What can your life insurance benefits do for you?

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1e benefts. For many people, this is enough coverage to provide 1or fnal arrangements. However, the State also recognizes that the kind of life insurance you need can change according to your age and stage of life. That 9s why the State of Tennessee is giving you the chance to buy two kinds of coverage: " Optional term life insurance " Optional universal life insurance Both plans provide a death bene't. They offer other features as well. Optional Term Li 1e insurance provides coverage as long as you pay the premium. This coverage does not gain any cash value. It is the most affordable kind of life coverage. It is offered at affordable rates that vary by age, and you can pay the premiums through payroll deduction. Optional Universal Li 1e insurance offers a higher level of 'nancial protection. This plan can gain cash value over time, and you can pay the premiums through payroll deduction. Both Optional Term Life and Universal Life insurance are plans you own as an individual. That means you can keep the coverage if you leave your job or retire. Depending on your needs, you may choose one or both plans. You can apply for either plan without answering health questions. Your li 2e 3 it 9s worth it! ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... Call 1-866-310-6784 to apply. Who relies on you? " parent " children/ grandchildren " grandparent " sibling " niece/nephew " spouse/ signifcant other " anyone with whom you share debt (co-signer, etc.) ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... A comparison o 2 voluntary li 2e benefts Term coverage can be su 1fcient 1or those with limited fnancial responsibilities. Single Increased fnancial responsibilities may call 1or added coverage. Family obligations Retirement/fxed income/reduced obligations Term coverage usually ends at retirement. Universal li 1e o 1 1ers coverage a 1ter retirement. Optional Term Li 2e Optional Universal Li 2e Funding Employee paid Employee paid Premium Lower ratesFlexible Maximum beneft $300,000$300,000 Family coverage Living beneft Coverage beyond employment Designed to build cash value The amount of coverage you can have from the two plans combined is limited. Here is how it works: " You can apply for a combined bene't amount up to three times your salary. " The amount of coverage you can get without answering health questions is called cguarantee issue. d " You can apply for a higher combined bene't amount but you will be asked health questions. The limit for this is 've times your salary. You can 9t request more than $300,000. Call 1-866-310-6784 to apply. ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... Call 1-866-310-6784 to apply. Optional term li 2e insurance ............................................................................................................................... .............................................................. ............................................................................................................................... .............................................................. ............................................................................................................................... .............................................................. ............................................................................................................................... .............................................................. ............................................................................................................................... .............................................................. ............................................................................................................................... .............................................................. Who is eligible? " Regular full-time employees scheduled to work at least 30 hours each week " Seasonal or part-time employees with 24 months of prior service and certi'ed by an appointing authority to work at least 1,450 hours per 'scal year How much term li 2e insurance coverage can I get? " Employee : up to three times* your annual base salary, in $5,000 increments, without answering health questions " Spouse under age 55: one times employee base salary up to $30,000, in increments of $5,000 " Spouse age 55 and over: $15,000 " Children up to age 24: you choose $2,500 or $5,000 in Children 9s Term Rider coverage In order to purchase term life insurance coverage for your eligible children, you must purchase coverage for yourself or your spouse, as the dependent child 9s coverage must cride d on or attach to an adult 9s coverage. Can I apply 2or more coverage? Employee: up to 've times your annual salary up to a maximum of $300,000, in increments of $5,000. You will be asked some health questions. You may increase your coverage during the annual enrollment transfer period. Family coverage** " This insurance is available for your spouse by answering questions about his or her health, even if you don 9t apply for your own coverage. " Coverage is available for your child(ren) ages 24 hours to 24 years old. Dependent children will not be covered if they are married or in military service on a full-time basis. Only one parent may cover your eligible child(ren) under the Children 9s Term Rider. *The combination of optional term life and optional universal life insurance cannot exceed three times your annual base salary, up to $300,000. **For detailed information on eligibility for dependents, please refer to the Insurance Handbook published by Bene'ts Administr ation. You may obtain a copy of the handbook from your Agency 9s Bene'ts Coordinator. MY CHECKLIST Mortgage or rent Child care Elder care Education Loans Credit card debt Ongoing li 1e expenses Final arrangements Consider these items when determining how much li 1e insurance you may need. ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... What other 2eatures are included? Advance Beneft Rider 4 If you become terminally ill and are not expected to live more than six months, you may request up to 50% of your life insurance amount, to a maximum of $100,000. A doctor must certify your condition. Any payout will reduce the death bene't. Upon your death, any remaining bene't will be paid to your designated bene'ciaries. Waiver o 1 premium 4 If you or your spouse become totally disabled before age 60 and remain disabled for nine consecutive months, the premium payment will be waived during the period of disability. You or your spouse may continue the waiver of premium provision up to age 70. This only applies to coverage for you and your spouse and does not apply to coverage for any dependent child. Applicant must complete a Waiver of Premium claim form #1249-02 and submit to Unum within one year of the date of disability. Continuation o 1 coverage 4 When you retire, reduce your hours or leave the employment of the State of Tennessee you may have the option to continue your life insurance coverage by paying your premiums directly to Unum. Unum will contact you at your last known address to let you know what options you may have to continue coverage. You may not continue your coverage if you retire after age 85. Call 1-866-310-6784 to apply. Effective July 1, 2010 3 December 31, 2011 Age**Monthly Rate Under 200.046 20 3 240.046 25 3 290.046 30 3 340.049 35 3 390.062 40 3 440.094 45 3 490.160 50 3 540.268 55 3 590.418 60 3 640.651 65 3 691.079 70 3 741.506 75 3 792.313 80 and over 4.181 Effective January 1, 2012 3 December 31, 2012 Age**Monthly Rate Under 200.045 20 3 240.045 25 3 290.045 30 3 340.048 35 3 390.060 40 3 440.091 45 3 490.155 50 3 540.260 55 3 590.405 60 3 640.631 65 3 691.047 70 3 741.461 75 3 792.244 80 and over 4.056 *Use this chart to 'gure out your total monthly premium. Multiply the desired amount of coverage by the appropriate rate per thousand from the table, then add a $.30 per month administrative charge. **As a new employee, your premium is based on your age as of January 1 st of the year you enroll. Optional term li 2e insurance Monthly premium rates 1or Children 9s Term Rider Effective July 1, 2010 3 December 31, 2012 AmountMonthly Rate $2,500 0.25 $5,000 0.50 For example: Let 9s say you are 38 and you would like to apply for $30,000 in optional term life coverage. Your rate calculation would look like this: My ratex Amount (in thousands)+Admin. Cost= Total monthly cost $.062 30$.30 $2.16 Term li 1e worksheet My ratex Amount (in thousands)+Admin. Cost= Total monthly cost $___________________$.30$__________ Monthly premium rates per $1,000 o 1 beneft amount* 1or employees and spouse Optional term li 2e insurance ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... .............................................................. ............................................................................................................................... .............................................................. ............................................................................................................................... .............................................................. ............................................................................................................................... .............................................................. ............................................................................................................................... .............................................................. ............................................................................................................................... .............................................................. Who is eligible? " Regular full-time employees scheduled to work at least 30 hours each week " Seasonal or part-time employees with 24 months of prior service and certi'ed by an appointing authority to work at least 1,450 hours per 'scal year How much universal li 2e insurance coverage can I get? " Employee: up to three times* your annual base salary, in $1,000 increments, without answering health questions " Spouse under age 55: one times employee annual base salary up to $30,000, in $5,000 increments " Spouse age 55 and over: $15,000 " Children up to age 24: you choose $2,500 or $5,000 in Children 9s Term Rider coverage In order to purchase the children 9s term rider insurance coverage for your eligible children, you must purchase coverage for yourself or your spouse. The children 9s coverage can cride d on or attach to an adult 9s term life or universal life coverage, not both. If you select both term and universal life coverage, the children 9s rider will automatically attach to the term life certi'cate. Can I apply 2or more coverage? Employee: up to 've times your annual salary up to a maximum of $300,000, in increments of $5,000. You will be asked some health questions. You may increase your coverage during the annual enrollment transfer period. Optional universal li 2e insurance Many families would have immediate trouble paying for everyday living expenses following a premature death. 