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Preliminary Group Life & AD&D Inquiry - Not an application for insurance
 
 

Background
P Submitted By  Date Needed: 
P Agency
P Group Name
P City    State: 
P    
P SIC Code   # of Lives 
P Options Life  Dep    VTL    STD    LTD VOLDIS  Effective Date
 

Basic Life, AD&D and Dependent Life
P

Participation:

   Non-Contributory   Contributory     Contributory Percent:
  Dependent AD&D

1=Yes/Seat Belt Rider
2=Yes/NO Seat Belt Rider
3=No

 Dependent Life 2-Tier 3-Tier
   Plan 1      Spouse   Child  
   Plan 2      Spouse   Child  
   Plan 3      Spouse   Child  
   Plan 4      Spouse   Child  
P Reduction Schedule ADEA        Special 
P Other Benefits ALB  Suicide Exclusion  Seat Belt Benefit
P Waiver Age    Waiting Period    Termination Age 
  Descriptions

For Basic Life, AD&D, Dependent Life

Multiple of Salary or Flat Amount
  Class 1 or Quote 1 Multiple    Flat Amount
  Class 2 or Quote 2 Multiple    Flat Amount
  Class 3 or Quote 3 Multiple    Flat Amount
  Class 4 or Quote 4 Multiple    Flat Amount
 

Long Term Disability
  Participation  90-100%   80-89%  75-79%  Non-contributory 
    Item Class 1 or Quote 1 Class 2 or Quote 2 Class 3 or Quote 3
    Benefit%
    Benefit Duration

    Benefit Maximum
    Elimination Period
    Integration

    Pre Exam

    Yes    No

    Yes    No

    Yes    No
    MMB
    Def of Disability
    Class Description Class 1 
    Class 2 
    Class 3 
 

Company Census Information     as of

 
   Employee Name Gender DOB Salary Job Title/Occupation Life Class LTD Class STD Class
01
02
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09
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