Attachment_B__Plan_Design_Worksheet.xlsx
XLSX spreadsheet 162 KB Posted
- Solicitation number
- RFP-1-26-12
- Issued by
- Brevard County, Florida
About this file
This is a Plan Design Worksheet for a Group Life & Disability and Supplemental Health Benefits contract opportunity issued by a Florida county. The County seeks to expand its current fully insured group benefits program, effective January 1, 2027, by contracting with a single carrier/administrator to provide group-sponsored Accident, Hospital Indemnity, and Critical Illness/Cancer coverage alongside its existing Group Term Life, Accidental Death & Dismemberment (AD&D), Short-Term Disability (STD), and Long-Term Disability (LTD) plans currently administered by Standard Insurance Company since January 1, 2019. The worksheet details comprehensive plan design specifications across six benefit categories: Life/AD&D with provisions for basic employer-paid coverage (1x annual earnings up to $200,000 with age-based reductions beginning at age 65), voluntary supplemental life coverage (up to $500,000), and retiree flat benefits of $5,000 or $10,000; STD with 60% income replacement up to $1,500 weekly with elimination periods of 14 or 90 days and maximum benefit durations of 24 or 13 weeks; LTD with 60% income replacement up to $5,000 monthly and benefit duration varying by age; Accident coverage providing 24-hour protection; Hospital Indemnity with perpetual guarantee issue and day-one pregnancy coverage; and Critical Illness/Cancer with multiple covered conditions. Proposers must submit completed worksheets in Excel format and may offer up to two plan options for Accident, Hospital Indemnity, and Critical Illness/Cancer lines, with the County reserving selection rights.
Key provisions indicate all disability coverages are 100% employee-paid, participation is limited to active full-time employees working 30 or more hours weekly with specified departmental exclusions, and all plans feature perpetual guarantee issue with no pre-existing condition limitations for supplemental products. Eligibility includes eligible dependents (spouse and unmarried children through age 26), with effectiveness occurring on the first or second month following hire date based on employment commencement timing. Tobacco rating applies to Life/AD&D and Critical Illness/Cancer products. Salary and age band changes are effective January 1st annually, and Life/AD&D benefits include provisions for waiver of premium, portability, conversion rights, and accelerated death benefits. The worksheet also includes an optional Permanent Life with Long-Term Care or Chronic Condition rider section requiring proposers to specify policy type, guaranteed issue minimums of $150,000, and rider specifications including care triggers, benefit payout structures, and compliance documentation. Proposers must provide monthly rate illustrations for a $50,000 benefit with applicable guaranteed cash values or paid-up benefits.
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Life-AD&D
| Attachment B - Plan Design Worksheet |
| Life/AD&D Plan Design |
| Instructions: |
| 1. Complete the highlighted cells for each line of coverage. For additional plan provisions, please see Exhibit B - Certificates of Coverage. |
| 2. You must submit this completed form with your proposal and include an electronic copy in Excel format per the Request for Proposal. |
| Item | Current Provision | Proposed Provision | Meets/Exceeds? (Y/N) | List Deviations |
| Eligibility & Enrollment | ||||
| Participation requirements | Waive | |||
| Eligibility Rules | Active FT 30+ Hours Per Week |
Cannot be insured as both an employee and dependent
Retirees can receive a flat $5,000 or $10,000 life without AD&D benefit if they elect at time of retirement Waiting period / Termination rules DOH on 1st-15th day of the month: Effective 1st of the following month
DOH on 16th - 31st day of the month: Effective 1st day of the 2nd month
Last day of employment is last day of coverage
| Dependent eligibility definitions (spouse/child) | Legal spouse and unmarried children through age 26; cannot be full-time members of the armed forces |
| Basic Life & AD&D (Employer Paid) | |
| Schedule of Benefits (Employees) | 1x annual earnings up to $200,000, rounded to the next higher $1,000 |
| AD&D bundling | Yes; matches life amount |
| Schedule of Benefits (Retirees) | Flat $5,000 or $10,000 life benefit without AD&D or age reduction |
