Employee Information / Last First Middle
Name: / EMPLOYEE #: 
**Your employee # can be found on the top right corner of your pay stub
Street: / HOME PHONE #: ( ) -
city:state: zip CODE: / WORK PHONE #: ( ) -
Employee Status: Staff Store Mgmt.
Basic Term Life Insurance / Without completing any paperwork, you are automatically enrolled for 2x your base annual salary in Basic Term Life coverage provided by McDonald's at no cost to you. Dependent Basic Term Life for your dependents is also provided to you at no cost.
Dependents
A spouse/domestic partner and/or child(ren) only may be considered dependents. / Full Name / Relationship / Date of Birth / SSN
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Election/ Change Choices and Instructions / •To elect (or change existing coverage) Universal Life with or without Dependent Optional Term Life complete and sign Section I.
•To decline (or stop existing coverage) Universal Life, complete and sign Section II only.
•If enrolling after initial eligibility date, you must complete a Statement of Physical Condition form, request form #3832 from the ServiceCenter.
Section I:
Universal Life Insurance / Universal Life Insurance is available at 1, 2 or 3 times your base annual salary. Plus, Dependent Optional Term Life is available on your spouse/domestic partner and/or children if you enroll in Universal Life. Check the appropriate box(es) of your choice. Call McDonald’s Employee Services to obtain your rates for Universal Life Insurance.
Universal Life Insurance / Dependent Optional Term Life Insurance
Employee / Spouse or Domestic Partner / Child(ren) Only
Coverage1 / Accum Cost2 / Monthly Account / Total Cost4 / Coverage3 / Monthly
Cost / Coverage / Monthly
Cost
1 x Salary / $10,000 (Employee’s Universal Life must
be at least $20,000) / $2,500 per child
(you must elect Employee Universal Life) / $.255
2 x Salary / $15,000 (Employee’s Universal Life must
be at least $30,000) / No coverage
3 x Salary / $25,000 (Employee’s Universal Life must
be at least $50,000) / Total cost for all children / $.255
No coverage
(Child(ren) are covered automatically for $2,500 each if spouse or domestic partner is covered)
Universal Life assumes you will be saving to purchase Paid-up Life coverage at age 65 in an amount of coverage equal to the Optional Term Life coverage you have enrolled for today. However, you may fund for a different Paid-up Life amount. The payroll deduction going into the Accumulation Account may be less than the amount resulting from the above assumption (to a minimum of $10 per month). Please call Met Life at 1-800-523-2894 and they can provide you with the Accumulation Account contribution appropriate for the amount you desire. Insert the amount in the space provided: I elect to have $______per month withheld from my salary and deposited into my Accumulation Account. This election automatically overrides the Accumulation Account amount above. (Do not complete if above Accumulation Account is correct.) If no amount is indicated, the minimum of $10 per month will be used. I have made the above life insurance coverage elections. I understand that if I am enrolling while on a leave of absence or Short Term Disability, this election will become effective the first of the month following my return to work. My beneficiary for this coverage is the same as for Basic Term Life.
Employee Signature: / Date:
Section II:
Decline/Stop Coverage / I elect to decline or stop coverage for the following (I understand to obtain coverage later, I must present evidence of good health by completing a Statement of Physical Condition form):
Universal Life (including Universal Life Optional Term and Accumulation Account (employee). You MUST immediately call
Met-Life 1-800-523-2894 to discuss Accumulation Account alternatives or payout.
Universal Life and elect Optional Term Life (must also complete the Optional Life Form).
Employee Signature: / Date:

1 At age 65, life insurance coverage is reduced to 65% of the amount of coverage in effect before age 65.

2 Based on your age as of the last January 1 and current salary. Includes Accidental Death and Dismemberment and Travel Accident coverage.

3 The maximum coverage for your spouse or domestic partner cannot be more than 50% of the Employee Optional Life coverage selected.

4 Includes a 2% premium tax, a monthly administration fee of $1.50 and the savings amount-subject to a minimum monthly contribution of $10.00.

Universal Life and Dependent Optional Term Life Rate Chart / Employee
Universal Life / Dependent Optional Term Life
Employee’s Age / Per $1,000 of Coverage
Per Month / Spouse/Domestic Partner or Spouse/Domestic Partner and Children Per $1,000 of Coverage Per Month* / Child Only (Flat Rate)
Per Month
Under 30 / $.093 / $.063 / $ .255
30–34 / $.113 / $.083 / $ .255
35–39 / $.127 / $.097 / $ .255
40–44 / $.138 / $.108 / $ .255
45–49 / $.192 / $.162 / $ .255
50–54 / $.280 / $.250 / $ .255
55–59 / $.498 / $.468 / $ .255
60–64 / $.736 / $.706 / $ .255
65–69 / $1.330 / $1.300 / $ .255
70 and Over / $2.090 / $2.060 / $ .255
* (Rate is based on employee’s age, not the spouse’s or domestic partner’s.)
Example 1
To compute
the monthly
cost of Employee Optional Term Life / 1)Multiply your base annual salary times the multiple of coverage (1, 2 or 3) you’ve chosen. Certified Swing and Primary Maintenance employee’s annual salary = hourly rate x 1950 hours. For Part-time Hourly staff, annual salary = hourly rate x 1500 hours. / Salary is / $15,021
Wants 2x in life / x2
$30,042
2)Round your answer up to the next highest $1,000 and then divide this number by $1,000. / Rounded up to next $1,000 / $31,000
Divided by $1,000 / ÷1000
31
3)Multiply this number by the monthly rate (from above Employee Optional Term Life chart) using your age as of last January 1. / Times rate for employee at age 33 / x.113
Monthly cost / $3.50
Example 2
To compute
the monthly
cost of Spouse/Domestic Partner Dependent Optional Term Life / 1)Choose an amount of Dependent Optional Term Life that is not more than half of your Optional Term coverage.
Employee chooses $15,000
of spousal coverage
$15,000
2)Divide the amount of spouse/domestic partner coverage ($10,000, $15,000, or $25,000) you’ve chosen by 1000. / Divided by 1,000 / ÷1,000
15
3)Multiply this number by the monthly rate (from above Dependent Optional Term Life chart) for Spouse/Domestic Partner or Spouse/Domestic Partner and Children using your age as of last January 1. / Times rate for employee at age 33 / x.083
Monthly cost / $1.25

Please forward this completed form and all required attachments (if applicable) to:

McDonald’s Service Center Dept. 238, McDonald’s Corporation, 2111 McDonald Drive, Oak Brook, IL, 60523
Telephone #: (877) 623-1955 Fax #: (630) 623-5027 E-mail: FORM 382302/15/07