Exhibit 5 - Supplemental Benefit Summary.pdf

Pl an H igh l ight s

Group Suppl ement al and Dependent L i fe Insurance

St. John River Water Management District

ELIGIBILITY

Employees: Each Active, Full‐time employee working 30 or more hours per week, and Part‐time employee

BENEFIT REDUCTION DUE TO AGE

(applicable to employee/spouse coverage) Original Benefit working 20 or more hours per week except any person Age Reduced To working on a temporary or seasonal basis.

Dependents: You must be insured in order for Dependents to be covered.

Dependents are:

your legal spouse not legally separated or divorced from you your unmarried financially dependent children* age 14 days to 20 years (to 26 years if full‐time student).

* children in your custody. natural and adopted children;

stepchildren and foster children in custody.

Age limit does not apply to handicapped children.

A person may not have coverage as both an Employee and

Dependent.

Only one insured spouse may cover Dependent children.

BENEFIT AMOUNT

Supplemental Life

Choose from a minimum of $10,000 to a maximum of

$500,000 in $10,000 increments

Amounts of life insurance equal to $150,000 or more may be subject to an earnings cap.

Dependent Life

Spouse

Choose from a minimum of $5,000 to a maximum of

$250,000 in $5,000 increments (not to exceed 5 times

Earnings)

(spouse amount may not exceed 50% of employee amount)

Dependent Child(ren)

14 days to age 20: $10,000 or $20,000

(up to age 26 if a full‐time student)

GUARANTEED ISSUE (INITIAL ELIGIBILITY PERIOD

ONLY)

Employee: $200,000

Spouse: $50,000

Child: all child amounts are guaranteed issue

65 65%

70 50%

RATE

See attached Rate Sheet.

FEATURES

Conversion Privilege

Portability

CONTRIBUTION REQUIREMENTS

Supplemental Life:

Coverage is 100% employee paid.

Spouse: Coverage is 100% employee paid.

Dependent Child(ren): Coverage is 100% employee paid.

EXCLUSIONS

For a comprehensive list of exclusions and limitations, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefits.

This Plan Highlights is a brief description of the key features of the RSL insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage. Insurance is provided under group policy form LRS‐6422, et al.

www.RelianceStandard.com

Reliance Standard Insurance Plans Supplemental Life Insurance

Premium Table Plan Holder: St. John River Water Management District - GL # 159541

Class

Reliance Standard Plans

Supplemental and Dependent Life Insurance

Premium Table

Plan Holder: St. Johns River Water Management District

Scheduled Benefit: Each eligible employee may elect for himself/herself and/or his/her eligible spouse an amount of insurance shown in the table below.

For employees age 65 and older: Benefit amounts are reduced according to the age-based reduction chart shown in the Supplemental Life brochure.

Employee/Spouse Premiums: To find you and your spouse's premium:

Determine your age band: Your age = your age at your last birthday.

Select a benefit amount (employees age 65 and older: see above comment).

Spouse premium: Repeat the steps above for your spouse at your age at your last birthday.

Employee and spouse rates change as insured moves from one age bracket to the next.

Employee Semi-Monthly Premiums

Benefit Amount

Age 18-24

Age 25-29

Age 30-34

Age 35-39

Age 40-44

Age 45-49

Age 50-54

Age 55-59

Age 60-64

Age 65-69

Age 70+

$10,000 $0.25 $0.30 $0.49 $0.59 $0.69 $1.03 $1.86 $3.71 $4.49 $8.10 $16.29

$20,000 $0.49 $0.59 $0.98 $1.17 $1.37 $2.05 $3.71 $7.41 $8.97 $16.19 $32.57

$30,000 $0.74 $0.89 $1.47 $1.76 $2.06 $3.08 $5.57 $11.12 $13.46 $24.29 $48.86

$40,000 $0.98 $1.18 $1.96 $2.34 $2.74 $4.10 $7.42 $14.82 $17.94 $32.38 $65.14

$50,000 $1.23 $1.48 $2.45 $2.93 $3.43 $5.13 $9.28 $18.53 $22.43 $40.48 $81.43

$60,000 $1.47 $1.77 $2.94 $3.51 $4.11 $6.15 $11.13 $22.23 $26.91 $48.57 $97.71

$70,000 $1.72 $2.07 $3.43 $4.10 $4.80 $7.18 $12.99 $25.94 $31.40 $56.67 $114.00

$80,000 $1.96 $2.36 $3.92 $4.68 $5.48 $8.20 $14.84 $29.64 $35.88 $64.76 $130.28

$90,000 $2.21 $2.66 $4.41 $5.27 $6.17 $9.23 $16.70 $33.35 $40.37 $72.86 $146.57

$100,000 $2.45 $2.95 $4.90 $5.85 $6.85 $10.25 $18.55 $37.05 $44.85 $80.95 $162.85

