Broker Namebroker Numberdate Submittedrequested Effective Date

Broker nameBroker numberDate submittedRequested effective date

TypeCurrent carrierAssociationRates:

NewChangeReinstatementComposite Age/Sex

Broker fax numberBroker phone number/emailGroup name/group numberGroup contact name/phone no.

Group addressCity, State, ZIP code

Anthem Life – Attach a copy of the current schedule of benefits or other complete description of the benefits desired.

Class / Class Description / Basic Term Life/AD&D / Optional Life (10-50) / Optional AD&D (10-50) / Dependent Life
Spouse/Child / Short Term
Disability / Long Term
Disability
Example / Managers

(Census must include salaries to quote salary-based life, STD or LTD and must include occupations for LTD.)

Group Term Life/AD&D
Group Term Life/AD&D: choose either Salary Based Benefits or Flat Amount Benefits:
Class # / Salary Based Benefits / Flat Amounts Benefit: / Reduction Schedule:
Choose only one: / Salary Based Maximum Benefit*:
1 times salary
1.5 times salary
2 times salary
2.5 times salary
3 times salary / Salary Maximum benefit is $
Guaranteed Issue Amount is $
Salary Maximum options are in increments of $1,000. There is a minimum benefit of $25,000. The maximum benefit amount may not be greater than $250,000. / The benefit is $
Guaranteed Issue Amount is $
Benefit options are in $1,000 increments. There is a minimum benefit of $10,000. The maximum benefit amount may not be greater than $250,000. / 35% reduction at age 65 and
50% reduction at age 70
Benefits terminate at retirement.
1 times salary
1.5 times salary
2 times salary
2.5 times salary
3 times salary / Salary Maximum benefit is $
Guaranteed Issue Amount is $
Salary Maximum options are in increments of $1,000. There is a minimum benefit of $25,000. The maximum benefit amount may not be greater than $250,000. / The benefit is $
Guaranteed Issue Amount is $
Benefit options are in $1,000 increments. There is a minimum benefit of $10,000. The maximum benefit amount may not be greater than $250,000. / 35% reduction at age 65 and
50% reduction at age 70
Benefits terminate at retirement.
1 times salary
1.5 times salary
2 times salary
2.5 times salary
3 times salary / Salary Maximum benefit is $
Guaranteed Issue Amount is $
Salary Maximum options are in increments of $1,000. There is a minimum benefit of $25,000. The maximum benefit amount may not be greater than $250,000. / The benefit is $
Guaranteed Issue Amount is $
Benefit options are in $1,000 increments. There is a minimum benefit of $10,000. The maximum benefit amount may not be greater than $250,000. / 35% reduction at age 65 and
50% reduction at age 70
Benefits terminate at retirement.

(continued)

Group Term Life/AD&D Standard Features:

Employer Contribution: 25-100%

Classes: up to 3 classes

Rate: per $1,000 2-9 employees: age-banded rates. 10-50 employees: composite rates

Rate Guarantee: 2 years

Rounding Rule (salary-based benefits): Round to the next higher $1,000

Guaranteed Issue (based on quoted # of employees): 2-9 employees: $30,000; 10-24 employees: $50,000; 25-50 employees: $100,000

Waiver of Premium: Included. six-month elimination period. Employee must be disabled prior to age 60. Benefit terminates at age 65.

Coverage for retirees not available.

Group Name:

Specialty Business (group size 2-50)

Anthem Life

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Dependent Life
Benefit Amount:
Employers can elect one option from below, or they can elect to offer multiple options under a class based plan.
Class # / Spouse/Child
$10,000/$5,000
$5,000/$2,500
$2,500/$1,000
$2,000/$1,000
$10,000/$5,000
$5,000/$2,500
$2,500/$1,000
$2,000/$1,000
$10,000/$5,000
$5,000/$2,500
$2,500/$1,000
$2,000/$1,000

Please note: Dependent Life is not offered as stand-alone coverage and can only be sold with Group Term Life.

