Voluntary Term Life and Accidental Death & Dismemberment (Issue Pricing) Designed for the Employees of ELIGIBILITY All eligible active employees working or more hours per week, their spouse under age 70, unmarried children ages 14 days 19 years (25 if a full time student), and handicapped children over the age of 19 are eligible for coverage. Dependent coverage is available only if the employee elects coverage. Dependents may not be insured if they are confined a medical facility. If the employee is not actively at work on the effective date of coverage, the insurance will become effective on the date of the employee s return active employment. BENEFITS Employee coverage maximum of sold in increments of. Coverage cannot exceed times base annual salary. Spouse coverage maximum of sold in increments of. Coverage cannot exceed of employee coverage amount elected. Child coverage: 14 days 1 year: $1,000. 1 19 years: $10,000 (age 25 for full-time students) COST OF COVERAGE The premium for your coverage is paid by you. Issue pricing means that your rates (and your spouse s if applicable) do not change with age. After the initial rate guarantee period, the employee s policy is subject an annual review and possible rate changes. GUARANTEED ISSUE No medical underwriting will be required unless you apply for coverage over the Guaranteed Issue amount, apply beyond the initial 31 day eligibility period, or have been previously declined coverage by Bosn Mutual. AGE EMPLOYEE SPOUSE REDUCTIONS IN BENEFITS All life insurance coverage for dependent children is guaranteed issue. Employee coverage reduces upon the attainment of age and periodically thereafter in accordance with the following schedule: Spouse insurance terminates upon the attainment of age. Dependent children coverage terminates upon notice that all dependent children are no longer eligible. All insurance benefits shall terminate upon the employee s retirement. see other side BOSTON MUTUAL LIFE INSURANCE COMPANY 120 Royall Street Cann, MA 02021 www.bosnmutual.com Policy Series GRTP 04/99 335-4302 12/17
ADDITIONAL FEATURES Accidental Death & Dismemberment: The Voluntary Life Insurance benefit is doubled if death is the result of a covered accident. Dismemberment benefits are payable for loss of eyesight or limbs according the policy provisions. Portability: If you leave your employer prior age, the coverage is portable for you, your spouse under age and all eligible dependent children. You may elect exercise this option in accordance with the provisions as defined by the policy. The coverage would not include Waiver of Premium or Group Voluntary AD&D. Conversion: Employees have 31 days from the date of termination convert the voluntary life insurance an individual permanent life insurance policy without evidence of insurability. The premium will be based on Bosn Mutual s usual rate for the insured s age on the date of conversion. Coverage will not include Waiver of Premium or Voluntary AD&D. Waiver of Premium: If you become tally disabled prior age 60 and remain tally disabled for the period stated in the policy, Bosn Mutual will continue your insurance without any further payment of premiums subject the provisions of the contract. Accelerated Death Benefit: This provision enables an employee diagnosed and certified by a Docr with a terminal illness, resulting in a life expectancy of twelve months or less, receive a portion of the life insurance benefit prior death. The remaining benefit will be paid the beneficiary. Also Included: Education Benefit, Seat Belt Benefit, and Repatriation of Remains Benefit. EXCLUSIONS Under the AD&D coverage, benefits are not payable for losses caused by or contributed by: intentionally self-inflicted injuries; suicide or attempted suicide; riot or war; diseases; pmaine or bacterial infection; drug and/or alcohol abuse; commission of an assault or felony by an employee; accident while serving on active duty; travel or flight in any aircraft or device which can fly above the earth s surface (does not apply commercial flights); or injury which occurred before the Employee was insured by this policy. All exclusion details are stated in the master policy and certificate which may be reviewed through your benefit administrar. BEREAVEMENT COUNSELING* This service is provided all beneficiaries who experience the loss of a loved one. Beneficiaries have access a ll-free counseling service supported by professional counselors experienced with the human emotions associated with the death of a loved one. * Services provided by Health Management Systems of America a nationally recognized leader in the field of Mental and Behavioral Health Care Services. These services are currently available but are not part of your Bosn Mutual policy/contract. This information is a summary of benefits; this summary is not your Certificate nor does it constitute coverage for claim. Any discrepancies between this summary and the master policy will be resolved by the language issued in the master policy. For complete details of coverage and availability, please refer the policy or contact your benefits administrar.