$110,000 $2.70 $3.25 $5.39 $6.44 $7.54 $11.28 $20.41 $40.76 $49.34 $89.05 $179.14

$120,000 $2.94 $3.54 $5.88 $7.02 $8.22 $12.30 $22.26 $44.46 $53.82 $97.14 $195.42

$130,000 $3.19 $3.84 $6.37 $7.61 $8.91 $13.33 $24.12 $48.17 $58.31 $105.24 $211.71

$140,000 $3.43 $4.13 $6.86 $8.19 $9.59 $14.35 $25.97 $51.87 $62.79 $113.33 $227.99

$150,000 $3.68 $4.43 $7.35 $8.78 $10.28 $15.38 $27.83 $55.58 $67.28 $121.43 $244.28

$160,000 $3.92 $4.72 $7.84 $9.36 $10.96 $16.40 $29.68 $59.28 $71.76 $129.52 $260.56

$170,000 $4.17 $5.02 $8.33 $9.95 $11.65 $17.43 $31.54 $62.99 $76.25 $137.62 $276.85

$180,000 $4.41 $5.31 $8.82 $10.53 $12.33 $18.45 $33.39 $66.69 $80.73 $145.71 $293.13

$190,000 $4.66 $5.61 $9.31 $11.12 $13.02 $19.48 $35.25 $70.40 $85.22 $153.81 $309.42

$200,000 $4.90 $5.90 $9.80 $11.70 $13.70 $20.50 $37.10 $74.10 $89.70 $161.90 $325.70

$210,000 $5.15 $6.20 $10.29 $12.29 $14.39 $21.53 $38.96 $77.81 $94.19 $170.00 $341.99

$220,000 $5.39 $6.49 $10.78 $12.87 $15.07 $22.55 $40.81 $81.51 $98.67 $178.09 $358.27

$230,000 $5.64 $6.79 $11.27 $13.46 $15.76 $23.58 $42.67 $85.22 $103.16 $186.19 $374.56

$240,000 $5.88 $7.08 $11.76 $14.04 $16.44 $24.60 $44.52 $88.92 $107.64 $194.28 $390.84

$250,000 $6.13 $7.38 $12.25 $14.63 $17.13 $25.63 $46.38 $92.63 $112.13 $202.38 $407.13

$260,000 $6.37 $7.67 $12.74 $15.21 $17.81 $26.65 $48.23 $96.33 $116.61 $210.47 $423.41

$270,000 $6.62 $7.97 $13.23 $15.80 $18.50 $27.68 $50.09 $100.04 $121.10 $218.57 $439.70

$280,000 $6.86 $8.26 $13.72 $16.38 $19.18 $28.70 $51.94 $103.74 $125.58 $226.66 $455.98

$290,000 $7.11 $8.56 $14.21 $16.97 $19.87 $29.73 $53.80 $107.45 $130.07 $234.76 $472.27

$300,000 $7.35 $8.85 $14.70 $17.55 $20.55 $30.75 $55.65 $111.15 $134.55 $242.85 $488.55

$310,000 $7.60 $9.15 $15.19 $18.14 $21.24 $31.78 $57.51 $114.86 $139.04 $250.95 $504.84

$320,000 $7.84 $9.44 $15.68 $18.72 $21.92 $32.80 $59.36 $118.56 $143.52 $259.04 $521.12

$330,000 $8.09 $9.74 $16.17 $19.31 $22.61 $33.83 $61.22 $122.27 $148.01 $267.14 $537.41

$340,000 $8.33 $10.03 $16.66 $19.89 $23.29 $34.85 $63.07 $125.97 $152.49 $275.23 $553.69

$350,000 $8.58 $10.33 $17.15 $20.48 $23.98 $35.88 $64.93 $129.68 $156.98 $283.33 $569.98

$360,000 $8.82 $10.62 $17.64 $21.06 $24.66 $36.90 $66.78 $133.38 $161.46 $291.42 $586.26

$370,000 $9.07 $10.92 $18.13 $21.65 $25.35 $37.93 $68.64 $137.09 $165.95 $299.52 $602.55

$380,000 $9.31 $11.21 $18.62 $22.23 $26.03 $38.95 $70.49 $140.79 $170.43 $307.61 $618.83

$390,000 $9.56 $11.51 $19.11 $22.82 $26.72 $39.98 $72.35 $144.50 $174.92 $315.71 $635.12

$400,000 $9.80 $11.80 $19.60 $23.40 $27.40 $41.00 $74.20 $148.20 $179.40 $323.80 $651.40

$410,000 $10.05 $12.10 $20.09 $23.99 $28.09 $42.03 $76.06 $151.91 $183.89 $331.90 $667.69

$420,000 $10.29 $12.39 $20.58 $24.57 $28.77 $43.05 $77.91 $155.61 $188.37 $339.99 $683.97