1 The amount o 1 coverage you can have 1rom the two plans combined is limited. Here is how it works: " You can apply 1or a combined beneft amount up to three times your salary. " You can apply 1or a higher combined beneft amount but you will be asked health questions. The limit 1or this is fve times your salary. You can 9t request more than $300,000. Call 1-866-310-6784 to apply. *The combination of optional term life and optional universal life insurance cannot exceed three times your annual base salary. ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... Optional universal li 2e insurance Call 1-866-310-6784 to apply. *For more information on family coverage, please refer to the Insurance Handbook. This is published by Bene'ts Administration. If you would like a copy, ask your Agency 9s Bene'ts Coordinator. 1 LIFE Foundation, cAmericans Willing to Risk Family 9s Financial Security to Save Money in Tough Times, d September 18, 2008. Family coverage available* " This insurance is available for your spouse, by answering questions on his or her medical history, even if you don 9t apply for your own coverage. " Coverage is available for your child(ren) ages 24 hours to 24 years old. Dependent children will not be covered if they are married or in military service on a full-time basis. Only one parent may cover your eligible child(ren) under the Children 9s Term Rider. What are the 2eatures o 2 universal li 2e coverage? " Your bene't and premium amount is Kexible. " This coverage can build cash value (see cash accumulation and interest credit features section). " You can keep the coverage even if you leave state employment or retire. " You can add universal life insurance to enhance an existing term life coverage. What other 2eatures are included? Cash accumulation and interest crediting 4 You will begin gaining cash value during the 'rst month after the effective date of coverage. For the period of July 1, 2008 through December 31, 2012, the interest crediting rate shall not be less than the greater of a) and b), where: a) Is 5.00% annual effective interest, administered as 4.89% annual nominal interest; and b) Is the published six-month United States Treasury Bill discount rate, established as a result of the auction coinciding with or immediately following the 15th day of the month preceding the monthly anniversary date, plus 0.50%. Advance Beneft Rider 4 If you become terminally ill and are not expected to live more than six months, you may request up to 50% of your life insurance amount, to a maximum of $100,000. A doctor must certify your condition. Any payout will reduce the death bene't. Waiver o 1 premium 4 If you or your spouse become totally disabled before age 60 and remain disabled for nine consecutive months, the premium payment will be waived during the period of disability. Applicant must complete a Waiver of Premium claim form #1249-02 and submit to Unum within one year of the date of disability. You or your spouse may continue the waiver of premium provision up to age 95. Applies only to coverage for you and your spouse and does not apply to coverage for any dependent child. Continuation o 1 coverage 4 When you retire, reduce your hours or leave the employment of the State of Tennessee you may have the option to continue your life insurance coverage by paying your premiums directly to Unum. A Unum representative will contact you to discuss your options. You may elect to continue your universal life coverage regardless of your age. ............................................................................................................................... ................................................... ............................................................................................................................... ................................................... ............................................................................................................................... ................................................... ............................................................................................................................... ................................................... ............................................................................................................................... ................................................... ............................................................................................................................... ................................................... ............................................................................................................................... ................................................... Call 1-866-310-6784 to apply. Optional universal li 2e insurance Monthly premium rates per $1,000 o 1 beneft amount* 1or employees and spouse Effective July 1, 2010 3 December 31, 2012 Age last birthday Monthly rate Age last birthday Monthly rate 15 0.20 46 1.21 16 0.21 47 1.30 17 0.22 48 1.42 18 0.23 49 1.55 19 0.24 50 1.69 20 0.25 51 1.85 21 0.26 52 2.04 22 0.27 53 2.26 23 0.28 54 2.51 24 0.30 55 2.48 25 0.31 56 2.64 26 0.33 57 2.77 27 0.35 58 2.91 28 0.36 59 3.04 29 0.38 60 2.83 30 0.41 61 2.97 31 0.43 62 3.12 32 0.45 63 3.28 33 0.48 64 3.44 34 0.53 65 3.61 35 0.56 66 3.80 36 0.60 67 3.99 37 0.64 68 4.19 38 0.68 69 4.41 39 0.72 70 4.64 40 0.79 71 4.88 41 0.84 72 5.14 42 0.89 73 5.42 43 0.96 74 5.71 44 1.04 75 6.03 45 1.11 *Use this