Issue Life and AD&D Premiums* 18-59 60-69 70+ Employees may elect in increments of $10,000 a maximum of the lesser of 7 times salary or $500,000. 1,000 $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 Under 20 $0.100 $0.46 $0.92 $1.38 $1.84 $2.30 $2.76 $3.23 $3.69 $4.15 $4.61 20-24 $0.100 $0.46 $0.92 $1.38 $1.84 $2.30 $2.76 $3.23 $3.69 $4.15 $4.61 25-29 $0.100 $0.46 $0.92 $1.38 $1.84 $2.30 $2.76 $3.23 $3.69 $4.15 $4.61 30-34 $0.100 $0.46 $0.92 $1.38 $1.84 $2.30 $2.76 $3.23 $3.69 $4.15 $4.61 35-39 $0.130 $0.60 $1.20 $1.80 $2.40 $3.00 $3.60 $4.20 $4.80 $5.40 $6.00 40-44 $0.180 $0.83 $1.66 $2.49 $3.32 $4.15 $4.98 $5.81 $6.64 $7.47 $8.30 45-49 $0.290 $1.33 $2.67 $4.01 $5.35 $6.69 $8.03 $9.36 $10.70 $12.04 $13.38 50-54 $0.470 $2.16 $4.33 $6.50 $8.67 $10.84 $13.01 $15.18 $17.35 $19.52 $21.69 55-59 $0.760 $3.50 $7.01 $10.52 $14.03 $17.53 $21.04 $24.55 $28.06 $31.56 $35.07 60-64 $1.110 $5.12 $10.24 $15.36 $20.49 $25.61 $30.73 $35.86 $40.98 $46.10 $51.23 65-69 $1.850 $8.53 $17.07 $25.61 $34.15 $42.69 $51.23 $59.76 $68.30 $76.84 $85.38 70-74 $3.230 $14.90 $29.81 $44.72 $59.63 $74.53 $89.44 $104.35 $119.26 $134.16 $149.07 75 & Over $5.330 $24.60 $49.20 $73.80 $98.40 $123.00 $147.60 $172.20 $196.80 $221.40 $246.00 1,000 $110,000 $120,000 $130,000 $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 Under 20 $0.100 $5.07 $5.53 $6.00 $6.46 $6.92 $7.38 $7.84 $8.30 $8.76 $9.23 20-24 $0.100 $5.07 $5.53 $6.00 $6.46 $6.92 $7.38 $7.84 $8.30 $8.76 $9.23 25-29 $0.100 $5.07 $5.53 $6.00 $6.46 $6.92 $7.38 $7.84 $8.30 $8.76 $9.23 30-34 $0.100 $5.07 $5.53 $6.00 $6.46 $6.92 $7.38 $7.84 $8.30 $8.76 $9.23 35-39 $0.130 $6.60 $7.20 $7.80 $8.40 $9.00 $9.60 $10.20 $10.80 $11.40 $12.00 40-44 $0.180 $9.13 $9.96 $10.80 $11.63 $12.46 $13.29 $14.12 $14.95 $15.78 $16.61 45-49 $0.290 $14.72 $16.06 $17.40 $18.73 $20.07 $21.41 $22.75 $24.09 $25.43 $26.76 50-54 $0.470 $23.86 $26.03 $28.20 $30.36 $32.53 $34.70 $36.87 $39.04 $41.21 $43.38 55-59 $0.760 $38.58 $42.09 $45.60 $49.10 $52.61 $56.12 $59.63 $63.13 $66.64 $70.15 60-64 $1.110 $56.35 $61.47 $66.60 $71.72 $76.84 $81.96 $87.09 $92.21 $97.33 $102.46 65-69 $1.850 $93.92 $102.46 $111.00 $119.53 $128.07 $136.61 $145.15 $153.69 $162.23 $170.76 70-74 $3.230 $163.98 $178.89 $193.80 $208.70 $223.61 $238.52 $253.43 $268.33 $283.24 $298.15 75 & Over $5.330 $270.60 $295.20 $319.80 $344.40 $369.00 $393.60 $418.20 $442.80 $467.40 $492.00 $1,000-14 days 1 year *Issue Premiums - The premium for your coverage is paid by you. Issue pricing means that your rates (and your spouse s if applicable) do not change with age. After the initial rate guarantee period, the employer is subject an annual review and possible rate changes. Rates are effective as of the date shown above. Group life policies are underwritten by Bosn Mutual Life Insurance Company under Policy form BML GRTP 4/99, subject state details of coverage and availability, please refer your certificate or contact your benefits administrar. BOSTON MUTUAL LIFE INSURANCE COMPANY - 120 Royall Street - Cann MA 02021 - www.bosnmutual.com
