For Allstate More Information

Transcription

1 For Allstate More Information Benefits The State of South Carolina CALL (866) Mitchell Prescott, LUTCF Group Accident CLICK Group Cancer Group Critical Illness Group Short-Term Disability Group Universal Life Meeting Your Needs Personalized Benefits Allstate Benefits has been helping the State of SC employees with their supplemental benefits since 1955 Group Rates Worry-Free Payroll Deduction SCEIS payroll code: American Heritage Life Easy Qualifications evidence of insurability at initial enrollment Individual & Family Coverage The Freedom of Portable Coverage Workplace Benefits Plus For More Information CALL (866) Workplace Benefits Plus Mitchell Prescott, LUTCF CLICK

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3 State of South Carolina Allstate Benefits Election Form Give this election form to your agent or Mail to: Allstate Benefits, PO Box 1148, Beaufort, SC EMPLOYEE INFORMATION Employee Name (First Name_ Middle Initial_ Last Name, Suffix) Agency or Subdivision Name Employee SSN Date of Birth (MM/DD/YY) Height Weight Sex Annual Salary Do you use tobacco? YES NO Mailing Address City State Zip Mobile Phone Home Phone Work Phone Primary Beneficiary's Full Name (First Name_ Middle Initial_ Last Name, Suffix) Beneficiary Relationship DEPENDENT INFORMATION Complete this section for persons to be insured Social Security # Relationship First Name Last Name Sex M /F Date of Birth (MM/DD/YY) Tobacco Use Spouse Election of Group Coverage Benefit Plan Benefit Election Benefit Option Coverage Tier Premium per pay Accident Enroll Change PLAN 1 Employee Only Employee & Spouse PLAN 2 EE & Children Family Cancer Enroll Change PLAN 1 Employee Only Employee & Spouse PLAN 2 EE & Children Family Critical Illness Enroll Change PLAN 1 (10,000) Employee Only Employee & Spouse PLAN 2 (20,000) EE & Children Family Disability Enroll Change PLAN 1 Monthly Benefit Employee Only PLAN 2 Universal Life Employee Spouse Enroll Enroll Change Change Face Amount Face Amount Employee Only Employee & Children* * 10,000 coverage on all children under age 26. Spouse Only ACCEPTANCE: I hereby request all coverage checked ENROLL or CHANGE above for which I am or may become eligible under the group coverage s issued by the insurance company. I UNDERSTAND that this is only an election form and you will be contacted to complete any carrier specific Evidence of Insurability (EOI) applications. The carrier EOI application must be completed before coverage can be considered. WAIVER/DECLINATION: I understand that if I refuse any coverage, that any guaranteed issue offer is also waived. Employee Signature Date Have Questions or need help? Contact Workplace Benefits Plus at (866)

4 Accident State of South Carolina Allstate Benefits Semi-monthly insurance premiums EO = Employee Only, ES = Employee & Spouse, EC = Employee & Children, FA = Family Cancer Option EO ES EC FA Option EO ES EC FA Plan Plan Plan Plan Critical Illness Critical Illness PLAN 1 (10,000) PLAN 2 (20,000) non-tobacco tobacco non-tobacco tobacco Ages EE, EC ES, FA EE, EC ES, FA Ages EE, EC ES, FA EE, EC ES, FA Disability Monthly Benefit Option Elimination Benefit 400 1,000 Plan 1 14 day 3 month Plan 2 7 day 6 month Universal Life Benefit amount based on premium Tier EO EC SO CO CO CO Plan Option Tier Accident Plan 1 EO Accident Plan 1 ES Cancer Plan 2 EO Critical Illness NT Plan 1 EO Annual VALUE ANALYSIS Annual Premium Wellness Benefit Net Cost (34.88) (162.40) (866)

5 State of South Carolina Allstate Benefits Disability Rates Semi-Monthly Rates PLAN 1 PLAN 2 Preferred Plus Elimination Period Benefit Period 14 Days Accident / 14 Days Sickness 3 Months 7 Days Accident / 7 Days Sickness 6 Months Issue Age Issue Age Monthly Benefit , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

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