$430,000 $10.54 $12.69 $21.07 $25.16 $29.46 $44.08 $79.77 $159.32 $192.86 $348.09 $700.26

$440,000 $10.78 $12.98 $21.56 $25.74 $30.14 $45.10 $81.62 $163.02 $197.34 $356.18 $716.54

$450,000 $11.03 $13.28 $22.05 $26.33 $30.83 $46.13 $83.48 $166.73 $201.83 $364.28 $732.83

$460,000 $11.27 $13.57 $22.54 $26.91 $31.51 $47.15 $85.33 $170.43 $206.31 $372.37 $749.11

$470,000 $11.52 $13.87 $23.03 $27.50 $32.20 $48.18 $87.19 $174.14 $210.80 $380.47 $765.40

$480,000 $11.76 $14.16 $23.52 $28.08 $32.88 $49.20 $89.04 $177.84 $215.28 $388.56 $781.68

$490,000 $12.01 $14.46 $24.01 $28.67 $33.57 $50.23 $90.90 $181.55 $219.77 $396.66 $797.97

$500,000 $12.25 $14.75 $24.50 $29.25 $34.25 $51.25 $92.75 $185.25 $224.25 $404.75 $814.25

Spouse Semi-Monthly Premiums

Benefit Amount

Age 18-24

Age 25-29

Age 30-34

Age 35-39

Age 40-44

Age 45-49

Age 50-54

Age 55-59

Age 60-64

Age 65-69

Age 70+

$5,000 $0.12 $0.15 $0.25 $0.29 $0.34 $0.51 $0.93 $1.85 $2.24 $4.05 $8.14

$10,000 $0.25 $0.30 $0.49 $0.59 $0.69 $1.03 $1.86 $3.71 $4.49 $8.10 $16.29

$15,000 $0.37 $0.44 $0.74 $0.88 $1.03 $1.54 $2.78 $5.56 $6.73 $12.14 $24.43

$20,000 $0.49 $0.59 $0.98 $1.17 $1.37 $2.05 $3.71 $7.41 $8.97 $16.19 $32.57

$25,000 $0.61 $0.74 $1.23 $1.46 $1.71 $2.56 $4.64 $9.26 $11.21 $20.24 $40.71

$30,000 $0.74 $0.89 $1.47 $1.76 $2.06 $3.08 $5.57 $11.12 $13.46 $24.29 $48.86

$35,000 $0.86 $1.03 $1.72 $2.05 $2.40 $3.59 $6.49 $12.97 $15.70 $28.33 $57.00

$40,000 $0.98 $1.18 $1.96 $2.34 $2.74 $4.10 $7.42 $14.82 $17.94 $32.38 $65.14

$45,000 $1.10 $1.33 $2.21 $2.63 $3.08 $4.61 $8.35 $16.67 $20.18 $36.43 $73.28

$50,000 $1.23 $1.48 $2.45 $2.93 $3.43 $5.13 $9.28 $18.53 $22.43 $40.48 $81.43

$55,000 $1.35 $1.62 $2.70 $3.22 $3.77 $5.64 $10.20 $20.38 $24.67 $44.52 $89.57

$60,000 $1.47 $1.77 $2.94 $3.51 $4.11 $6.15 $11.13 $22.23 $26.91 $48.57 $97.71

$65,000 $1.59 $1.92 $3.19 $3.80 $4.45 $6.66 $12.06 $24.08 $29.15 $52.62 $105.85

$70,000 $1.72 $2.07 $3.43 $4.10 $4.80 $7.18 $12.99 $25.94 $31.40 $56.67 $114.00

$75,000 $1.84 $2.21 $3.68 $4.39 $5.14 $7.69 $13.91 $27.79 $33.64 $60.71 $122.14

$80,000 $1.96 $2.36 $3.92 $4.68 $5.48 $8.20 $14.84 $29.64 $35.88 $64.76 $130.28

$85,000 $2.08 $2.51 $4.17 $4.97 $5.82 $8.71 $15.77 $31.49 $38.12 $68.81 $138.42

$90,000 $2.21 $2.66 $4.41 $5.27 $6.17 $9.23 $16.70 $33.35 $40.37 $72.86 $146.57

$95,000 $2.33 $2.80 $4.66 $5.56 $6.51 $9.74 $17.62 $35.20 $42.61 $76.90 $154.71

$100,000 $2.45 $2.95 $4.90 $5.85 $6.85 $10.25 $18.55 $37.05 $44.85 $80.95 $162.85

$105,000 $2.57 $3.10 $5.15 $6.14 $7.19 $10.76 $19.48 $38.90 $47.09 $85.00 $170.99

$110,000 $2.70 $3.25 $5.39 $6.44 $7.54 $11.28 $20.41 $40.76 $49.34 $89.05 $179.14

