SUPPLEMENTAL LIFE/AD&D

THIS ENROLLMENT PAGE IS FOR EMPLOYEES WHO

WISH TO PURCHASE SUPPLEMENTAL LIFE/AD&D

- In addition to the employer-paid Basic Life/AD&D -

First things first...

Do I need to complete a health statement?

READ through four scenarios to determine if you will be required to complete a health statement - Evidence of Insurability (EOI):

You were hired after 9/15/24, it’s your first open enrollment period ( with 1/01/25 effective date), you may elect the Guaranteed Issue Amount of 150K - NO EOI Required
You already have 150k of Voluntary Life benefit, at open enrollment period (1/01/25 effective date) you may elect an additional 20k, and you will now have 170k benefit, - NO EOI Required
You already have 150k of Voluntary Life, at open enrollment period (1/01/25 effective date) you may purchase the max 500K benefit - if over 20K increment - YES, EOI Required
You went through previous open enrollment and declined the Guaranteed Issue amount of 150k, at open enrollment period (1/01/25 effecitve date) you may now decide you would like a benefit that’s over 20k - YES, EOI Required

More info about EOI

In other words, if you are requesting a benefit amount greater than the Guaranteed Issue amount, have previously waived Voluntary Life, or are increasing the coverage amount,

you are required to complete the Evidence of Insurability form below.

ENROLL BELOW AND THEN SEND COMPLETED EOI FORM TO: groupbenefitsadmin@principal.com

EOI Form

How much will it cost?

Supplemental (VOLUNTARY) Life/AD&D is available to purchase through your employer. Pricing for both employee and spouse is based on Age/Rate grid below.

Your per pay period deduction is calculated as follows using the

Age/Rate grid below:

Step 1: Find EMPLOYEE Age Bracket and Rate

Step 2: Consider COVERAGE AMOUNT you wish to purchase ($500,000 Maximum Benefit / $150,000 Guaranteed Issue without Evidence of Insurability completed / $20,000 Increment Guaranteed Issue - see scenarios above)

Step 3: Multiply Employee COVERAGE AMOUNT by age-banded RATE = Gross amount

Step 4: Divide GROSS AMOUNT by 1000 = Monthly Rate

Step 5:

Biweekly Employees:

Multiply MONTHLY RATE by .4615 = Pay Period Deduction (biweekly)

Should you have any questions, please contact your Human Resources Manager, MaryPat Pohlig at (203) 792-4515 x1121.

Voluntary Life Benefit Summary

ENROLL / Purchase Supplemental Life/AD&D:
Enter Information on our Secure Site
*Required fields

EMPLOYEE

Employee #

First Name

Last Name

Gender

Male

Female

Social Security #

Date of Birth (xx/xx/xxxx)

How much coverage do you wish to purchase? Increments of $10k not to exceed $500,000 (Guaranty Issue Amount is $150k). NOTE: You may need to complete and Evidence of Insurability / Statement of Health - see above).

Life/AD&D Total Benefit Amount

If desired coverage amount is over $150,000 or your specific Guaranteed Issue amount, you waived it previously, or you are increasing the amount of coverage, you must complete and submit the Evidence of Insurability (EOI) Application (form below).

SPOUSAL COVERAGE

Spousal coverage is available to purchase in increments of $5,000 not to exceed 50% of employee coverage amount. See pricing grid for cost. NOTE: You can not get spousal coverage without employee coverage.

Spouse Benefit Amount

If desired coverage amount is over $20,000, your Spouse must complete and submit the Evidence of Insurability (EOI) Application (below).

CHILD BENEFIT

A child benefit is available to purchase in increments of $2,500 not to exceed $10,000 Per pay period deduction below. No EOI required.

Select Child Benefit Amount you wish to purchase (rates below):

$5,000 ($0.46 biweekly)

$10,000 ($0.92 biweekly)

$15,000 ($1.38 biweekly)

$20,000 ($1.84 biweekly)

How many children do you wish to cover at the above rate per child?

SEND COMPLETED EOI FORM TO: groupbenefitsadmin@principal.com

EOI Form

Your Signature

Thank you for submitting! Please email your health statement if required.

ADD or CHANGE BENEFICIARY INFORMATION