Mandatory Basic Life and Accidental Death & Dismemberment Insurance

/ Life Insurance Information Sheet & Enrollment form /

8/19/15

The Standard insures our Basic Life and Accidental Death & Dismemberment (AD&D) Insurance, Additional/Optional Life and AD&D Insurance and Voluntary AD&D (Personal Accident) program.

Mandatory Basic Life and Accidental Death & Dismemberment Insurance

Basic Life and Accidental Death & Dismemberment Insurance is a mandatory benefit for all benefit-eligible employees in all bargaining units. It provides coverage equal to your Basic Annual Earnings, to a maximum of $100,000. The monthly premium of $8.85 will be deducted from the State Benefit Allocation dollars in the Employer Deduction section of your paycheck.

Employee Additional/Optional Life and Accidental Death & Dismemberment Insurance (Employee Paid)

You have the option to purchase additional Life and Accidental Death & Dismemberment Insurance in an equal to your Basic Annual Earnings, to a maximum of $100,000. If you elect coverage, a monthly premium of $13.20 will be deducted from your paycheck.

Please note that this benefit is available to you regardless of your health status if you enroll within 31 days of your date of employment. If you enroll after this date, you will be required to complete a Medical History Statement. The Standard reserves the right to deny coverage.

Additional Dependent Life Insurance (Employee Paid)

You also have the option to purchase additional Life Insurance for your spouse in $5,000 increments to a maximum of $100,000. However, the amount chosen may not exceed 100% of your Additional/Optional Life coverage. Medical History Statements are required for amounts in excess of $25,000.

You may also elect $10,000 of Dependent Life Insurance coverage for your eligible children. The amount chosen may not exceed 100% of your Additional/Optional Life coverage.

Additional Employee and Dependent Accidental Death & Dismemberment Insurance (Employee Paid)

You also have the option to purchase additional Accidental Death & Dismemberment Insurance for yourself and your family. This coverage provides additional benefits in the event of accidental death or dismemberment (i.e., loss of sight, loss of a limb.) If you are insured for Voluntary AD&D Insurance, you may elect to insure your eligible dependents. The amount of insurance for each dependent is determined as follows:

· Spouse only – 60% of employee amount

· Spouse and children – 50% of the employee amount for the Spouse and 10% of the employee amount for each child.

· Child (ren) only – 15% of the employees amount for each child, but not to exceed $25,000

If You Need More Information

If you have questions about any of these employee benefits plans, you may contact Michelle Thorpe, at 206-393-4329 or .

In addition, Marnie White at Sprague Israel Giles, Inc., (the District’s insurance consultants) is available to discuss your questions. She can be reached at 206-957-7055.

Return the completed and signed Enrollment & Change Form

Please return to Michelle Thorpe
Shoreline School District
Human Resources Department
18560 1st Avenue NE
Shoreline, WA, 98155-2148.

Please refer to the plan documents available from Human Resources for more information on the plan’s provisions, special features and exclusions.

8/19/15

/ Life Insurance Information Sheet & Enrollment form /

1. Mandatory Basic Life and AD&D – All Employees - MANDATORY

You are automatically enrolled for this coverage. If you do not wish to purchase additional insurance for yourself or family members:

ð Complete the Applicant and Beneficiary Section of the Enrollment and Change Form, sign “Signature”, and return to Michelle Thorpe, Shoreline School District Human Resources Department.

2. Employee Additional Life and Accidental Death & Dismemberment Insurance (AD&D) – OPTIONAL

Additional Life and AD&D Insurance is an amount equal to your Basic Annual Earnings, to a maximum of $100,000. Please note that this benefit is available to you regardless of your health status, if you enroll within 31 days of your date of employment. If you enroll after this date, you will be required to provide evidence of good health that is satisfactory to The Standard, who reserves the right to deny coverage.

ð Check box “Additional/Optional Life with AD&D: 1 Times Annual Salary Cost: $13.20

3. Additional Spousal Life Insurance - OPTIONAL

The rate used to determine the cost of your spouse’s Additional Life Insurance is based on your age as of October 1, 2016. Rates will be recalculated each January 1st.

You must choose Employee Additional Life & AD&D, to Add Spousal/Dependent Life Insurance.

Your Age

As of 10/1/2016 /

Rate

(Per $1,000 of Total Coverage)

To calculate the premium for your spouse:

1. Amount: Line 1______

Life Insurance for your spouse may be in $5,000 increments to a

maximum of $100,000. However, the amount chosen may notexceed 100% of your Supplemental Life coverage.Medical Statement required for amounts over $25,000.