Dependent Life Standard Features:

Employer Contribution: 0-100%

Classes: up to 3 classes

Maximum Benefit Amount: Dependent coverage cannot exceed 50% of employee coverage.

Rate: Flat rate per family

Rate Guarantee: 2 years

Guaranteed Issue: All amounts guaranteed issue

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Group Name:

Specialty Business (group size 2-50)

Anthem Life

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Optional Life/AD&D (10-50)
Optional Life/AD&D: Choose EITHER Incremental Benefits or Salary-based Benefits.
Class # / Incremental Benefits
Choose EITHER Increments of $5,000 or
Increments of $10,000 / Salary-based Benefits / Optional AD&D
Salary-based Benefit
/ Salary-based
Maximum Benefit
Increments of $5,000. Maximum Amount:
$5,000 $55,000
$10,000 $60,000
$15,000 $65,000
$20,000 $70,000
$25,000 $75,000
$30,000 $80,000
$35,000 $85,000
$40,000 $90,000
$45,000 $95,000
$50,000 $100,000
Increments of $10,000. Maximum Amount:
$10,000 $50,000 $90,000
$20,000 $60,000 $100,000
$30,000 $70,000
$40,000 $80,000
Guaranteed Issue Amount is $ / 1 X salary
2 X salary
1 or 2 X salary / Salary Maximum benefit is $
Guaranteed Issue Amount is $
Salary Maximum options are in increments of $1,000. There is a minimum benefit of $25,000. The maximum benefit amount may not be greater than $100,000. / Include Optional AD&D. If the employer elects Optional AD&D, it is included for all employees who elect Optional Life and will be equal to the amount of Optional Life the employee elects.
Increments of $5,000. Maximum Amount:
$5,000 $55,000
$10,000 $60,000
$15,000 $65,000
$20,000 $70,000
$25,000 $75,000
$30,000 $80,000
$35,000 $85,000
$40,000 $90,000
$45,000 $95,000
$50,000 $100,000
Increments of $10,000. Maximum Amount:
$10,000 $50,000 $90,000
$20,000 $60,000 $100,000
$30,000 $70,000
$40,000 $80,000
Guaranteed Issue Amount is $ / 1 X salary
2 X salary
1 or 2 X salary / Salary Maximum benefit is $
Guaranteed Issue Amount is $
Salary Maximum options are in increments of $1,000. There is a minimum benefit of $25,000. The maximum benefit amount may not be greater than $100,000. / Include Optional AD&D. If the employer elects Optional AD&D, it is included for all employees who elect Optional Life and will be equal to the amount of Optional Life the employee elects.
Increments of $5,000. Maximum Amount:
$5,000 $55,000
$10,000 $60,000
$15,000 $65,000
$20,000 $70,000
$25,000 $75,000
$30,000 $80,000
$35,000 $85,000
$40,000 $90,000
$45,000 $95,000
$50,000 $100,000
Increments of $10,000. Maximum Amount:
$10,000 $50,000 $90,000
$20,000 $60,000 $100,000
$30,000 $70,000
$40,000 $80,000
Guaranteed Issue Amount is $ / 1 X salary
2 X salary
1 or 2 X salary / Salary Maximum benefit is $
Guaranteed Issue Amount is $
Salary Maximum options are in increments of $1,000. There is a minimum benefit of $25,000. The maximum benefit amount may not be greater than $100,000. / Include Optional AD&D. If the employer elects Optional AD&D, it is included for all employees who elect Optional Life and will be equal to the amount of Optional Life the employee elects.

Please note: The employee must be enrolled in Group Term Life to purchase Optional Life.

Optional Life/Optional AD&D Standard Features:

The group must offer Group Term Life Insurance/AD&D in order to offer
Optional Life/Optional AD&D.

100% employee paid

Participation Requirements: The greater of 20% or 10 lives.

Classes: up to 3 classes

Rate: per $1,000. Optional Life: age-banded rates. Optional AD&D: composite rates

Rate Guarantee: 2 years

Guaranteed Issue: Guaranteed issue varies by group.