chart to 'gure out your total monthly premium. Multiply the desired amount of coverage by the appropriate rate per thousand from the table, then add a $1 per month administrative charge. Optional universal li 2e insurance Monthly premium rates 1or Children 9s Term Rider Effective July 1, 2010 3 December 31, 2012 AmountMonthly Rate $2,500 0.25 $5,000 0.50 There is no administrative charge for dependent children 9s coverage. Universal li 1e worksheet My ratex Amount (in thousands)+Admin. Cost= Total monthly cost $___________________$1.00$__________ For example: Let 9s say you are 38 and you would like to apply for $30,000 in optional universal life coverage. Your rate calculation would look like this: My ratex Amount (in thousands)+Admin. Cost= Total monthly cost $.68 30$1.00 $21.40 What 9s next? Review the in 1ormation on the back cover, complete the application or call 1-866-310-6784 to apply . Optional universal li 2e insurance ............................................................................................................................... ..................................................... ............................................................................................................................... .................................................... ............................................................................................................................... .................................................... ............................................................................................................................... ..................................................... ............................................................................................................................... ..................................................... ............................................................................................................................... ..................................................... What else do I need to know? The amount of coverage you can have from the two plans combined is limited. Here is how it works: " You can apply for a combined bene't amount up to three times your salary. " You can apply for a higher combined bene't amount but you will be asked health questions. The limit for this is 've times your salary. You can 9t request more than $300,000. Additional coverage If you are applying for amounts over and above the guarantee issue amount, call 1-866-310-6784. Optional term li 2e insurance Length of coverage " You are covered as long as you pay your premium. Limitations/exclusions Life insurance bene'ts will not be paid for deaths caused by suicide in the 'rst 24 months after your coverage takes effect. If you add or increase coverage, those added or increased bene'ts won 9t be paid for deaths caused by suicide within 24 months of the date the changes were made. Optional universal li 2e insurance Length of coverage " You are covered as long as you pay your premium. Limitations/exclusions If within 24 months from the date of issue of this coverage the insured individual dies by suicide, while sane or insane, the amount payable by Unum in place of all other bene'ts shall be the sum of the premiums paid, without interest, less any debt secured by this coverage. What happens i 1 my employment ends? When you are no longer employed by the State, payroll deduction will not be available. Unum will contact you at your last known address to inform you of your options to continue life insurance coverage once we receive notice from the State. Termination o 1 insurance 1or employees Your insurance will terminate: " If you stop paying the monthly term premium; " If you stop paying the monthly universal life premium and there is insuf'cient cash value to continue paying the monthly premiums; " If you cease to be an eligible employee; or " If the optional life insurance plan is discontinued by the State of Tennessee or Unum. If you stop cactive d work for any reason, Unum will contact you at your last known home address to offer continuance of life insurance coverage by direct billing. Termination o 1 insurance 1or dependent spouses The optional life insurance for dependent spouse will terminate: " If the monthly term premium is not paid; " If the monthly universal life premium is not paid and there is insuf'cient cash value to continue paying the monthly premiums; " If the dependent spouse is no longer eligible; or " If the optional life insurance plan is discontinued by the State of Tennessee or Unum. If the covered employee stops cactive d work for any reason, Unum will mail to the employee 9s last known home address an offer to continue dependent spouse life insurance by direct bill. Termination o 1 Children 9s Term Rider Dependent children are covered under a term rider which cannot stand alone. Dependent coverage must cride d on or attach to the employee or spouse coverage. The dependent Children 9s Term Rider WILL terminate: " If the monthly children 9s term premium is not paid; " If the employee ceases to be eligible; " If the certi'cate to which the Children 9s Term Rider attaches should terminate; " If the optional life insurance plan is discontinued by the State of Tennessee or Unum; or " If the dependent is no longer eligible. Call Unum 9s customer service center when a dependent is no longer eligible due to the plan 9s eligibility rules (i.e. marriage, divorce, reaching maximum age, etc.) Upon noti'cation that your dependent is no longer eligible, Unum will send a letter to your last known home address advising of the dependent 9s options to convert term coverage to universal life. The dependent will have 31 days from the date on the Unum letter to convert to a universal life insurance policy. Failure to notify your employer and Unum of your dependent 9s change in eligibility status will result in termination of coverage and a forfeiture of any conversion privilege. No refunds will be made. If the dependent child/children do not wish to convert, coverage will end on the last day of the month in which they become ineligible. Call 1-866-310-6784 to apply. ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... Call 1-866-310-6784 to apply. Who can choose to enroll in coverage? You are eligible to enroll within the 'rst 30 days of employment in the optional term life and/or optional universal life insurance program if you are a regular full-time employee of the State of Tennessee or higher education and are scheduled to work at least 30 hours per week. If you do not enroll during this period, you cannot apply for coverage until the next annual enrollment transfer period, and you will need to answer health questions at that time. Can I apply 2or spouse coverage? Yes, you are eligible to enroll your spouse within the 'rst 30 days of employment in the optional term life and/ or optional universal life insurance program if you are a regular full-time employee of the State of Tennessee and are scheduled to work at least 30 hours per week. If you do not enroll your spouse during this period, you cannot apply for this coverage until the next annual enrollment transfer period. Your spouse will be required to answer health questions. If your spouse is also employed by the State of Tennessee, he or she cannot be covered under spouse coverage. They must apply for their own coverage as an employee. Can I apply 2or child(ren) coverage? Yes, the children must be at least one day or 24 hours old, and they may remain covered until the end of the month in which they turn 24 years of age as long as they continue to meet eligibility requirements. If you do not enroll within the 'rst 30 days of employment, you cannot apply for coverage for your child(ren) until the FAQ Frequently asked questions next annual enrollment transfer period. Answering health questions will be required for any child(ren). Also, you can add coverage for a newborn child within 30 days of the birth. If you do not add coverage during this time, you must apply for coverage for children during the next annual enrollment transfer period. I 2 both parents are State or higher education employees, can each employee carry coverage 2or the child(ren)? No, only one parent may cover the eligible children under the Children 9s Term Rider. If you purchase coverage, children 9s coverage must be attached to your coverage. Is children 9s coverage automatically terminated when they reach age 24? Children 9s coverage will not be continued past age 24. However, it will be your responsibility to notify Unum when your child/children are no longer eligible. Is guarantee issue coverage available 2or new employees? Yes, as a new employee, you are eligible to enroll for an amount up to three times your annual base salary. That amount is called cguarantee issue. d You must apply during the 'rst full month of employment. If you apply for any amount over three times (up to the plan maximum of 've times), you will need to answer health questions. Is guarantee issue coverage available 2or my spouse? If you are a new employee, your spouse may apply for coverage in $5,000 increments. If your spouse is under age 55, you can choose coverage equal to one times your annual base salary, up to a maximum of $30,000. If your spouse is age 55 or older, the maximum available for guarantee issue is $15,000. If the answer is cyes d to the hospital/medical question in Section 3 of the application (regardless of age), guarantee issue coverage will not be provided, and he or she will be required to answer health questions by completing a supplemental application. ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... Is guarantee issue coverage available 2or my child(ren)? Yes, you may choose either $2,500 or $5,000 in coverage, and they will not have to answer any health questions. This will be guarantee issue as long as you apply for coverage within the 'rst 30 days of employment. I 2 I have to answer medical questions to quali 2y 2or coverage, what kind o 2 questions will I be asked? You will be asked various questions about your medical history over the last 10 years, such as, cHave you had a heart attack, stroke, or been diagnosed with diabetes or HIV? d etc. When does my coverage take e 2 2ect? If you enroll as a new employee, your coverage will become effective the 'rst day of the month after you have completed three full calendar months of employment. When does coverage take e 2 2ect 2or my dependents? If your dependents enroll at the same time you enroll, their insurance will become effective on the same date as yours. (See previous question.) Is there a waiver o 2 premium beneft? Yes, if you or your spouse become totally disabled before age 60 and remain disabled for nine consecutive months, you will no longer be required to pay the insurance premium for the disabled person. What happens i 2 my employment ends? Unum will contact you at your last known address to let you know what options you may have to continue coverage. Can I decrease my coverage? Yes, but you can only decrease your coverage during the annual enrollment transfer period. How are employee and dependent claims fled? You