| Age reductions (if any) and timing | Reduce by 8% at age 65 |
Reduce by 16% at age 66 Reduce by 24% at age 67 Reduce by 32% at age 68 Reduce by 40% at age 69 Reduce by 50% at age 70 or older
Age reductions take effect January 1
| Accelerated Death Benefit | Up to 75% of benefit to $500,000 combined basic and voluntary life amount for those with 12 months life expectancy |
| Repatriation Benefit | Not to exceed $5,000 or 10% benefit, whichever is less |
| Disability waiver of premium | Included |
| Portability / Conversion | Both included |
| Voluntary (Additional) Life & AD&D | |
| Participation Requirements | N/A |
| Employee Voluntary Life/AD&D Benefit Maximum & Increments | $500,000 (5x annual earnings limit) in $10,000 increments |
| AD&D bundling | Yes; matches life amount |
| Age reductions (if any) and timing | Reduce by 8% at age 65 |
Reduce by 16% at age 66 Reduce by 24% at age 67 Reduce by 32% at age 68 Reduce by 40% at age 69 Reduce by 50% at age 70 or older
Age reductions take effect January 1
| Employee Guarantee Issue Amount | 3x annual earnings up to $350,000 |
| Spouse Voluntary Life/AD&D Benefit Maximum & Increments | $250,000 (not to exceed 50% of employee election) in $5,000 increments |
| Spouse Guarantee Issue Amount | $30,000 |
| Spouse Life/AD&D age band based on Employee or Spouse Age | Employee age |
| Spouse Life/AD&D age reductions based on Employee or Spouse Age | Employee age |
| Child Voluntary Life Amount | $10,000 (not to exceed 50% of employee election) in $1,000 increments |
| Child AD&D availability | AD&D not offered for children |
| Child Life/AD&D Age Limit and Termination Rule | Unmarried child up to age 26. Terminates end of calendar year following 26th birthday |
| Evidence of insurability rules (late entrant, increases) | EOI required for any increase outside of new hire guarantee issue. EOI not required for children. |
| Tobacco rating (Y/N) | Yes |
| Accelerated Death Benefit | Up to 75% of benefit |
| Disability waiver of premium | Included |
| Portability / Conversion | Both included |
| Grandfathered coverage rules | N/A |
| Administration & Claims | |
| Salary change effective date | January 1st |
| Age band change effective date | January 1st |
| Rounding rules | Round to the next higher $1,000 |
STD
| Attachment B - Plan Design Worksheet |
| STD Plan Design |
| Instructions: |
| 1. Complete the highlighted cells for each line of coverage. No plan design change desired for STD (match current). For additional plan provisions, please see Exhibit B - Certificates of Coverage. |
| 2. You must submit this completed form with your proposal and include an electronic copy in Excel format per the Request for Proposal. |
| Item | Current Provision | Proposed Provision | Meets/Exceeds? (Y/N) | List Deviations |
| Eligibility & Enrollment | ||||
| Participation requirements | Waive | |||
| Eligibility Rules | Active FT 30+ Hours Per Week |
Clerk of Courts & Tax Collector employees excluded Waiting period / Termination rules DOH on 1st-15th day of the month: Effective 1st of the following month
DOH on 16th - 31st day of the month: Effective 1st day of the 2nd month
Last day of employment is last day of coverage
| Employee / Employer Contribution | 100% Employee Paid |
| Benefit Design – Match Current | |
| Benefit percentage | 60% of the first $2,500 of predisability earnings, before reduction by Deductible Income |
| Maximum weekly benefit | $1,500 |
| Maximum benefit duration | Plan 1: 24 weeks |
Plan 2: 13 weeks Elimination period (accident / sickness) Plan 1: 14 days (accident & sickness) Plan 2: 90 days (accident & sickness)
| Occupational sickness or injury | Not covered |
| Definition of earnings | Earnings in effect on last full day of active work. Does not include bonuses, commissions, overtime pay, stock options or stock bonuses, employer contributions on employee's behalf to any deferred compensation arrangement or pension plan, or any other extra compensation |
| Pre-existing condition limitation (if any) | None |
| Guarantee issue / EOI requirements | EOI required if coverage isn't elected in first 30 days of employment. No EOI required if switching from Plan 1 to Plan 2 |
| Grandfathered coverage rules | N/A |
| Sick time offset | Yes (employees can utilize sick pay before going out on a disability claim) |
| Deductible Income | See plan certificate for details |
| Administration & Claims | |
| Age banded or composite rates | Age banded |
