Page 16 - Sample Life STD LTD Enrollment kit

Short-term Disability Insurance Plan
Summary of Benefits

Prepared for: [Sample Company Employees]
Enrollment Deadline: [Month XX, 2017]

Group rates for [Sample employees] make short-term
disability insurance more affordable than ever. This coverage
provides a weekly cash benefit if you are not able to work
due to injury, illness, surgery, or recovery from childbirth.
Additional plan benefits are outlined on the following pages.
[To take advantage of this coverage, simply complete and
return your Enrollment Form by Month XX, 2017. Your
premium comes out of your paycheck, so no money is
due now.]

Cash Benefit

Short-term Disability

[00% of your weekly salary (up to a
Weekly benefit amount
maximum benefit of $000 per week]
Sickness elimination period [00 days]

Accident elimination period [00 days]
[First day hospitalization] [0 day]
Maximum coverage period [00 weeks]

Weekly Benefit Amount
• [Your weekly benefit is tax-free, since your premium is paid with after-tax dollars (through payroll
deduction).]

Sickness Elimination Period
• You must be out of work for [00 days] due to an illness before you can collect disability benefits. You
can begin collecting benefits on [day 0].

Accident Elimination Period
• You must be out of work for [00 days] due to an accidental injury before you can collect disability
benefits. You can begin collecting benefits on [day 0].

[First Day Hospitalization]
• [The elimination period is reduced to if you are hospitalized due to an illness or accidental injury. You
can begin collecting benefits on the first day of hospitalization.]

[Form Filing Number] Short-term Disability Insurance Plan Summary of Benefits