Waiver of Premium: Included. six-month elimination period. Employee must be disabled prior to age 60. Benefit terminates at age 65.

Reduction Schedule: 35% reduction at age 65 and 50% reduction at age 70. Benefits terminate at retirement. If Optional Life is included with Basic Group Term Life, the reduction schedule of Basic Group Term Life will apply to Optional Life.

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Group Name:

Specialty Business (group size 2-50)

Anthem Life

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Optional Dependent Life (10-50)
Benefit Amount:
Employers can elect one option from below, or they can elect to offer multiple options under a class based plan. Each class can only have one option.
Class # / Optional Spouse – increments of $5,000. / Optional Child – increments of $5,000. Select Maximum Amount:
Benefit is in $5,000 increments to a maximum of $.
Guaranteed Issue Amount is $25,000.
Maximum amount may not be greater than $50,000. / $5,000
$10,000
$15,000
Benefit is in $5,000 increments to a maximum of $.
Guaranteed Issue Amount is $25,000.
Maximum amount may not be greater than $50,000. / $5,000
$10,000
$15,000
Benefit is in $5,000 increments to a maximum of $.
Guaranteed Issue Amount is $25,000.
Maximum amount may not be greater than $50,000. / $5,000
$10,000
$15,000

Please note: Optional Dependent Life must be sold with Optional Life.
Optional Dependent Life is not offered as stand-alone coverage.

Optional Dependent Life Standard Features:

Employer Contribution: 0-100%

Classes: Up to 3 classes

Maximum Benefit Amount: Dependent coverage cannot exceed 50% of employee coverage. Employer chooses the maximum amount available. Employee chooses benefit amount from these options, up to the maximum amount available.

If Group Term Life and Optional Life are sold together, only one option for Dependent Life

may be sold, meaning Optional Dependent Life cannot be sold in conjunction with Basic Dependent Life.

Rate: Age-banded rates per $1,000 for spouse and composite rates per $1,000 for child.

Rate Guarantee: Two years

Portability: Included for Optional Dependent life only.

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Group Name:

Specialty Business (group size 2-50)

Anthem Life

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Short Term Disability
Choose EITHER Percentage of Salary Benefits or Flat Amount Benefits
Class # / Salary Based Benefits / Flat Amounts Benefit
(weekly benefit): / Plan Design:
Benefits begin day Injury/Benefits begin day Illness/ Benefit Duration
Percentage of Salary Benefits:
Benefit % of Salary (weekly benefit): / Percentage of Salary Benefits:
Maximum Benefit:
50%
60%
66.67% / Maximum Weekly Benefit is $.
Maximum Weekly Benefit options are in increments of $50. There is a minimum benefit of $200. The maximum benefit amount may not be greater than $1,350.
2-5 employees: Guaranteed Issue amount is $500.
6+ employees: All amounts are Guaranteed Issue. / $100/week
$150/week
$200/week
$250/week / 1/8/13
1/8/26
8/8/13
8/8/26
15/15/13
15/15/26
50%
60%
66.67% / Maximum Weekly Benefit is $.
Maximum Weekly Benefit options are in increments of $50. There is a minimum benefit of $200. The maximum benefit amount may not be greater than $1,350.
2-5 employees: Guaranteed Issue amount is $500.
6+ employees: All amounts are Guaranteed Issue. / $100/week
$150/week
$200/week
$250/week / 1/8/13
1/8/26
8/8/13
8/8/26
15/15/13
15/15/26
50%
60%
66.67% / Maximum Weekly Benefit is $.
Maximum Weekly Benefit options are in increments of $50. There is a minimum benefit of $200. The maximum benefit amount may not be greater than $1,350.
2-5 employees: Guaranteed Issue amount is $500.
6+ employees: All amounts are Guaranteed Issue. / $100/week
$150/week
$200/week
$250/week / 1/8/13
1/8/26
8/8/13
8/8/26
15/15/13
15/15/26

Short Term Disability Standard Features:

