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Comprehensive Behavioral Health
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BASIC LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT
INSURANCE
This benefit is paid by Comprehensive Behavioral Health for all employees who participate in the medical plan. It is administered
through Mutual of Omaha. In the event of your death, your beneficiary will receive $25,000. The Accidental Death and
Dismemberment (AD&D) benefit is equal to your basic group life insurance benefit. This benefit also includes dependent life
insurance in the amount of $2,000 on your spouse and children age 6 months to 19; 25 if they are a full time student at
no cost
to
you.
VOLUNTARY LIFE AND ACCIDENTAL DEATH &
DISMEMBERMENT INSURANCE
Your Voluntary Life/AD&D is administered through Mutual of Omaha. An equal amount of AD&D coverage is provided when you
elect voluntary life. You must purchase voluntary life on yourself in order to purchase
coverage for your spouse and dependent children.
Employees can purchase up five times their annual salary in $10,000 up to $250,000.
The Guarantee Issue amount for employees is the $100,000 not to exceed five times
salary.
Spousal coverage is available in $5,000 increments not to exceed 50% of the employee
amount up to a maximum of $50,000. Coverage is available for children 14 days up to
19 or 25 if a full time student in increments of $2,000 not to exceed 50% of the employee
amount up to $10,000.
Please note:
If you and/or your dependents chose not to enroll in the Voluntary Life/
AD&D plan during your initial enrollment period you and/or your dependents will be
required to complete an Evidence of Insurability form and be approved by Mutual of
Omaha before you are able to obtain coverage in the future. Newly hired employees who
are currently in their initial eligibility period can obtain up to $100,000 without completing
an Evidence of
Insurability form for
themselves.
This is meant to be
a summary of
benefits only. Please review to your certificate of coverage
for information pertaining to the policies benefits and
limitations.
VOLUNTARY LIFE/AD&D
EMPLOYEE CONTRIBUTION
(Rates are per month)
Age Band
Employee/Spouse
Rate per $1,000*
Under 35
$.08
35-39
$.10
40-44
$.16
45-49
$.27
50-54
$.45
55-59
$.70
60-64
$1.09
65-69
$1.96
70-74
$3.50
75-79
$5.77
80+
$11.70
AD&D
$.02
Child Life/
AD&D
$0.15/$0.04
*Spouse rates are based on the
employees age
$50,000
Elected
Coverage
÷ 1,000
=
50
Units
X
$0.27
Rate
* See
Note
=
$13.50
Monthly
Cost
*The premium calculation is based upon the life rate for an
employee age 45.
HOW TO CALCULATE VOLUNTARY PREMIUM