| Salary change effective date | Current salary |
| Age band change effective date | January 1st |
| Pregnancy coverage | Treated as sickness |
| Rounding rules | None |
LTD
| Attachment B - Plan Design Worksheet |
| LTD Plan Design |
| Instructions: |
| 1. Complete the highlighted cells for each line of coverage. No plan design change desired for LTD (match current). For additional plan provisions, please see Exhibit B - Certificates of Coverage. |
| 2. You must submit this completed form with your proposal and include an electronic copy in Excel format per the Request for Proposal. |
| Item | Current Provision | Proposed Provision | Meets/Exceeds? (Y/N) | List Deviations |
| Eligibility & Enrollment | ||||
| Participation requirements | Waive | |||
| Eligibility Rules | Active FT 30+ Hours Per Week |
Tax Collector and Transportation & Planning Office employees excluded Waiting Period / Termination rules DOH on 1st-15th day of the month: Effective 1st of the following month
DOH on 16th - 31st day of the month: Effective 1st day of the 2nd month
Last day of employment is last day of coverage
| Employee / Employer Contribution | 100% Employee Paid |
| Benefit Design – Match Current | |
| Benefit percentage | 60% of the first $8,333 of predisability earnings, reduced by Deductible Income |
| Maximum monthly benefit | $5,000 before reduction by Deductible Income |
| Maximum benefit duration | 61 or younger to age 65, or to SSNRA, or 3 years 6 months whichever is longest; Age 62 to SSNRA or 3 years 6 months; Age 63 to SSNRA or 3 years; Age 64 to SSNRA or 2 years 6 months; Age 65 2 years; Age 66 1 year 9 months; Age 67 1 year 6 months; Age 68 1 year 3 months; Age 69 or older 1 year. |
| Elimination Period | Plan 1: 90 days |
Plan 2*: 180 days
*If enrolled on STD and LTD is also requested, must elect Plan 2 LTD Definition of earnings Earnings in effect on last full day of active work. Includes commissions averaged over the preceding 12 months or over the period of your employment if less than 12 months.
Does not include bonuses, overtime pay, stock options or stock bonuses, employer contributions on employee's behalf to any deferred compensation arrangement or pension plan, or any other extra compensation
| Earnings Test First 24 Months Initial | Loss of at least 20% of pre-disability earnings |
| Earnings Test After 24 Months Initial | Loss of at least 40% of pre-disability earnings |
| Social Security Offset | Primary Only |
| Zero Day Residual | Included |
| Pre-existing condition limitation (if any) | 3 month look-back, 12 month exclusion |
| Prudent Person Language | Included in Pre-Ex |
| Mental/Nervous Limitation | 24 months |
| Substance Abuse Limitation | 24 months |
| Limited Conditions Language | Included |
| Mandatory Rehabilitation | Yes |
| Reasonable Accomodation | Up to $25,000 |
| Survivor Benefits | Included |
| Waiver of Premium | Included |
| Guarantee issue / EOI requirements | EOI required if coverage isn't elected in first 30 days of employment |
| Grandfathered coverage rules | N/A |
| Own occupation period | 24 months |
| Any occupation definition | Expected to earn at least 60% of Indexed Predisability Earnings within 12 months following return to work, regardless of whether working in that or any other occupation. |
| Deductible Income | See plan certificate for details |
| Assisted living benefit (if any) | Yes |
| Return to Work Incentives | See plan certificate for details |
| Administration & Claims | |
| Age banded or composite rates | Age banded |
| Salary change effective date | Current salary |
| Age band change effective date | January 1st |
| Rounding rules | None |
Accident
| Attachment B - Plan Design Worksheet |
| Accident - Plan Design |
| Instructions: |
| 1. Complete the highlighted cells for each line of coverage. Include no more than 2 plan options. County reserves the right to choose one or both options. For current plan provisions, please see Exhibit B - Certificates of Coverage. |
| 2. You must submit this completed form with your proposal and include an electronic copy in Excel format per the Request for Proposal. |
| Item | Desired Provision | Proposed Plan 1 | Proposed Plan 2 | Meets/Exceeds? (Y/N) | List Deviations |
| Eligibility & Enrollment | |||||
| Participation Requirements | Waive | ||||
| Eligibility Rules | State your minimum rules; age; length of service; FT/PT Status; exclusions if any | ||||
| Covered Dependents | Spouse and Child(ren) | ||||
