Page 33 - Prestige Brochures & Enrollment Packet

Supplemental Insurances

Name: _____________________________________

1. Please indicate whether or not you would like to enroll in each benefit by checking either
“Enroll” or “Waive.”

2. Please indicate who you would like to cover by checking the box next to the coverage you
want.

Group Accident Coverage Enroll Waive

Who would you like to cover for the Accident Coverage?
Choose Plan 1 or Plan 2

Choose Plan:
Choose Coverage: Plan 1 Plan 2
Employee Only $4.73 /Week $6.27 /Week
Employee & Spouse $8.97 /Week $12.05 /Week
Employee & Child(ren) $9.66 /Week $13.08 /Week
Employee, Spouse & Child(ren) $11.66 /Week $15.94 /Week

Critical Illness/Cancer Plan Enroll Waive

Please circle the coverage you want based on your age, smoking status, and who you would like to cover.
Non-Smoker WEEKLY Rates Smoker WEEKLY Rates
Ages EE + EE + EE + EE +
EE SP CH F EE SP CH F
18-29 $2.33 $4.19 $2.33 $4.19 $2.90 $5.05 $2.90 $5.05
30-39 $3.26 $5.58 $3.26 $5.58 $4.44 $7.36 $4.44 $7.36
40-49 $5.04 $8.25 $5.04 $8.25 $8.05 $12.76 $8.05 $12.76
50-59 $8.04 $12.75 $8.04 $12.75 $12.79 $19.88 $12.79 $19.88
60-63 $12.34 $19.21 $12.34 $19.21 $20.34 $31.20 $20.34 $31.20
64+ $15.80 24.38 $15.80 $24.38 $26.51 $40.45 $26.51 $40.45

Coverage Key:

EE Employee Only Coverage
EE + SP Employee & Spouse Coverage
EE + CH Employee & Child(ren) Coverage
F Employee, Spouse & Child(ren)

Dependent children can remain on your Accident and/or Critical Illness/Cancer Plan
until their 26 birthday. 4
th