Page 21 - Demo

Guardian Group Plan Number: 00051143 Please print employee name: DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER www.guardianlife.com3Vision Coverage: You must be enrolled to cover your dependents/family members. Check only one box.Your Monthly Premium Employee/Member Only Employee/Member & Spouse Employee/Member & Dependent/Child(ren) Employee/Member, Spouse & Dependent/Child(ren)Full Featureq $3.96q $7.50q $7.64q $12.10q I do not want this Vision coverage because (Check as applicable): q I am covered under another Vision planq My spouse is covered under another Vision planq My dependents/family members are covered under another Vision plan Short-T erm Disability (ST D) C overage: The amount of STD coverage you select may be either a specific dollar amount or an amount that is a multiple of your salary and may be subject to certain reductions. Weekly BenefitR 60% of salary to a maximum of $1,000 Long-Term Disability (LTD) Coverage: The amount of LTD coverage you select may be either a specific dollar amount or an amount that is a multiple of your salary and may be subject to certain reductions. Monthly BenefitR 60% of salary to a maximum of $7,000 Accident Coverage You must be enrolled to cover your family members.Your Monthly premium Employee/Member Only Employee/Member & Spouse Employee/Member & Dependent/Child(ren) Employee/Member, Spouse & Dependent/Child(ren)q $8.56q $13.99q $14.50q $19.93q I do not want this coverage.21