IFE
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University of Utah Division of Human Resources – Benefits Department
420 Wakara Way, Suite 105 (801) 581-7447
Salt Lake City, UT 84108 Fax: (801) 585-7375
L
IFE
I
NSURANCE
S
PECIAL
E
NROLLMENT
F
ORM
Name: Empl
ID#:
Date of Hire:
Hours Worked Each Week:
University employees in benefit-eligible positions have a Special Enrollment opportunity to
enroll in Spouse and Dependent Child Life Insurance Coverage through Hartford Life and
Accident Insurance Company without providing evidence of good health.
The Special Enrollment period runs from April 1 through April 30, 2008.
Coverage elected during the Special Enrollment will become effective on the first day of the
month following the date the enrollment form is submitted to the Benefits Department.
Spouse Supplemental Term Life Insurance
You may apply for up to $250,000 in Supplemental Term Life Insurance on
your Spouse.
During this Special Enrollment, you may enroll in up to $30,000 (minimum
$20,000) without providing evidence of good health. If you already have
$30,000 or more in Spouse coverage or would like more than $30,000 in
coverage, you will need to provide evidence of good health for additional
amounts.
To be eligible for this special enrollment, you must have Supplemental Term
Life Insurance on your own life (or apply for coverage on your own life), in an
amount equal to or greater than the amount of Spouse coverage you elect.
1
I WISH TO ENROLL IN SPOUSE
SUPPLEMENTAL TERM LIFE INSURANCE
IN THE AMOUNT OF
$______________________________
(You may enroll in up to $30,000 through this Special
Enrollment Offer without providing evidence of good
health.)
Dependent Child Supplemental Term Life Insurance
You may apply for Dependent Child Supplemental Term Life Insurance in the
amount of $5,000 or $10,000.
This insurance covers all your unmarried dependent children, legally adopted
children, stepchildren, and foster children from live birth through age 25
(coverage may be continued at age 26 for a disabled child).
To be eligible for this coverage, you must have Supplemental Term Life
Insurance on your own life (or apply for coverage on your own life).
1
I WISH TO ENROLL IN DEPENDENT CHILD
SUPPLEMENTAL TERM LIFE INSURANCE
IN THE AMOUNT OF
?
$5,000
?
$10,000
Part III Basic Dependent Life Insurance
You may apply for Part III Basic Dependent Life Insurance in the amount of
$2,000.
This insurance covers your spouse and all your unmarried dependent children,
legally adopted children, stepchildren, and foster children from live birth
through age 25 (coverage may be continued at age 26 for a disabled child).
To be eligible for this coverage, you must have or apply for Part II Basic Life
Insurance on your own life.
1
?
I WISH TO ENROLL IN PART III
BASIC DEPENDENT LIFE
INSURANCE
I have read and understand the information provided. I acknowledge that I have been given this special enrollment
opportunity and understand that if I decline now, but later decide to enroll, I will be required to provide evidence of good
health that is satisfactory to Hartford Life and understand my request for coverage may be denied. I hereby apply for
the coverages I have indicated above and authorize the University to make the appropriate deductions from may wages
to pay for my share of the cost.
Employee Signature: _______________________________________________ Date: ______________________
1
To apply for Employee Supplemental Term Life Insurance, Employee Part II Basic Life Insurance, or Spouse Supplemental Term Life Insurance in an
amount over $30,000, you must provide evidence of good health. Applications are available on the Benefits Department’s website
www.hr.utah.edu/ben
or by contacting the Benefits Department at 581-7447.
In the event of any discrepancy between this document and the policy, the terms of the policy apply. Complete coverage information is in the certificate
of insurance booklet issued to each insured individual.
Entered By: ______ QC By: ______
Date: _________________________
Beneficiary Designation for Coverage Elected During Special Enrollment
You are the Primary Beneficiary for the coverage elected on the reverse side of this form. You may change your
beneficiary designation at any time. Contact the Benefits Department at (801) 581-7447 for information or forms to
change beneficiaries on your coverage.
Spouse Supplemental
Term
Name/Address/Social Security Number
Relationship to
Employee
Percent
Allocation
Contingent Beneficiary(ies)
Dependent Child
Supplemental Term
Name/Address/Social Security Number
Relationship to
Employee
Percent
Allocation
Contingent Beneficiary(ies)
Part III Basic Dependent Name/Address/Social Security Number
Relationship to
Employee
Percent
Allocation
Contingent Beneficiary(ies)
Monthly Premium Rates
Part II Basic Employee Life Insurance
Dependent Child Supplemental Term Life Insurance
$.20 per $1,000 (Standard Benefit Program Employees)
$.60 for coverage in the amount of $5,000
$.25 per $1,000 (HPP Benefit Program Employees)
$1.20 for coverage in the amount of $10,000
Part III Basic Dependent Life Insurance
$.50 (Standard Benefit Program Employees)
Employee and/or Spouse Supplemental Term Life Insurance
$.75 (HPP Benefit Program Employees)
Monthly Premium Rate Per $1,000 of Coverage:
Non-tobacco Tobacco
Non-tobacco Tobacco Non-tobacco Tobacco
Age
User User
Age User
User
Age User
User
Under 30
$ .04
$ .09
30
.05
.10
31
.05
.11
32
.05
.11
33
.05
.11
34
.05
.12
35
.05
.13
36
.06
.13
37
.06
.15
38
.06
.15
39
.07
.17
40
.07
.18
41
.08
.19
42
.08
.22
43
.09
.23
44
.10
.25
45
.11
.27
46
.12
.29
47
.13
.33
48
.15
.36
49
.17
.40
50
.19
.45
51
.22
.51
52
.24
.56
53
.28
.63
54
.32
.72
55
.36
.76
56
.38
.83
57
.42
.91
58
.47
.99
59 .52 1.08
60 .58 1.18
61 .65 1.30
62 .73 1.41
63 .80 1.53
64 .89 1.66
65 .99 1.82
66
1.09
1.98
67
1.20
2.14
68
1.31
2.33
69
1.46
2.51
70
1.79
2.97
71
2.10
3.35
72
2.46
3.74
73
2.86
4.17
74
3.29
4.66
75
3.75
5.22
76
4.23
5.88
77
4.76
6.47
78
5.26
7.05
79
5.82
7.68
80
6.45
8.39
81
7.17
9.18
82
7.99
10.07
83
8.94
11.09
84 10.05
12.26
85 10.99
13.19
86 12.08
14.25
87 13.23
15.35
88 14.40
16.42
89 15.62
17.49
90 16.93
18.62
91 18.41
19.88
92 20.07
21.27
93 21.89
22.77
94 23.78
24.26
95 25.68
25.68
To determine premium cost: Determine the premium rate that applies to your age and tobacco use. Calculate the premium cost by multiplying the
desired coverage by the premium rate (minimum coverage is $20,000).
For example, assume you are age 45, do not use tobacco, and want
$150,000 of coverage. Your premium rate would be $.11 per $1,000 of desired coverage ($.11 multiplied by 150), for a total premium of $16.50 per
month.
