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BK:00024 PG:0872 n I <br />Group Name: CL] u n`� , c L.¢ <br />Life/ADD/STD: N I H ❑ Renewal (No Changes) <br />Only complete this section if you are adding or changing coverage for Life /Accidental Death & Qfyou chock No Charges -do not <br />Dismemberment (ADD)Mort Term Disability (STD) .,plate rho ❑fe /ADFVSM section.) <br />Underwritten by USAble Life, an independent life insurance company, that does not provide SCBSNC <br />El Renewal (With Changes) <br />products or services and is solely responsible for the life and disability insurance coverage below. <br />22a. Number of Employees: <br />22b. Employer Contribution (percentage): <br />Life and ADD % Supplemental % <br />Eligible: Enrolled: <br />Dependent Life % STD % <br />23. Supplemental Short Term Disability <br />L'de /ADD• ❑Life ❑ADD Salary Flat <br />Multiple ❑Schedule <br />Class Descriptions <br />❑ Amount of Insurance Amount of Insurance Maximum. Weekly Benefit <br />2. 2. 2. 2. <br />3. 3. 3. 3. <br />4. 4. 4. C <br />If Life and ADD benefit is a multiple of salary, the amount will be rounded to the next higher $1,000. <br />24. Short Tenn The maximum weekly and the benefit <br />Accident Sickness Duration <br />Disability STD benefits is $ may not exceed % <br />(non - occupational): •weekl bonuses, overtime or an <br />of an insured's <br />Daysr Days Weeks / Income excludin (excluding y <br />form of extra p ay ) <br />25. Dependent Life Insurance (Benefit amounts are limited in some states): Dyes ❑ No <br />❑ from birth to 6 months $ Spouse; $ <br />Children: <br />❑ 6 months to 26 years $ <br />26. Reductions and Termination (Benefit reduction due to age will be effective on the in ured's birthday.) <br />Employee Life and ADD benefits reduce by the following percent or to the amount shown. Benefits terminate when an employee is no longer eligible <br />as an active employee or at retirement. <br />At Age 65 <br />At Age 70 <br />Terminates <br />tither <br />27. Guaranteed Issue Amount $ (Life and ADD amounts over Guaranteed Issue are subject to evidence of insumbillty.) <br />COMPLIANCE NOTICE: USAble Life does not provide legal or tax advice. Based upon information you have provided USAble about your group, <br />USAble Life will notify you if USAble Life perceives any obvious deficiency in your plan, but you must consult your own legal counsel for definitive <br />advice and opinions regarding your plan's compliance. <br />WARNING: It is or may be a crime to knowingly provide false incomplete or misleading information to USAble Life for the purposes of defrauding <br />USAble Life or other person. Penalties may include imprisonment, fines or denial of insurance benefits in accordance with applicable state law. It <br />is further understood and agreed that this application shall be made a part of the USAble Life policy or policies applied for and that no insurance <br />shall be effective until approved by USAble Life's home office. ' <br />PAGES o+4 <br />