Supplemental Life Insurance

Current elections:

Self:  <EMPLOYEESUPPLIFE>

Spouse/Partner:  <SPOUSESUPPLIFE>

Child(ren): <CHILDSUPPLIFE>

There is a special opportunity to enroll or add supplemental life insurance coverage up to $40,000 (employee only) without having to prove good health (provided you’ve no previously been declined coverage).

I wish to elect an additional $<DROP DOWN OPTIONS> worth of supplemental life insurance coverage effective 1/1/2014.

Drop Down Options:

$10,000

$20,000

$30,000

$40,000

This will increase my monthly premium rate for supplemental life insurance by $INSERT CALCULATION.