| Waiting Period / Termination rules | No waiting periods | ||||
| Pre-existing condition limitation | No pre-existing conditions | ||||
| Benefit Reduction | None | ||||
| Employee / Employer Contribution | Employee contributions; State if both pre-tax and post-tax would be options | ||||
| Plan Scope | |||||
| Coverage type (24 Hour or Off Job) | 24 hour | ||||
| Guaranteed issue / late entrant rules | Perpetual Guarantee Issue | ||||
| Portability / Conversion | Full portability at the same rates even if the master contract is cancelled in the future | ||||
| Exclusions | Please list | ||||
| Coverage Outside the United States | Indicate if benefits are payable if the accident occurs and/or if treatment is received outside the United States | ||||
| Waiver of Premium | Include if available | ||||
| Benefits (Provide Schedule) | |||||
| Initial treatment (Hospital/Urgent Care/Physician) | Match or improve | ||||
| Follow up Treatments | Match or improve | ||||
| Hospital admission | Match or improve | ||||
| Hospital confinement (per day and max) | Match or improve | ||||
| ICU confinement (per day and max) | Match or improve | ||||
| Rehabilitation Unit Confinement (per day and max) | Match or improve | ||||
| Therapy - occupational, physical, or speech (per day and max) | Match or improve | ||||
| Ambulance (ground/air) | Match or improve | ||||
| Blood/Plasma/Platelets | Match or improve | ||||
| Lacerations max (provide schedule) | Match or improve | ||||
| Outpatient Surgery & Anesthesia | Match or improve | ||||
| Inpatient Surgery & Anesthesia | Match or improve | ||||
| Transportation | Match or improve | ||||
| Family Member Lodging | Match or improve | ||||
| Burn - Second Degree max (provide schedule) | Match or improve | ||||
| Burn - Third Degree max (provide schedule) | Match or improve | ||||
| Paralysis (Paraplegia / Quadriplegia) | Match or improve | ||||
| Prosthesis | Match or improve | ||||
| Concussion | Match or improve | ||||
| Coma | Match or improve | ||||
| Dislocation max (provide schedule) | Match or improve | ||||
| Fracture max (provide schedule) | Match or improve | ||||
| Medical imaging (CT, CAT, EEG, EMG, MR, or MRI) | Match or improve | ||||
| Knee cartilage surgical repair | Match or improve | ||||
| Ruptured disc surgical repair | Match or improve | ||||
| Tendon/ligament/rotator cuff surgical repair | Match or improve | ||||
| Dental Injury | Match or improve | ||||
| Eye Injury | Match or improve | ||||
| Hearing loss injury | Match or improve | ||||
| Accidental Death Benefit (Employee / Spouse / Child) | Match or improve | ||||
| Dismemberment max (provide schedule) | Match or improve | ||||
| Organized Sports Benefit | Include for all covered persons | ||||
| Wellness / Health Screening Benefit | $100 for all covered persons |
Hospital Indemnity
| Attachment B - Plan Design Worksheet |
| Hospital Indemnity - Plan Design |
| Instructions: |
| 1. Complete the highlighted cells for each line of coverage. Include no more than 2 plan options. County reserves the right to choose one or both options. For current plan provisions, please see Exhibit B - Certificates of Coverage. |
| 2. You must submit this completed form with your proposal and include an electronic copy in Excel format per the Request for Proposal. |
| Item | Desired Provision | Proposed Plan 1 | Proposed Plan 2 | Meets/Exceeds? (Y/N) | List Deviations |
| Eligibility & Enrollment | |||||
| Participation Requirements | Waive | ||||
| Eligibility Rules | State your minimum rules; age; length of service; FT/PT Status; exclusions if any | ||||
| Covered Dependents | Spouse and Child(ren) | ||||
| Waiting Period / Termination rules | No waiting periods | ||||
| Pre-existing condition limitation | No pre-existing conditions | ||||
| Benefit Reduction | None | ||||
| Pregnancy Day 1 benefit | Pregnancy included day 1, no limitations or waiting periods | ||||
| Employee / Employer Contribution | Employee contributions; State if both pre-tax and post-tax would be options | ||||
| HSA Compatible | Yes | ||||
| Plan Scope | |||||
| Guaranteed Issue / late entrant rules | Perpetual Guarantee Issue | ||||
| Portability / Conversion | Full portability at the same rates even if the master contract is cancelled in the future | ||||
| Exclusions | Please list | ||||
| Coverage Outside the United States | Indicate if benefits are payable if occurred and/or if treatment is received outside the United States | ||||
