DEPENDENT GROUP TERM LIFE INSURANCE
Issued by the Prudential Insurance Company of America
Plan benefits help reduce the financial hardship of losing a spouse or child
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Eligibility RequirementsYou must be enrolled in SAMBA's Group Term Life Insurance Plan. Evidence of insurability is required.
Benefits offered by the Plan:Term Life Insurance: This program offers Group Term Life Insurance benefits for eligible dependents, including your spouse and unmarried eligible children under the age of 22.
Accelerated Death Benefit: If your spouse has a Terminal Medical Condition (explain), this feature allows him or her to use up to 75% of the Dependent Group Term Life insurance amount, up to $250,000 to
help with medical expenses or put your financial affairs in order.
Survivor Benefit: Your dependents are eligible to continue their coverage in the event of your death.
How benefits and rates are determinedThe amount of coverage for which your dependents may be enrolled depends on your current GS level. (See chart below).
Your Gateway to Additional CoverageIf you are enrolled in the Dependent Group Term Life Insurance Plan, you are qualified to apply for additional coverage under SAMBA's
Supplemental Group Term Life Insurance.
Your coverage can continue when you retireIf you continue your own Group Term Life Insurance into retirement, you may also continue coverage for your family into retirement. Family coverage will be linked to the Group Term life plan option you select for retirement. (See chart below).
Beyond Age 70: The Dependent Group Term Life Insurance plan coverage ends at age 70. If you wish to continue coverage, SAMBA has made arrangements for you to purchase
up to $5,000 of insurance coverage under another policy.
Limitations and Exclusions (explain)
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| Rates Effective January 1, 2004 |
| Dependent Coverage for Active Employees |
| Job Classification |
Spouse Insurance Amount |
Child Insurance Amount |
Biweekly Premium |
GS-9 & Below
| If eligible children |
| If no eligible children |
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GS-10 thru GS-15
| If eligible children |
| If no eligible children |
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SES & SL
| If eligible children |
| If no eligible children |
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| Rates Effective January 1, 2004 |
| Dependent Coverage for Retired Employees |
| GTL Plan Selected by Retired Member |
Spouse's Insurance Amount (Based on Member's Age) |
Child's Insurance Amount |
Quarterly Premium |
| Thru Age 59 |
Ages 60-64 |
Ages 65-69 |
| 1, 2, 3, 4 |
$20,000 |
$15,000 |
$10,000 |
$5,000 |
$40.00 |
| 5, 6, 7 |
$25,000 |
$17,500 |
$12,500 |
$5,000 |
$50.00 |
| 8 |
$35,000 |
$25,000 |
$17,500 |
$5,000 |
$70.00 |
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