Life and Accidental Death & Dismemberment ( AD & D ) Insurance Voluntary Life and Voluntary AD & D Insurance
Eligibility
Davis Behavioral Health
Basic Life Benefit Amounts
Basic Accidental Death & Dismemberment Benefit Amount
Employee Supplemental Life and AD & D Benefit Amounts
Spouse Supplemental Life and AD & D Benefit Amounts
Child Supplemental Life and AD & D Benefit Amounts ( Birth to age 26 )
Group Basic Life and Supplemental Life Benefit Highlights
As an active full-time employee , you and your dependents are eligible for the Group Basic Life and Supplemental Life insurance plans as further defined within your certificate . Basic Life insurance is provided to you and your eligible dependents by Davis Behavioral Health at no cost to you . Following are the Basic Life benefit amounts :
Employee : 2 times your base annual earnings , rounded to the nearest $ 1,000 ( to a maximum of $ 300,000 ). Spouse : $ 10,000 Child ( ren ): $ 5,000 on each eligible Dependent child Basic Accidental Death & Dismemberment insurance is provided to you by Davis Behavioral Health at no cost to you in the following amount :
Employee : 2 times your base annual earnings , rounded to the nearest $ 1,000 ( to a maximum of $ 300,000 ). Please Note : Spouse and Dependent Children are not eligible for coverage under the Basic Accidental Death & Dismemberment plan .
Increments : $ 5,000 Benefit Minimum : $ 10,000 Life Benefit Maximum : The lesser of 5 times salary , up to $ 500,000 . AD & D Benefit Maximum : The lesser of 10 times salary , up to $ 500,000 . Life Guarantee Issue ( if you are 69 or younger ): The lesser of 5 times salary , up to $ 300,000 . AD & D Guarantee Issue : The lesser of 10 times salary , up to $ 500,000 .
Increments : $ 5,000 Benefit Minimum : $ 10,000 Benefit Maximum : Lesser of 100 % of Employee ’ s approved coverage or $ 250,000 Life Guarantee Issue ( if you are 69 or younger ): $ 50,000 AD & D Guarantee Issue : The lesser of 100 % of Employee ’ s approved coverage or $ 250,000 .
Increments : $ 2,000 Benefit Minimum : $ 2,000 Benefit Maximum : $ 10,000 Guarantee Issue : $ 10,000
Evidence of Good Health Requirements Evidence of good health will be required for all coverage above the Guarantee Issue limit .
Benefit Reductions
Your Employee and Spouse Basic and Supplemental Life coverage amounts are reduced by 35 % at age 65 , an additional 15 % at age 70 .
The above items are only highlights of your coverage . For a full description , please read the entire Group Insurance Certificate .
Premium Calculation
Use the calculation line below to determine your cost for this coverage .
___________ / $ 1,000 = ___________ x ___________ = $ ___________
Life Elected Benefit Amount
___________ / $ 1,000 = ___________ x ___________ = $ ___________
AD & D Elected Benefit Amount
Rate Above
Rate Above
Your Monthly Cost
Your Monthly Cost
Supplemental Life Insurance Monthly Rate Chart Worksheet
Supplemental Life Insurance for Employee and Spouse
Age Band Rate per $ 1,000 Under Age 30 $ 0.054 30 – 34 $ 0.059 35 – 39 $ 0.073 40 – 44 $ 0.109 45 – 49 $ 0.174 50 – 54 $ 0.263 55 – 59 $ 0.372 60 – 64 $ 0.625 65 – 69 $ 1.229 70 – 74 $ 2.559 75 – 79 $ 4.683 AD & D ( optional ) $ 0.02
Supplemental Life Insurance for Children Child Life Rate per $ 1,000 $ 0.12 Child AD & D Rate per $ 1,000 $ 0.011
Davis Behavioral Health
30