| Waiver of Premium | Include | ||||
| Core Benefits | |||||
| Hospital Admission (per confinement) | Match or improve | ||||
| Hospital Confinement (per day and max) | Match or improve | ||||
| ICU Confinment (per day and max) | Match or improve | ||||
| Intermediate ICU Step-Down Unit (per day and max) | Match or improve | ||||
| Major Diagnostic Exams | Match or improve | ||||
| Outpatient Doctor's Office Visit (per visit and max) | Match or improve | ||||
| Inpatient Surgery and Anesthesia | Match or improve | ||||
| Outpatient Surgery and Anesthesia (Hospital or ASC) | Match or improve | ||||
| Outpatient Surgery and Anesthesia (Doctor's Office, Urgent Care, or ER) | Match or improve | ||||
| Newborn Benefits | Include | ||||
| Wellness / Health Screening Benefit | $100 for all covered persons |
Critical Illness + Cancer
| Attachment B - Plan Design Worksheet |
| Critical Illness + Cancer - Plan Design |
| Instructions: |
| 1. Complete the highlighted cells for each line of coverage. Include no more than 2 plan options. County reserves the right to choose one or both options. For current plan provisions, please see Exhibit B - Certificates of Coverage. |
| 2. You must submit this completed form with your proposal and include an electronic copy in Excel format per the Request for Proposal. |
| Item | Desired Provision | Proposed Plan 1 | Proposed Plan 2 | Meets/Exceeds? (Y/N) | List Deviations |
| Eligibility & Enrollment | |||||
| Participation Requirements | Waive | ||||
| Eligibility Rules | State your minimum rules; age; length of service; FT/PT Status; exclusions if any | ||||
| Covered Dependents | Include 100% of employee amount for all covered dependents | ||||
| Waiting Period / Termination rules | No Waiting Periods | ||||
| Pre-existing condition limitation | No Pre-existing conditions | ||||
| Benefit Reduction | None | ||||
| Coverage Outside the United States | List any stipulations; for example if diagnosis is made outside the United States would a benefit be payable? | ||||
| Employee / Employer Contribution | Employee contributions; State if both pre-tax and post-tax would be options | ||||
| Plan Scope | |||||
| Guarantee Issue Amounts (Employee / Spouse / Child) | $50,000 GI in increments of $5k | ||||
| Issue or attained age | Attained Age; include Child in Employee Rate; 5 year age bands | ||||
| Guaranteed issue / late entrant rules | Perpetual Guarantee Issue | ||||
| Benefit amounts available (min/increments/max for Employee / Spouse / Child) | All covered persons: $5,000 - $50,000 in $5,000 increments | ||||
| Age | Is age based on effective date; what date is used when changing age bands; is Spouse based on their age or employee age? | ||||
| Tobacco rating (if any) | Indicate if quoting NT/T or Antitobacco. If NT/T is spouse status based on employee NT/T status? | ||||
| Portability / Conversion | Full portability at the same rates even if the master contract is cancelled in the future | ||||
| Exclusions | Please list | ||||
| Waiver of Premium | Include | ||||
| Additional Diagnosis Benefit | Include with no limits or caps; quote with the minimum separation period available | ||||
| Recurrence Benefit | Include with no limits or caps; quote with the minimum separation period available | ||||
| Covered Conditions | |||||
| Heart Attack (not cardiac arrest) | Include, or state if unavailable to include | ||||
| Cardiac Arrest | Include, or state if unavailable to include | ||||
| Stroke | Include, or state if unavailable to include | ||||
| Major Organ Failure / Transplant | Include, or state if unavailable to include | ||||
| Kidney Failure (End-Stage Renal Failure) | Include, or state if unavailable to include | ||||
| Bone Marrow Transplant (Stem Cell Transplant) | Include, or state if unavailable to include | ||||
| Coma | Include, or state if unavailable to include | ||||
| Paralysis | Include, or state if unavailable to include | ||||
| Severe Burns | Include, or state if unavailable to include | ||||
| Loss of Sight | Include, or state if unavailable to include | ||||
| Loss of Hearing | Include, or state if unavailable to include | ||||
| Loss of Speech | Include, or state if unavailable to include | ||||
| HIV or Hepatitis | Include, or state if unavailable to include | ||||
| Advanced Alzheimer's Disease | Include, or state if unavailable to include | ||||
| Advanced Parkinson's Disease | Include, or state if unavailable to include | ||||