2. Line 1 divided by $1000 = Line 2 Line 2______

3. Rate from Chart. Use your age. Line 3______

4. Line 2 multiplied by Line 3 = your monthly cost Line 4______

<30

$0.06

30-34

$0.08

35-39

$0.09

40-44

$0.10

45-49

$0.15

50-54

$0.23

55-59

$0.43

60-64

$0.66

65-69

$1.27

70+

$2.06

ð “Dependent Life Insurance”. Indicate Spouses name, date of birth and the life insurance amount you wish to enroll for them.

4. Additional Child (ren) Life Insurance - OPTIONAL

The amount of insurance for each child is $10,000. The cost is a flat $.50.

ð “Dependent Life Insurance”. Mark the box “Children: $10,000”

5. Voluntary Accidental Death & Dismemberment (AD&D) - OPTIONAL

You may cover yourself for amounts between $25,000 and $500,000 (not to exceed 10 times your salary from Shoreline School District) in $25,000 increments. The Option you choose determines the amounts you can purchase on your Spouse and/or Children. You must enroll in order to cover family members.

Option / Monthly
Cost for EE only / Benefit Amount Employee / Monthly
Cost for EE + Dependents / Benefit Amount Employee & Spouse / Benefit Amount
Employee, Spouse & Child / Benefit Amount Employee & Child
1 / $0.63 / $25,000 / $1.00 / $25,000 / $15,000 / $25,000 / $12,500 / $2,500 / $25,000 / $3,750
2 / $1.25 / $50,000 / $2.00 / $50,000 / $30,000 / $50,000 / $25,000 / $5,000 / $50,000 / $7,500
3 / $1.88 / $75,000 / $3.00 / $75,000 / $45,000 / $75,000 / $37,500 / $7,500 / $75,000 / $11,250
4 / $2.50 / $100,000 / $4.00 / $100,000 / $60,000 / $100,000 / $50,000 / $10,000 / $100,000 / $15,000
5 / $3.13 / $125,000 / $5.00 / $125,000 / $75,000 / $125,000 / $62,500 / $12,500 / $125,000 / $18,750
6 / $3.75 / $150,000 / $6.00 / $150,000 / $90,000 / $150,000 / $75,000 / $15,000 / $150,000 / $22,500
7 / $4.36 / $175,000 / $7.00 / $175,000 / $105,000 / $175,000 / $87,500 / $17,500 / $175,000 / $25,000
8 / $5.00 / $200,000 / $8.00 / $200,000 / $120,000 / $200,000 / $100,000 / $20,000 / $200,000 / $25,000
9 / $5.63 / $225,000 / $9.00 / $225,000 / $135,000 / $225,000 / $112,500 / $22,500 / $225,000 / $25,000
10 / $6.25 / $250,000 / $10.00 / $250,000 / $150,000 / $250,000 / $125,000 / $25,000 / $250,000 / $25,000
11 / $6.88 / $275,000 / $11.00 / $275,000 / $165,000 / $275,000 / $137,500 / $25,000 / $275,000 / $25,000
12 / $7.50 / $300,000 / $12.00 / $300,000 / $180,000 / $300,000 / $150,000 / $25,000 / $300,000 / $25,000
13 / $8.13 / $325,000 / $13.00 / $325,000 / $195,000 / $325,000 / $162,500 / $25,000 / $325,000 / $25,000
14 / $8.75 / $350,000 / $14.00 / $350,000 / $210,000 / $350,000 / $175,000 / $25,000 / $350,000 / $25,000
15 / $9.38 / $375,000 / $15.00 / $375,000 / $225,000 / $375,000 / $187.500 / $25,000 / $375,000 / $25,000
15 / $10.00 / $400,000 / $16.00 / $400,000 / $240,000 / $400,000 / $200,000 / $25,000 / $400,000 / $25,000
17 / $10.63 / $425,000 / $17.00 / $425,000 / $255,000 / $425,000 / $212,500 / $25,000 / $425,000 / $25,000
18 / $11.25 / $450,000 / $18.00 / $450,000 / $270,000 / $450,000 / $225,000 / $25,000 / $450,000 / $25,000
19 / $11.88 / $475,000 / $19.00 / $475,000 / $285,000 / $475,000 / $237,500 / $25,000 / $475,000 / $25,000
20 / $12.50 / $500,000 / $20.00 / $500,000 / $300,000 / $500,000 / $250,000 / $25,000 / $500,000 / $25,000

ð Voluntary Accidental Death and Dismemberment (AD&D) Insurance. Indicate if you want just coverage for yourself or for you and your dependent(s). Then indicate your amount of coverage.