Issue Life and AD&D Premiums* 18-59 60-69 70+ Employees may elect in increments of $10,000 a maximum of the lesser of 7 times salary or $500,000. 1,000 $210,000 $220,000 $230,000 $240,000 $250,000 $260,000 $270,000 $280,000 $290,000 $300,000 Under 20 $0.100 $9.69 $10.15 $10.61 $11.07 $11.53 $12.00 $12.46 $12.92 $13.38 $13.84 20-24 $0.100 $9.69 $10.15 $10.61 $11.07 $11.53 $12.00 $12.46 $12.92 $13.38 $13.84 25-29 $0.100 $9.69 $10.15 $10.61 $11.07 $11.53 $12.00 $12.46 $12.92 $13.38 $13.84 30-34 $0.100 $9.69 $10.15 $10.61 $11.07 $11.53 $12.00 $12.46 $12.92 $13.38 $13.84 35-39 $0.130 $12.60 $13.20 $13.80 $14.40 $15.00 $15.60 $16.20 $16.80 $17.40 $18.00 40-44 $0.180 $17.44 $18.27 $19.10 $19.93 $20.76 $21.60 $22.43 $23.26 $24.09 $24.92 45-49 $0.290 $28.10 $29.44 $30.78 $32.12 $33.46 $34.80 $36.13 $37.47 $38.81 $40.15 50-54 $0.470 $45.55 $47.72 $49.89 $52.06 $54.23 $56.40 $58.56 $60.73 $62.90 $65.07 55-59 $0.760 $73.66 $77.16 $80.67 $84.18 $87.69 $91.20 $94.70 $98.21 $101.72 $105.23 60-64 $1.110 $107.58 $112.70 $117.83 $122.95 $128.07 $133.20 $138.32 $143.44 $148.56 $153.69 65-69 $1.850 $179.30 $187.84 $196.38 $204.92 $213.46 $222.00 $230.53 $239.07 $247.61 $256.15 70-74 $3.230 $313.06 $327.96 $342.87 $357.78 $372.69 $387.60 $402.50 $417.41 $432.32 $447.23 75 & Over $5.330 $516.60 $541.20 $565.80 $590.40 $615.00 $639.60 $664.20 $688.80 $713.40 $738.00 1,000 $310,000 $320,000 $330,000 $340,000 $350,000 $360,000 $370,000 $380,000 $390,000 $400,000 Under 20 $0.100 $14.30 $14.76 $15.23 $15.69 $16.15 $16.61 $17.07 $17.53 $18.00 $18.46 20-24 $0.100 $14.30 $14.76 $15.23 $15.69 $16.15 $16.61 $17.07 $17.53 $18.00 $18.46 25-29 $0.100 $14.30 $14.76 $15.23 $15.69 $16.15 $16.61 $17.07 $17.53 $18.00 $18.46 30-34 $0.100 $14.30 $14.76 $15.23 $15.69 $16.15 $16.61 $17.07 $17.53 $18.00 $18.46 35-39 $0.130 $18.60 $19.20 $19.80 $20.40 $21.00 $21.60 $22.20 $22.80 $23.40 $24.00 40-44 $0.180 $25.75 $26.58 $27.41 $28.24 $29.07 $29.90 $30.73 $31.56 $32.40 $33.23 45-49 $0.290 $41.49 $42.83 $44.16 $45.50 $46.84 $48.18 $49.52 $50.86 $52.20 $53.53 50-54 $0.470 $67.24 $69.41 $71.58 $73.75 $75.92 $78.09 $80.26 $82.43 $84.60 $86.76 55-59 $0.760 $108.73 $112.24 $115.75 $119.26 $122.76 $126.27 $129.78 $133.29 $136.80 $140.30 60-64 $1.110 $158.81 $163.93 $169.06 $174.18 $179.30 $184.43 $189.55 $194.67 $199.80 $204.92 65-69 $1.850 $264.69 $273.23 $281.76 $290.30 $298.84 $307.38 $315.92 $324.46 $333.00 $341.53 70-74 $3.230 $462.13 $477.04 $491.95 $506.86 $521.76 $536.67 $551.58 $566.49 $581.40 $596.30 75 & Over $5.330 $762.60 $787.20 $811.80 $836.40 $861.00 $885.60 $910.20 $934.80 $959.40 $984.00 $1,000-14 days 1 year *Issue Premiums - The premium for your coverage is paid by you. Issue pricing means that your rates (and your spouse s if applicable) do not change with age. After the initial rate guarantee period, the employer is subject an annual review and possible rate changes. Rates are effective as of the date shown above. Group life policies are underwritten by Bosn Mutual Life Insurance Company under Policy form BML GRTP 4/99, subject state details of coverage and availability, please refer your certificate or contact your benefits administrar. BOSTON MUTUAL LIFE INSURANCE COMPANY - 120 Royall Street - Cann MA 02021 - www.bosnmutual.com
Issue Life and AD&D Premiums* 18-59 60-69 70+ Employees may elect in increments of $10,000 a maximum of the lesser of 7 times salary or $500,000. 1,000 $410,000 $420,000 $430,000 $440,000 $450,000 $460,000 $470,000 $480,000 $490,000 $500,000 Under 20 $0.100 $18.92 $19.38 $19.84 $20.30 $20.76 $21.23 $21.69 $22.15 $22.61 $23.07 20-24 $0.100 $18.92 $19.38 $19.84 $20.30 $20.76 $21.23 $21.69 $22.15 $22.61 $23.07 25-29 $0.100 $18.92 $19.38 $19.84 $20.30 $20.76 $21.23 $21.69 $22.15 $22.61 $23.07 30-34 $0.100 $18.92 $19.38 $19.84 $20.30 $20.76 $21.23 $21.69 $22.15 $22.61 $23.07 35-39 $0.130 $24.60 $25.20 $25.80 $26.40 $27.00 $27.60 $28.20 $28.80 $29.40 $30.00 40-44 $0.180 $34.06 $34.89 $35.72 $36.55 $37.38 $38.21 $39.04 $39.87 $40.70 $41.53 45-49 $0.290 $54.87 $56.21 $57.55 $58.89 $60.23 $61.56 $62.90 $64.24 $65.58 $66.92 50-54 $0.470 $88.93 $91.10 $93.27 $95.44 $97.61 $99.78 $101.95 $104.12 $106.29 $108.46 55-59 $0.760 $143.81 $147.32 $150.83 $154.33 $157.84 $161.35 $164.86 $168.36 $171.87 $175.38 60-64 $1.110 $210.04 $215.16 $220.29 $225.41 $230.53 $235.66 $240.78 $245.90 $251.03 $256.15 65-69 $1.850 $350.07 $358.61 $367.15 $375.69 $384.23 $392.76 $401.30 $409.84 $418.38 $426.92 70-74 $3.230 $611.21 $626.12 $641.03 $655.93 $670.84 $685.75 $700.66 $715.56 $730.47 $745.38 75 & Over $5.330 $1,008.60 $1,033.20 $1,057.80 $1,082.40 $1,107.00 $1,131.60 $1,156.20 $1,180.80 $1,205.40 $1,230.00 $1,000-14 days 1 year *Issue Premiums - The premium for your coverage is paid by you. Issue pricing means that your rates (and your spouse s if applicable) do not change with age. After the initial rate guarantee period, the employer is subject an annual review and possible rate changes. Rates are effective as of the date shown above. Group life policies are underwritten by Bosn Mutual Life Insurance Company under Policy form BML GRTP 4/99, subject state details of coverage and availability, please refer your certificate or contact your benefits administrar. BOSTON MUTUAL LIFE INSURANCE COMPANY - 120 Royall Street - Cann MA 02021 - www.bosnmutual.com