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Life and AD&D insurance
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Long Term Disability
RETIRED PARTICIPANTS
Life and AD&D insurance
MEDEX® Travel Assist
Needs Estimator
Premium Calculator
How to Enroll
Booklets
-Active Employees-
Group Basic Life/AD&D Insurance
Group Voluntary Life/AD&D Insurance
Group Short Term Disability Insurance
Group Long Term Disability Insurance
-Retirees-
Group Basic Life Insurance
Group Voluntary Life Insurance
Forms
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Enrollment and Change Form for Active Employees
Enrollment and Change Form for Retired Employees
-Life Forms-
Beneficiary Designation and Change Form
Group Life Conversion Packet Request
Group Life Portability Insurance Application
Life Insurance Benefits Application and Claim Form
-Short Term Disability Form-
STD Claim Form
-Long Term Disability Forms-
Group Long Term Disability Conversion Packet Request
Long Term Disability Claim Form
Certificates
-Active Employees-
Life Insurance (Basic)
Life Insurance (Voluntary)
Short Term Disability Insurance
Long Term Disability Insurance
-Retirees-
Life Insurance
Active Employee
My age on July 1 of this year is:
Amount of Life and AD&D coverage
I'd like to apply for:
0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
$160,000
$180,000
$200,000
$220,000
$240,000
$260,000
$280,000
$300,000
$320,000
$340,000
$360,000
$380,000
$400,000
$420,000
$440,000
$460,000
$480,000
$500,000
Calculate
Monthly premium:
Spouse of Active Employee
Spouse age on July 1 of this year is:
Amount of Life and AD&D coverage
I'd like my spouse to apply for:
(Note: Rates for spouse coverage are based on the age of the spouse. Coverage cannot exceed 100% of employee coverage with $250,000 maximum.)
0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$110,000
$120,000
$130,000
$140,000
$150,000
$160,000
$170,000
$180,000
$190,000
$200,000
$210,000
$220,000
$230,000
$240,000
$250,000
Calculate
Monthly premium:
Clear