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2011-02-10 version 10.6d <br />Mayfield Village -Home Office <br />Proposed Effective Date: 04/01/2011 <br />Life Insurance offered by Anthem Life Insurance Company <br />Schedule of Benefits <br />Class Description Term Life AD&D STD Dep. Life Sp/Ch <br />1 All eligible employees $20,000 Equal To Term Life N/A N/A <br />Refer to your Insurer's sales brochure(s) for benefit details and limitations. <br />Benefit Plan Highlights <br />-Term Life Guarantee Issue Limit is $20,000 for all ages. <br />- Term Life includes waiver of premium for total disability beginning before age 60 with a 6 month elimination period. <br />- Waiver terminates at age 65 or prior retirement. <br />- Accelerated Death Benefit standard: Benefit may be up to 75% of the group term life face amount to a maximum of <br />$250,000. <br />- Basic Life includes standard commissions for OH. <br />-Term Life and AD&D benefits reduce by the following percents: 35% at age 65; 50% at age 70. Benefits terminate <br />at retirement. <br />- If police and/or fire employees make up more than 40% of the entire group, AD&D benefits will be <br />non-occupational. <br />-The Term Life rate provided is based on anon-contributory plan. However, if the coverage is contributory, 75% <br />participation will be required of those eligible to enroll, and the rate may need to be adjusted. <br />- Term Life Rate(s) are guaranteed for 2 year(s). <br />- AD&D benefits include Seat Belt Rider, Airbag Rider, Education, Repatriation Benefit, Common Carrier and Coma. <br />- The Resource Advisor phone/web member assistance program is included in this proposal. <br />- Employees whose wages are reported on Form 1099 in lieu of Form W-2 are not eligible for coverage. <br />-All employees under the age of 17 (seventeen) are ineligible to receive benefits. <br />- Insurer reserves the right to review rates if final census differs by more than 10% and or benefits/provisions desired <br />by group differ from those included in this proposal. <br />- Open enrollment for any line of coverage is not permitted. <br />-Travel Assistance is included in this proposal. <br />Proposed Rates <br />Coverage Monthly Rate Lives Volume Monthly Annual <br />Costs Costs <br />Term Life 0.28 (Per $1,000) 59 1,160,000 324.80 3,897.60 <br />AD&D 0.020 (Per $1,000) 59 1,160,000 23.20 278.40 <br />348.00 4,176.00 <br />This proposal is subject to underwriting approval by Insurer,• please do not cancel your coverage until the application has been approved in writing. This <br />information is intended to present only a general overview of the benefits. Not all details, limitations, and exclusions are included. This quote was prepared <br />using an SIC code of 9111 in state of OH -44125. The proposal expires 90 days from the date quoted. Ver.• 10.7.101111 a <br />This coverage has been selected for employees and eligible dependents; subject to the terms and conditions of this proposal and the application to which <br />this is attached. Insurer's standard policy provisions will apply, unless otherwise noted. <br />Authorized Signature Date <br />EXHIBIT B <br />Life UW: Page: 1 <br />