelt or approved child restraint. We will increase the benefit by an additional 5% but not more than $10,000 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). For Comas 1% of full benefit amount, for up to 11 months, if you, your spouse, or your children are in a coma for 30 days or more as a result of a covered accident. If the covered person is still in a coma after 11 months, or dies, the full benefit amount will be paid. For Exposure & Disappearance Benefits are payable if you or an insured family member suffer a covered loss due to unavoidable exposure to the elements as a result of a covered accident. If your or an insured family member's body is not found within one year of the disappearance, wrecking or sinking of the conveyance in which you or an insured family member were riding, on a trip otherwise covered, it will be presumed that you sustained loss of life as a result of a covered accident. For Furthering Education If you die in a covered accident, we will pay an extra benefit for each insured child under age 26 who enrolls in a school of higher learning within one year of your death. We will increase your benefit by 5% to a maximum of $5,000 for each qualifying child, each year for 4 consecutive years as long as your child continues his/her education. If there is no qualifying child, we will pay an additional $1,000 to your beneficiary. For Spouse Training If you die as a result of a covered accident, we will pay a benefit for a surviving spouse who receives education or training for employement withing 3 years of your death. The benefit is 5% of your benefit amount up to $5,000. For Felonious Assault/Violent Crime If loss occurs while on business for/or on the premises of their employer we will pay a benefit for additional 10% of principal sum to $25,000. What is Not Covered Self-inflicted injuries or suicide while sane or insane; commission or attempt to commit a felony or assault; any act of war, declared or undeclared; any active participation in a riot or insurrection; bungee jumping; parachuting; skydiving; parasailing; hang-gliding; sickness, disease, physical or mental impairment, or surgical or medical treatment thereof, or bacterial or viral infection; voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed; while operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it; while the covered person is engaged in the activities of active duty service in military, navy or air force of any country or international organization (does not include Reserve or National Guard training, unless it extends beyond 31 days); traveling in aircraft that is owned, leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates; air travel, except as a passenger on a regularly scheduled commercial airline or an aircraft used by the Air Mobility Command or its foreign equivalent; being flown by the covered person or in which the covered person is a member of the crew. When Your Coverage Begins and Ends Coverage becomes effective on the later of the program s effective date, the date you become eligible, the date we receive your completed

5 enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. Coverage will continue while you and your dependents remain eligible, the group policy is in force, and required premiums are paid. Conversion If, before you reach age 70, this group coverage is reduced or ends for any reason except nonpayment of premium or age, you can convert to an individual policy. No medical certification is needed. To continue coverage, you must apply for the conversion policy and pay the first premium in effect for your age and occupation within 31 days after your group coverage ends. Family members may convert their coverage as long as they have not reached the maximum age limitation. Converted policies are subject to certain benefits and limits as outlined in your certificate, should you become insured under the plan.

