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HomeMy WebLinkAboutCORRESPONDENCE - RFP - 7053 BENEFITS - LIFE AND DISABILITY-7flS 3 CONFIRMATION OF COVERAGE: 2011:Renewal — Voluntary Life CARRIER/POLICY #: Client / Legal name: ERISA Plan name: Eligible employees: Client / Insured Address: Anthem City of Fort Collins City of Fort Collins 1,400 215 North Mason Street, 2nd Floor Fort Collins, CO 80522 This document will confirm placement of the following coverage(s): � Voluntary Life Coverage will be effective on: 1/1/2011 For a period of: Rate guarantee until 12/31/2011 Rates / fees (including any subsequent period caps or guarantees) for the above -referenced coverage(s) are: Voluntary Ilfe Rates (Smoker) (per $10.000 Age Rate Age Rate <35 $0.60 60 — 64 $8.60 35 — 39 $0.90 65 — 69 $14.00 40 — 44 $1.40 70 — 74 $22.00 45 — 49 $2.50 75 — 79 $40.70 50 — 54 $4.00 55 — 59 $7.00 Voluntary life Rates (Non -Smoker) (per $10.000 Age Rate Age Rate <35 $0.40 60 — 64 $4.90 35 — 39 $0.50 65 — 69 $8.30 40 — 44 $0.80 70 — 74 $14.50 45 — 49 $1.30 75 — 79 $29.80 50 — 54 $2.00 55 — 59 $3.80 Voluntary Dependent Life Per dependent unit: $1.50 for $5,000 MERCER r]_ MARSH MERCER KROLL �C OVYCARPENTER OLNER WVMAH Description of benefits: Life Schedule $10,000 increments Maximum $300,000 Conversion Included Portability Included Waiver of Premium Provision Included Accelerated Death Benefit 50% to $100.000 AD&D Amount $10,000 Increments EE maximum $150,000 Spouse maximum NIA Spouse Schedule $10,000 Spouse Maximum $300,000 Child Schedule $5,000 per child Conditions of coverage(s): None As an authorized representative, I accept this confirmation of coverage. By signing below, I acknowledge agreement with the rates and benefits described above and that subsequent contract(s) shall conform to this document unless otherwise aareed to in writina_ Authorized Representati, Legal Name of Insurer/ Administrator Signature: Date: This form must be signed and MERCER MARS" MERCER KROLI GUYCARPENTER OUVERWYMAN