Life & AD&D enrollment instructions (UNUM Provident)

You pay 100% of the cost. You are eligible for coverage of one (1) to six (6) times your salary to a maximum of $600,000; spousal coverage of 50% of employee's coverage in increments of $25,000, $50,000, $75,000 or $100,000; and child coverage of 0-6 months $5,000 and above 6 months $10,000. Guaranteed issue is $150,000 or 3 times, whichever is less for employee, and $25,000 for spouse. Rates are based on age and benefit selection.

• For more information, click here, handbook pages 28-29).

To enroll, verify all information is correct and complete. If not, make corrections and fill in missing information. Instructions for the following sections include:

Supplemental term employee life and AD&D

• Select one option A-F.
• Indicate the "Amount of Coverage." Coverage is rounded to the next $1,000 of your base salary.
• Indicate the "Monthly Cost" based on the insurance premium rates sheet.

Supplemental term spouse life and AD&D

• Select one option A-E.
• If enrolling in spousal coverage, indicate the "Monthly Cost." The employee's age is used to calculate the rate.

Child and AD&D

• Select one option A-B.
• If enrolling in child(ren) coverage, the total monthly cost is $2.08 whether enrolling one or more children.

Total amount of ALL elections

• Indicate total cost by adding each section together.

Beneficiary information

• Complete all information in this section.

Certification

• Print, sign and date

To waive

Verify all information is correct and complete. If not, make changes and fill in missing information.

• Supplemental term employee life and AD&D
  • Select G, "No Coverage"
• Supplemental term spouse life and AD&D
  • Select E, "No Coverage."
• Child & AD&D
  • Select B, "No Coverage."
• Certification
• Print, sign and date.