6 Use the grids below to find the cost of insurance for yourself, your spouse, and your children. Voluntary Term Life - Monthly Cost Per Coverage Amount Employee Voluntary Life Insurance ($10,000 units up to $500,000, not to exceed five times annual salary) Spouse Voluntary Life Insurance ($5,000 units up to $300,000, not to exceed 100% of employee's benefit) Amount Under Amount Premium 10,000 $0.53 $0.50 $0.58 $0.78 $1.14 $1.77 $2.81 $4.40 $6.17 $6.50 $8.92 $12.26 $ ,000 $ ,000 $1.06 $1.00 $1.16 $1.56 $2.28 $3.54 $5.62 $8.80 $12.34 $13.00 $17.85 $24.51 $ ,000 $ ,000 $1.59 $1.50 $1.74 $2.34 $3.42 $5.31 $8.43 $13.20 $18.51 $19.50 $26.77 $36.77 $ ,000 $ ,000 $2.12 $2.00 $2.32 $3.12 $4.56 $7.08 $11.24 $17.60 $24.68 $26.00 $35.69 $49.02 $ ,000 $ ,000 $2.65 $2.50 $2.90 $3.90 $5.70 $8.85 $14.05 $22.00 $30.85 $32.50 $44.62 $61.28 $ ,000 $ ,000 $3.18 $3.00 $3.48 $4.68 $6.84 $10.62 $16.86 $26.40 $37.02 $39.00 $53.54 $73.53 $ ,000 $ ,000 $3.71 $3.50 $4.06 $5.46 $7.98 $12.39 $19.67 $30.80 $43.19 $45.50 $62.46 $85.79 $ ,000 $ ,000 $4.24 $4.00 $4.64 $6.24 $9.12 $14.16 $22.48 $35.20 $49.36 $52.00 $71.39 $98.04 $ ,000 $ ,000 $4.77 $4.50 $5.22 $7.02 $10.26 $15.93 $25.29 $39.60 $55.53 $58.50 $80.31 $ $ ,000 $ ,000 $5.30 $5.00 $5.80 $7.80 $11.40 $17.70 $28.10 $44.00 $61.70 $65.00 $89.24 $ $ ,000 $ ,000 $5.83 $5.50 $6.38 $8.58 $12.54 $19.47 $30.91 $48.40 $67.87 $71.50 $98.16 $ $ ,000 $ ,000 $6.36 $6.00 $6.96 $9.36 $13.68 $21.24 $33.72 $52.80 $74.04 $78.00 $ $ $ ,000 $ ,000 $6.89 $6.50 $7.54 $10.14 $14.82 $23.01 $36.53 $57.20 $80.21 $84.50 $ $ $ ,000 $ ,000 $7.42 $7.00 $8.12 $10.92 $15.96 $24.78 $39.34 $61.60 $86.38 $91.00 $ $ $ ,000 $ ,000 $7.95 $7.50 $8.70 $11.70 $17.10 $26.55 $42.15 $66.00 $92.55 $97.50 $ $ $ ,000 $ ,000 $8.48 $8.00 $9.28 $12.48 $18.24 $28.32 $44.96 $70.40 $98.72 $ $ $ $ ,000 $ ,000 $9.01 $8.50 $9.86 $13.26 $19.38 $30.09 $47.77 $74.80 $ $ $ $ $ ,000 $ ,000 $9.54 $9.00 $10.44 $14.04 $20.52 $31.86 $50.58 $79.20 $ $ $ $ $ ,000 $ ,000 $10.07 $9.50 $11.02 $14.82 $21.66 $33.63 $53.39 $83.60 $ $ $ $ $ ,000 $ ,000 $10.60 $10.00 $11.60 $15.60 $22.80 $35.40 $56.20 $88.00 $ $ $ $ $ ,000 $ ,000 $11.13 $10.50 $12.18 $16.38 $23.94 $37.17 $59.01 $92.40 $ $ $ $ $ ,000 $ ,000 $11.66 $11.00 $12.76 $17.16 $25.08 $38.94 $61.82 $96.80 $ $ $ $ $ ,000 $ ,000 $12.19 $11.50 $13.34 $17.94 $26.22 $40.71 $64.63 $ $ $ $ $ $ ,000 $ ,000 $12.72 $12.00 $13.92 $18.72 $27.36 $42.48 $67.44 $ $ $ $ $ $ ,000 $ ,000 $13.25 $12.50 $14.50 $19.50 $28.50 $44.25 $70.25 $ $ $ $ $ $ ,000 $ ,000 $13.78 $13.00 $15.08 $20.28 $29.64 $46.02 $73.06 $ $ $ $ $ $ ,000 $ ,000 $14.31 $13.50 $15.66 $21.06 $30.78 $47.79 $75.87 $ $ $ $ $ $ ,000 $ ,000 $14.84 $14.00 $16.24 $21.84 $31.92 $49.56 $78.68 $ $ $ $ $ $ ,000 $ ,000 $15.37 $14.50 $16.82 $22.62 $33.06 $51.33 $81.49 $ $ $ $ $ $ ,000 $ ,000 $15.90 $15.00 $17.40 $23.40 $34.20 $53.10 $84.30 $ $ $ $ $ $ ,000 $ ,000 $16.43 $15.50 $17.98 $24.18 $35.34 $54.87 $87.11 $ $ $ $ $ $ ,000 $ ,000 $16.96 $16.00 $18.56 $24.96 $36.48 $56.64 $89.92 $ $ $ $ $ $ ,000 $ ,000 $17.49 $16.50 $19.14 $25.74 $37.62 $58.41 $92.73 $ $ $ $ $ $ ,000 $ ,000 $18.02 $17.00 $19.72 $26.52 $38.76 $60.18 $95.54 $ $ $ $ $ $ ,000 $ ,000 $18.55 $17.50 $20.30 $27.30 $39.90 $61.95 $98.35 $ $ $ $ $ $ ,000 $ ,000 $19.08 $18.00 $20.88 $28.08 $41.04 $63.72 $ $ $ $ $ $ $ ,000 $ ,000 $19.61 $18.50 $21.46 $28.86 $42.18 $65.49 $ $ $ $ $ $ $ ,000 $ ,000 $20.14 $19.00 $22.04 $29.64 $43.32 $67.26 $ $ $ $ $ $ $ ,000 $ ,000 $20.67 $19.50 $22.62 $30.42 $44.46 $69.03 $ $ $ $ $ $ $ ,000 $ ,000 $21.20 $20.00 $23.20 $31.20 $45.60 $70.80 $ $ $ $ $ $ $ ,000 $ ,000 $21.73 $20.50 $23.78 $31.98 $46.74 $72.57 $ $ $ $ $ $ $ ,000 $ ,000 $22.26 $21.00 $24.36 $32.76 $47.88 $74.34 $ $ $ $ $ $ $ ,000 $ ,000 $22.79 $21.50 $24.94 $33.54 $49.02 $76.11 $ $ $ $ $ $ $ ,000 $ ,000 $23.32 $22.00 $25.52 $34.32 $50.16 $77.88 $ $ $ $ $ $ $ ,000 $ ,000 $23.85 $22.50 $26.10 $35.10 $51.30 $79.65 $ $ $ $ $ $ $ ,000 $ ,000 $24.38 $23.00 $26.68 $35.88 $52.44 $81.42 $ $ $ $ $ $ $ ,000 $ ,000 $24.91 $23.50 $27.26 $36.66 $53.58 $83.19 $ $ $ $ $ $ $ ,000 $ ,000 $25.44 $24.00 $27.84 $37.44 $54.72 $84.96 $ $ $ $ $ $ $ ,000 $ ,000 $25.97 $24.50 $28.42 $38.22 $55.86 $86.73 $ $ $ $ $ $ $ ,000 $ ,000 $26.50 $25.00 $29.00 $39.00 $57.00 $88.50 $ $ $ $ $ $ $ ,000 $15.00 Highlighted cost reflects premium based on reduced benefit amount. Spouse coverage ends at age 70. Voluntary AD&D Employee/Spouse Coverage options same as life insurance Voluntary Term Life Children Voluntary AD&D Children $2,000 units up to $10,000 $2,000 units up to $10,000 Amount Premium Amount Premium 2,000 $0.22 2,000 $0.26 4,000 $0.45 4,000 $0.52 6,000 $0.67 6,000 $0.78 8,000 $0.90 8,000 $ ,000 $ ,000 $1.30

7 INSURANCE APPLICATION * BENEFICIARY

8 Applicant s Name Social Security #

9 Applicant s Name Social Security #