CALCULATE YOUR MONTHLY PREMIUMS / Cost
Basic Life & AD&D / Employee / 1x Salary to $100,000 / Mandatory
Additional Life & AD&D / Employee / 1x Salary to $100,000 / $ 13.20 / $_____
Additional Life / Spouse / Amount from line 1 / $______/ $_____
Cost from Line 4
Child (ren) / $10,000 / $0.50 / $_____
Voluntary AD&D / Employee / Amount chosen from chart above / $______
Cost from chart above / $______
OR / Employee + Dependent(s) / Amount chosen from chart above / $______
Cost from chart above / $______
Add Cost Column - this will be your monthly deduction $______

Benefit allocation dollars may not be used to pay for Additional Life, or Voluntary AD&D

> Return the completed and signed Enrollment & Change Form <

Please return to Michelle Thorpe, Shoreline School District Human Resources Department
18560 1st Avenue NE, Shoreline, WA, 98155-2148.

8/19/15

Standard Insurance Company Enrollment and Change Form

Mark all boxes and complete all sections that apply. Return completed form to your Human Resources Department.

APPLICANT / Your Name (Last, First, Middle) / Group Name
Shoreline School District No 412 / Group Number(s)
613023
Your Address / City / State / ZIP
Your Soc. Sec. No. / Date of Birth / Male Female / Job Title/Occupation
LIFE / Check with your Human Resources Department about coverage options available to you and Evidence Of Insurability requirements.
Life Insurance
Life with AD&D Employer Paid
Additional/Optional Life
Additional/Optional Life with AD&D: 1 times Annual Salary, up to a maximum of $100,000
Dependents Life Insurance
Spouse requested amount $______Spouse Name & DOB:______
Children: $10,000
Voluntary Accidental Death and Dismemberment (AD&D) Insurance
Employee Only Employee and Children Employee and Spouse Employee, Spouse, and Children
Your requested amount $______
DISABILITY / Check with your Human Resources Department about coverage options available to you and Evidence Of Insurability requirements.
Long Term Disability
Employer Paid LTD
BENEFICIARY / This designation applies to Life/Life with AD&D Insurance available through your Employer, if any. Unless specified otherwise on a separate sheet of paper, this designation will also apply to Accidental Death and Dismemberment (AD&D) Insurance available through your Employer, if any. Designations are not valid unless signed, dated, and delivered to the Employer during your lifetime. See page 2 for further information.
Primary - Full Name Address Soc. Sec. No. Relationship % of Benefit
Contingent - Full Name Address Soc. Sec. No. Relationship % of Benefit
CHANGE / Use this section only when you wish to make a change after insurance becomes effective. Complete all boxes and sections that apply.
Add Dependent Delete Dependent Name Change Beneficiary Change
Date of add/delete ______Former name ______Other ______
SIGNATURE / I wish to make the choices indicated on this form. If electing coverage, I authorize deductions from my wages to cover my contribution, if required, toward the cost of insurance. I understand that my deduction amount will change if my coverage or costs change.
Member/Employee Signature Required / Date (Mo/Day/Yr)
Human Resources Department - Complete this section. Retain form for your records.
Dvsn ID
00 / Billing Cat.
0001 / Date of Hire/Rehire / Hrs. Worked Per Wk. / Earnings $______Per: Hour Wk Mo Yr

SI 7533D-613023 (10/15)

Beneficiary Information
· Your designation revokes all prior designations.
· Benefits are only payable to a contingent Beneficiary if you are not survived by one or more primary Beneficiary(ies).
· If you name two or more Beneficiaries in a class:
1. Two or more surviving Beneficiaries will share equally, unless you provide for unequal shares.
2. If you provide for unequal shares in a class, and two or more Beneficiaries in that class survive, we will pay each surviving Beneficiary his or her designated share. Unless you provide otherwise, we will then pay the share(s) otherwise due to any deceased Beneficiary(ies) to the surviving Beneficiaries prorata based on the relationship that the designated percentage or fractional share of each surviving Beneficiary bears to the total shares of all surviving Beneficiaries. / 3. If only one Beneficiary in a class survives, we will pay the total death benefits to that Beneficiary.
· If a minor (a person not of legal age), or your estate, is the Beneficiary, it may be necessary to have a guardian or a legal representative appointed by the court before any death benefit can be paid. If the Beneficiary is a trust or trustee, the written trust must be identified in the Beneficiary designation. Forexample, “Dorothy Q. Smith, Trustee under the trust agreement dated ______
· A power of attorney must grant specific authority, by the terms of the document or applicable law, to makeor change a Beneficiary designation. If you have any questions, consult your legal advisor.
Dependents Insurance, if any, is payable to you, if living, or as provided under your Employer’s coverage under the Group Policy.

8/19/15