Page 8 - Sample Life STD LTD Enrollment kit

Coverage for Your Spouse[/Domestic Partner]

You can secure term life and AD&D insurance for your spouse[/domestic partner] when you choose
coverage for yourself.

Term Life Insurance | Spouse[/Domestic Partner]

Guaranteed coverage amount [$00,000]
[50% of the employee coverage amount
Maximum coverage amount
($000,000 maximum)]
Minimum coverage amount [$0,000]

AD&D (Accidental Death & Dismemberment) | Spouse[/Domestic Partner]

Coverage amount [Equal to the life insurance coverage amount chosen]

Guaranteed Life Insurance Coverage Amount
• You can choose a coverage amount [up to $00,000] for your spouse[/domestic partner] without
providing evidence of insurability.
• [You can increase this amount by up to [$0,000] during the limited open enrollment period.]

Maximum Life Insurance Coverage Amount
• You can choose a coverage amount [up to 50% of your coverage amount ($000,000 maximum)] for
your spouse[/domestic partner] with evidence of insurability.
• [The maximum coverage amount for spouses[/domestic partners] [70 and older who are electing
coverage for the first time] is [$00,000].]
• Coverage amounts are reduced when [a spouse][/domestic partner] reaches [age 70].
• For complete plan details, please see your contract.

AD&D (Accidental Death & Dismemberment) Coverage Amount
• [When you choose term life insurance for your spouse[/domestic partner], that person receives the
same amount of AD&D insurance at no additional cost.]

[Employee] Life and
Age Range AD&D Group Rates for Your Spouse[/Domestic Partner]
Premium Rate
[< 25] [.000000] The estimated [monthly] premium for life and AD&D insurance is
[25 - 29] [.000000] determined by multiplying the desired amount of coverage [(in
[30 - 34] [.000000] increments of $0,000)] by the [spouse][/domestic partner]
[35 - 39] [.000000] age-range premium rate.
[40 - 44] [.000000]
[45 - 49] [.000000] $ X = $
[50 - 54] [.000000] coverage amount premium rate [monthly] premium
[55 - 59] [.000000]
[60 - 64] [.000000]
[65 -69] [.000000]
[70 -74] [.000000]
[75 - 99] [.000000]

LFE-ENRO-BRC001-XX Life and AD&D Insurance Summary of Benefits