Employer Contribution: 25-100%

Classes: up to 3 classes

Rate: per $10 of weekly benefit. 2-9 employees:
age-banded rates. 10-50 employees: composite rates

Rate Guarantee: 2 Years

Rounding Rule: Round to the next higher $10

Guaranteed Issue: 2-5 employees: $500.
6+ employees: All amounts guaranteed issue

Partial Disability: Included

Minimum Benefit (salary based plans): $50.00

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Group Name:

Specialty Business (group size 2-50)

Anthem Life

Long Term Disability
Class # / Benefit % of Salary
(monthly benefit): / Maximum Monthly Benefit: / Benefit Duration: / Elimination Period: / Definition of Disability: / Pre-existing Condition Limitation:
60%
Additional benefit % available for 10-50 only:
50%
66.67% / $3,000/month
$6,000/month
$1.000/month1
$2,000/month1
$4,000/month1
$7,000/month1
$8,000/month1
$9,000/month1
$10,000/month1
(1Only available to groups of 10+ employees
if the top five salaries qualify.)
Guaranteed Issue: 2-5 $0
6+ all amounts guaranteed issue / 2 years/RBD
5 years/RBD
To age 65/RBD
SSNRA / 90 days
180 days
365 days only available to groups of 10+ employees
/ 2 year own occupation
3 year own occupation2
5 year own occupation2
To age 65 own
occupation2
To SSNRA own
occupation2
(2Only available for groups with 10+ employees)) / Groups of 2-9 employees:
12/6/24
Groups of 10-24 employees:
12/6/24
6/12/24
Groups of 25-50 employees:
12/6/24
6/12/24
3/6/12
3/12
60%
Additional benefit % available for 10-50 only:
50%
66.67% / $3,000/month
$6,000/month
$1.000/month1
$2,000/month1
$4,000/month1
$7,000/month1
$8,000/month1
$9,000/month1
$10,000/month1
(1Only available to groups of 10+ employees
if the top five salaries qualify.)
Guaranteed Issue: 2-5 $0
6+ all amounts guaranteed issue / 2 years/RBD
5 years/RBD
To age 65/RBD
SSNRA / 90 days
180 days
365 days only available to groups of 10+ employees
/ 2 year own occupation
3 year own occupation2
5 year own occupation2
To age 65 own
occupation2
To SSNRA own
occupation2
(2Only available for groups with 10+ employees)) / Groups of 2-9 employees:
12/6/24
Groups of 10-24 employees:
12/6/24
6/12/24
Groups of 25-50 employees:
12/6/24
6/12/24
3/6/12
3/12
60%
Additional benefit % available for 10-50 only:
50%
66.67% / $3,000/month
$6,000/month
$1.000/month1
$2,000/month1
$4,000/month1
$7,000/month1
$8,000/month1
$9,000/month1
$10,000/month1
(1Only available to groups of 10+ employees
if the top five salaries qualify.)
Guaranteed Issue: 2-5 $0
6+ all amounts guaranteed issue / 2 years/RBD
5 years/RBD
To age 65/RBD
SSNRA / 90 days
180 days
365 days only available to groups of 10+ employees
/ 2 year own occupation
3 year own occupation2
5 year own occupation2
To age 65 own
occupation2
To SSNRA own
occupation2
(2Only available for groups with 10+ employees)) / Groups of 2-9 employees:
12/6/24
Groups of 10-24 employees:
12/6/24
6/12/24
Groups of 25-50 employees:
12/6/24
6/12/24
3/6/12
3/12

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Wisconsin ("BCBSWi")underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the
HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

BWIGQ1014A Rev. 07/12

Long Term Disability Standard Features:

Employer Contribution: 50-100%

Classes: up to 3 classes

Rate: per $100 of monthly covered payroll. 2-9 employees: age-banded rates. 10-50 employees: composite rates

Rate Guarantee: 2 Years

Rounding Rule: Round to the next higher $1

Guaranteed Issue: 2-5 employees: Medical questionnaires required; 6+ employees: All amounts guaranteed issue