Sample Company, Inc. Employee Benefit Website

Employee Benefit Program

Voluntary Life Insurance

Employee Coverage

Employees can elect coverage in $10,000 increments, up to $250,000.
$90,000 of coverage is available on a guaranteed acceptance basis.
Employees age 60 - 69 receive $10,000 of coverage on a guaranteed acceptance basis.
Employees 70 and over are not eligible for coverage on a guaranteed acceptance basis.

Employees must be actively at work on the day coverage takes effect and have also been at work 15 out of the last 20 working days immediately preceding that date. New employees have 31 days to enroll from the day they are first eligible in order to take advantage of the guaranteed acceptance offer.

Spouse Coverage

$25,000 of coverage is available on a guaranteed acceptance basis.
Spouses age 60 and over are not eligible for coverage on a guaranteed acceptance basis.

Spouses must not be in a period of limited activity on the date coverage takes effect. Newly eligible spouses have 31 days to enroll in the program to take advantage of the guaranteed acceptance offer.

Dependent Children Coverage

$8,000 of coverage is available on a guaranteed acceptance basis.

Children must be at least 14 days old and not be in a period of limited activity on the date coverage takes effect. Newborn children are automatically covered when they reach 14 days of age at no additional cost if the dependent children benefit has been elected.

Employee & Spouse Monthly Rates

per $1,000 of coverage

Age

Rate

<30

$0.12

30-34

$0.13

35-39

$0.15

40-44

$0.22

45-49

$0.34

50-54

$0.49

55-59

$0.72

60-64

$1.19

65-69

$2.01

70-74

$2.96

75-99

$6.09

These rates are:

Same for male & female
Same for smokers & non-smokers
Shown as a monthly rate per $1,000 of Life Insurance Coverage
Adjusted once each year on January 1

Dependent Children coverage is $2.00 per month, regardless of the number of children.

Sample Calculation: Employee & Spouse both age 40-44

Amount Rate Premium

Employee $100,000 100 x .22 = $22.00

Spouse $50,000 50 x .22 = $11.00

Total = $33.00

per pay $15.23

Voluntary Life Insurance

Please click on the Enrollment Form link to view and print a Voluntary Life Insurance Enrollment Form. You will need Adobe Acrobat Reader to view the form. If you do not have this software, you can download it for free from Adobe by clicking on the PDF icon.

Voluntary Life Insurance

Enrollment Form

Evidence of Insurability (Form required if coverage was waived when first eligible)

In order to provide insurance coverage on a fair and equitable basis, information must be collected about you and others for whom coverage may be provided. This information includes age, occupation, physical condition, health history, general reputation, mode of living and other personal characteristics.

Please click on the Evidence of Insurability link to view and print a form that will need to be submitted with your enrollment form.

Evidence of Insurability

E of I Form

Questions? Comments?

E-mail EBSC by clicking

Employee Benefit Service Center