ITT HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

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GROUP LIFE AND DISABILITY INSURANCE ENROLLMENT FORM. Name: Annual Earnings: ... rounded to the next higher $1,000 to a maximum of $500,000 .
PAUL SMITH’S COLLEGE

THE BUSINESS COUNCIL OF NEW YORK STATE AETNA INSURANCE GROUP LIFE AND DISABILITY INSURANCE ENROLLMENT FORM Name:

Annual Earnings:

Address:

Social Security #: Phone:

Email Address:

Date of Hire:

Date of Birth:

Gender:

Effective Date:

Basic Life/ADPL Insurance - Employee Your employer provides basic Life/ADPL coverage equal to 1 times your basic annual earnings, rounded to the next higher $1,000 to a maximum of $500,000. The guaranteed issue amount is $400,000. Supplemental Life Insurance – Employee You have the opportunity to elect Supplemental Life coverage. Your election may be made in increments of $10,000 to a maximum of $150,000. The guaranteed issue amount is $150,000. Age Rate

Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ $0.02 $0.02 $0.025 $0.03 $0.045 $0.08 $0.13 $0.205 $0.325 $0.58 $1.035 *Please note premium is based on age as of January 1st of this year.

I elect Supplemental Life coverage: ÷ $1,000 =

x

Amount elected

= Rate above

Monthly cost

I decline Supplemental Life coverage.

Dependent Life Insurance Employees covered by Basic Life may elect coverage for their dependents. If a husband and wife are both employed by Paul Smith’s College, they cannot cover each other as dependents. Coverage Details: Spouse $5,000/Child(ren) $2,000 Cost: $1.52 per family/month I elect Dependent Life :_____ Write in the name(s) and date(s) of birth of eligible dependents* to be covered: _____________________________________________________________________________ * The term “dependent” is limited to the employee’s spouse, children to age 26, residing in the United States or Canada. I decline Dependent Life:______

Short Term Disability (STD) Insurance You have the opportunity to elect Short Term Disability (STD) coverage. STD provides you with income protection to replace up to 60% of your weekly earnings, to a maximum benefit of $2,000. Annual Salary/52 =Weekly SalaryX.60=Weekly Benefit/10 X .44=Monthly premium______ I elect STD coverage at a monthly cost of $0.44/$10 Weekly benefit I decline STD coverage.

Long Term Disability (LTD) Insurance You have the opportunity to elect Long Term Disability (LTD) coverage. LTD provides income protection to replace 67% of your monthly earnings, to a maximum benefit of $6,000. Benefits begin after you have been disabled during the 180 day elimination period. Annual Salary/12 =Monthly Salary/100 X .07 = Monthly premium__________ I elect LTD coverage at a monthly cost of $0.07/$100 Monthly Covered Payroll I decline LTD coverage.

Beneficiary Designation It is important that your beneficiary designation be clear so that there will be no question as to your meaning. It is also important that you name a primary and contingent beneficiary. When naming your beneficiary(ies) please indicate their full name, address, relationship and, if a minor, the age of that minor. If the beneficiary is not related either by blood or by marriage, insert the words, “Not Related.” If you need assistance, contact Human Resources or your own legal counsel. Following are examples of the most common designations:    

Mary J. Doe, Wife (not Mrs. John Doe). Mary J. Doe, Wife, if living, otherwise to Joseph W. Doe, Son. Mary J. Doe, Wife, if living, otherwise to Jane Doe, Daughter, and Joseph W. Doe, Son, in equal shares or to the survivor. Estate of the Insured.

If you name more than one beneficiary with unequal shares, please show the amount of insurance to be paid to each beneficiary in fractional parts, for example “1/3 to Mary Jones, Mother, and 2/3 to Edith Jones, Wife.” Full Name Address Relationship Date of Birth Primary Contingent A beneficiary for employee’s Life Insurance may be changed upon written request. Employee Confirmation I have been given the opportunity to enroll in Paul Smith’s College’s group Dependent Life, STD, LTD and Supplemental Life coverages. I understand that if I decline now, but later decide to enroll, I will be required to provide evidence of good health that is satisfactory to the insurance carrier and understand my request for coverage may be denied. I authorize my employer to make the appropriate payroll deductions from my wages. I am not now disabled and I am performing all the duties of my occupation on a full-time basis. Signature:

Date:

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