$115,000 $2.82 $3.39 $5.64 $6.73 $7.88 $11.79 $21.33 $42.61 $51.58 $93.09 $187.28

$120,000 $2.94 $3.54 $5.88 $7.02 $8.22 $12.30 $22.26 $44.46 $53.82 $97.14 $195.42

$125,000 $3.06 $3.69 $6.13 $7.31 $8.56 $12.81 $23.19 $46.31 $56.06 $101.19 $203.56

$130,000 $3.19 $3.84 $6.37 $7.61 $8.91 $13.33 $24.12 $48.17 $58.31 $105.24 $211.71

$135,000 $3.31 $3.98 $6.62 $7.90 $9.25 $13.84 $25.04 $50.02 $60.55 $109.28 $219.85

$140,000 $3.43 $4.13 $6.86 $8.19 $9.59 $14.35 $25.97 $51.87 $62.79 $113.33 $227.99

$145,000 $3.55 $4.28 $7.11 $8.48 $9.93 $14.86 $26.90 $53.72 $65.03 $117.38 $236.13

$150,000 $3.68 $4.43 $7.35 $8.78 $10.28 $15.38 $27.83 $55.58 $67.28 $121.43 $244.28

$155,000 $3.80 $4.57 $7.60 $9.07 $10.62 $15.89 $28.75 $57.43 $69.52 $125.47 $252.42

$160,000 $3.92 $4.72 $7.84 $9.36 $10.96 $16.40 $29.68 $59.28 $71.76 $129.52 $260.56

$165,000 $4.04 $4.87 $8.09 $9.65 $11.30 $16.91 $30.61 $61.13 $74.00 $133.57 $268.70

$170,000 $4.17 $5.02 $8.33 $9.95 $11.65 $17.43 $31.54 $62.99 $76.25 $137.62 $276.85

$175,000 $4.29 $5.16 $8.58 $10.24 $11.99 $17.94 $32.46 $64.84 $78.49 $141.66 $284.99

$180,000 $4.41 $5.31 $8.82 $10.53 $12.33 $18.45 $33.39 $66.69 $80.73 $145.71 $293.13

$185,000 $4.53 $5.46 $9.07 $10.82 $12.67 $18.96 $34.32 $68.54 $82.97 $149.76 $301.27

$190,000 $4.66 $5.61 $9.31 $11.12 $13.02 $19.48 $35.25 $70.40 $85.22 $153.81 $309.42

$195,000 $4.78 $5.75 $9.56 $11.41 $13.36 $19.99 $36.17 $72.25 $87.46 $157.85 $317.56

$200,000 $4.90 $5.90 $9.80 $11.70 $13.70 $20.50 $37.10 $74.10 $89.70 $161.90 $325.70

$205,000 $5.02 $6.05 $10.05 $11.99 $14.04 $21.01 $38.03 $75.95 $91.94 $165.95 $333.84

$210,000 $5.15 $6.20 $10.29 $12.29 $14.39 $21.53 $38.96 $77.81 $94.19 $170.00 $341.99

$215,000 $5.27 $6.34 $10.54 $12.58 $14.73 $22.04 $39.88 $79.66 $96.43 $174.04 $350.13

$220,000 $5.39 $6.49 $10.78 $12.87 $15.07 $22.55 $40.81 $81.51 $98.67 $178.09 $358.27

$225,000 $5.51 $6.64 $11.03 $13.16 $15.41 $23.06 $41.74 $83.36 $100.91 $182.14 $366.41

$230,000 $5.64 $6.79 $11.27 $13.46 $15.76 $23.58 $42.67 $85.22 $103.16 $186.19 $374.56

$235,000 $5.76 $6.93 $11.52 $13.75 $16.10 $24.09 $43.59 $87.07 $105.40 $190.23 $382.70

$240,000 $5.88 $7.08 $11.76 $14.04 $16.44 $24.60 $44.52 $88.92 $107.64 $194.28 $390.84

$245,000 $6.00 $7.23 $12.01 $14.33 $16.78 $25.11 $45.45 $90.77 $109.88 $198.33 $398.98

$250,000 $6.13 $7.38 $12.25 $14.63 $17.13 $25.63 $46.38 $92.63 $112.13 $202.38 $407.13

Dependent Child(ren) Semi-Monthly Premiums:

Benefit Amount

Premium

$10,000 $0.55

$20,000 $1.10

(One rate and benefit amount for all eligible children in family, regardless of number)

PREMIUM CALCULATION (Add your elections here):

Employee

Spouse

Dependent Child(ren)

Total

(Rates are calculated as of coverage effective date and are based on insured's age in relation to Plan anniversary date. Billed rates may be higher if, at application, the person is at the highest age in an age band).

Please read this important information:

You may not have coverage as both an employee and as a dependent.

Only one insured spouse may cover the eligible dependent children.

Rates are subject to change.