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In addition to the Basic Life and AD&D benefit that XYZ Company provides at no cost, employees can
purchase Supplemental Life and AD&D insurance for themselves as well as spouses and dependent children.
In order to elect coverage for a spouse or child, employees must enroll in the life coverage themselves.
Employees can also elect the Buy-Up Short-Term Disability option and can increase their weekly disability
benefit. The Buy-Up option is available to employees with normal salaries in excess of $500 per week.
The Supplemental Life and Buy-Up Short-Term Disability plans are guaranteed at initial eligibility only. If you
previously waived the coverage and would like to elect during a subsequent open enrollment, you must
complete an Evidence of Insurability form and be approved by the insurance company.
LIFE AND AD&D
Employee
Spouse
Dependent Child(ren)
Benefit Reduction
Supplemental Life Rates
Age
< 30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75 or over
Dependent Child(ren) Life Rates
Supplemental AD&D Rates
Weekly Cost
Amount of Benefit
When Benefits Begin
Benefit Duration
Weekly Cost
$2.41
$4.19
$0.16 per $1,000
$0.03 per $1,000 (for Employee/Spouse) $0.04 per $1,000 (for Dependent Children)
Buy Up Short Term Disability
To calculate weekly cost:
1) Multiply weekly earnings by 60%. 2) Divide this amount by 10. 3) Multiply by the weekly rate of .0415.
Example: $800 x 60% = $480
÷
10 = $48 x .0415 = $1.99 per week
60% of weekly earnings to a $1,000 maximum
8th Day of Accident / 8th Day of Sickness
12 weeks
To calculate weekly cost:
1) Choose coverage amount per plan details above. 2) Divide this amount by 1000.
3) Multiply by the appropriate age banded rate above. 4) Multiply by 0.23.
Example: $20,000
÷
1000 = $20 x .15 (for 42 year old employee) = $3.00 per month x .23 = $0.69 per week
Supplemental Life and AD&D Coverage
Increments of $10,000 up to lesser of 5 Times Annual Earnings or $300,000
Guaranteed Issue: $80,000 (only guaranteed at initial enrollment)
Increments of $5,000 up to lesser of $50,000 or 100% of Employee benefit
Guaranteed Issue: $25,000 (only guaranteed at initial enrollment)
Increments of $1,000 up to $10,000 : 14 days to 21 years (or 25 years if full time student)
Rates are determined by employee
age as of September 1, 2017.
The Life and AD&D benefit will reduce to 65% of the original benefit amount when the enrollee attains age
70, 45% of the original benefit amount when the enrollee attains age 75, and 30% of the original benefit
amount when the enrollee attains age 80.
$0.06
Monthly Employee Rate (per $1,000)
$0.07
$0.10
$0.15
$0.24
$0.41
$0.66
$0.88
$1.38