| Benign Brain Tumor | Include, or state if unavailable to include | ||||
| Coronary Artery Disease (Major) | Include, or state if unavailable to include | ||||
| Coronary Artery Bypass Surgery | Include, or state if unavailable to include | ||||
| Mitral/Aortic Valve Replacement or Repair | Include, or state if unavailable to include | ||||
| Surgical Treatment of Abdominal Aortic Aneurysm | Include, or state if unavailable to include | ||||
| Wellness / Health Screening Benefit | $100 for all covered persons | ||||
| Dependent Child Covered Conditions | |||||
| Cerebral Palsy | Include, or state if unavailable to include | ||||
| Cleft Lip or Palate | Include, or state if unavailable to include | ||||
| Cogenital Heart Disease | Include, or state if unavailable to include | ||||
| Cystic Fibrosis | Include, or state if unavailable to include | ||||
| Down Syndrome | Include, or state if unavailable to include | ||||
| Sickle Cell Anemia | Include, or state if unavailable to include | ||||
| Spina Bifida | Include, or state if unavailable to include | ||||
| Type 1 Diabetes | Include, or state if unavailable to include | ||||
| Other | Additional conditions not listed above | ||||
| Cancer Specific Conditions | |||||
| Internal or Invasive Cancer | Include, or state if unavailable to include | ||||
| Non-Invasive Cancer | Include, or state if unavailable to include | ||||
| Skin Cancer | Include, or state if unavailable to include | ||||
| Additional Covered Conditions Not Listed Above | Please list; include infectious diseases |
Permanent Life with LTC
| Attachment B - Plan Design Worksheet |
| OPTIONAL - Permanent Life with Long Term Care or Chronic Condition |
Instructions: Include 1 plan option. County reserves the right not to offer this plan, or may choose to offer at a future date, including the ability to offer offcycle from Open Enrollment.
| LIFE INSURANCE | Desired Provisions | Proposed Plan 1 | Meets/Exceeds? (Y/N) | List Deviations |
| Policy Type | State Type Quoting - UL/WL/Term | |||
| Eligibility Rules | State your minimum rules; age; length of service; FT/PT Status; exclusions if any | |||
| Dependent Coverage | Spouse; Child(ren); and Grandchild(ren) | |||
| Participation Requirement | Waive | |||
| Portability | Include | |||
| Maximum Benefit Amount | State Maximum Benefit available | |||
| Guaranteed Issue | Minimum of $150,000 | |||
| Benefit Reduction | None | |||
| Cash Value or Paid Up Benefits | State if policy builds cash value or provides paid up benefits | |||
| Guaranteed Interest Rate | State if applicable | |||
| Current Interest Rate | State if applicable | |||
| LTC/CC RIDER | ||||
| Long Term Care or Chronic Condition Rider | State Rider | |||
| Trigger for benefit to be payable under this rider | Provide cert language | |||
| Payout | State how the benefit is paid; monthly benefit percent and/or lump sum options | |||
| Extension of Benefits | Include maximum benefit | |||
| Restoration | Include maximum benefit | |||
| Care Requirement | State care and/or confinement requirements | |||
| Family Care | State if a family member can provide care including any licensed care requirements | |||
| Permanency Language | State if the condition has to be deemed permanent | |||
| Pre-ex | State if there is a pre-ex | |||
| Waiver of Premium | State if premiums are waived while benefits are being paid under this rider | |||
| Compliance | State if the plan is considered to be 7702(b) or 101(g) compliant. | |||
| Other Rider(s) | ||||
| Accelerated Death Benefit for Terminal Illness | State if available and automatically included or optional at the employee or employer level | |||
| Spouse Term Rider | State if available and automatically included or optional at the employee or employer level | |||
| Child Term Rider | State if available and automatically included or optional at the employee or employer level | |||
| Accidental Death Benefit | State if available and automatically included or optional at the employee or employer level | |||
| Waiver of Premium for Disability | State if available and automatically included or optional at the employee or employer level | |||
| Other Riders not listed above | List any additional riders not listed above | |||
| Rate Illustrations | Provide monthly rates for a $50,000 benefit. As applicable include either guaranteed cash values at age 65 or Paid up Benefits. |
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