may download a claim form from unum.com, or you may call the Contact Center at 1-866-298-7636. Who do I contact i 2 my spouse or I become disabled? Call the Unum Contact Center at 1-866-298-7636 to report your disability. How do I apply 2or an advanced beneft? You may download a claim form from unum.com, or you may call the Contact Center at 1-866-298-7636. What happens i 2 I recover? If you recover, you will not be required to refund your bene't. Simply notify Unum of your recovery and resume paying the premiums for your coverage. What can the Contact Center do 2or me? Contact Center representatives are there to answer your questions and guide you through the claims process. Who do I call about questions on eligibility and enrollment? Call 1-866-310-6784 for questions about eligibility and enrollment, Monday through Friday 8 a.m. to 8 p.m. Eastern Standard Time. Can I cancel coverage? Yes, you can cancel your coverage at any time by completing a Customer Service Request Form (L-52490). What i 2 I need to make changes on a policy? You can make changes such as name, address, bene'ciary by completing a Customer Service Request form (L-52490). However, changes regarding face amount such as an increase or decrease may only be processed during the annual enrollment transfer period. Call 1-866-310-6784 to apply. ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... You can apply for up to 5 times your annual earnings , up to $300,000, by answering a 1ew health questions. Call 1-866-310-6784 and speak to a benefts representative to apply. Don 9t miss your opportunity to apply! Instructions for completing State o 2 Tennessee term li 2e/universal li 2e Form #AE-1115 Insurance enrollment applications Employee/spouse (Section 1/Section 3) Please note: If applying for spouse coverage, the employee portion on the application must also be completed. " Check the appropriate box for the type of coverage you want 4 term life, universal life or both. " Check the appropriate box for application type 4 annual enrollment or new hire. " Enter the full name of the employee/spouse ('rst, middle, last). " Enter the full street address or post of'ce box number. " Enter the full city, state & ZIP. " Enter employee e-mail address " Enter the annual base salary, excluding over-time and longevity (employee only). " Enter Social Security number. " Enter gender. " Enter birth date. " Enter daytime and cell phone number. WE MUST HAVE THIS INFORMATION (employee only). " Enter date the employee was hired (employee only). " For employees: Enter the amount of insurance desired. If you elect coverage in both the optional universal life and the optional term life plans, the total COMBINED amount of coverage cannot exceed three times the employee 9s salary (without answering any health questions) or 've times the employee 9s salary (by answering health questions), excluding over-time and longevity, rounded to the next $5,000, with a maximum of $300,000. " For spouse: Enter the amount of insurance desired. If you elect coverage in both the optional universal life and the optional term life plans, the total COMBINED amount of coverage cannot exceed one times employee 9s annual base salary, excluding over-time and longevity, rounded to the next $5,000 with a maximum of $30,000. For spouses age 55 and older the maximum amount IS $15,000. " Enter amount of Children 9s Term Rider (if applying). You may apply 1or a Children 9s Term Rider on one policy (employee or spouse) only. If applying for employee and spouse coverage, the Children 9s Term Rider will be added to the employee 9s policy. You will need to indicate 'rst, middle and last name, Social Security number, date of birth, age, gender and relationship to employee in section 5. " Enter the full name and address of the bene'ciary(ies) and the relationship to the employee. " If you have multiple bene'ciaries, indicate the bene't amount you would like to designate to each bene'ciary. " Employee MUST sign and date the application. Mail your application to: Unum Attention: VB New Business, 2W P.O. Box 190002 Chattanooga, TN 37401-7210 or to apply, call: 1-866-310-6784 ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... STATE OF TENNESSEE APPLICATION FOR l OPTIONAL TERM LIFE l OPTIONAL UNIVERSAL LIFE Provident Life and Accident Insurance Company Chattanooga, TN 37402 Application Type: l Annual Enrollment l New Hire SECTION 1: Employee Information 3 Always Complete Employee Name (First, Middle, Last) Social Security Number Home Address (Street/PO Box) Gender l F l M City Date of Birth (mm/dd/yyyy) State ZIP Code Daytime Phone Email Address Cell Phone Employee Annual Base Salary Date of Hire (mm/dd/yyyy) $ SECTION 2: Certi+cate Information Employee Coverage Minimum - $5,000 Maximum - Five times your annual base salary, rounded to the next higher multiple of $5,000 up to $300,000. A supplemental application must be completed and submitted for amounts over three times annual base salary. Term Life Universal Life Employee Coverage Amount $ Employee Coverage Amount $ Bene<ciary Relationship Bene<ciary Relationship Address Percentage Address Percentage Bene<ciary Relationship Bene<ciary Relationship Address Percentage Address Percentage Children 9s Coverage Children 9s coverage will be automatically attached to the employee certi<cate if employee coverage is selected. Children 9s coverage is only available on the term certi<cate, unless only universal life coverage is selected. If coverage is attached to the employee certi<cate, it cannot be attached to the spouse certi<cate. If selecting children 9s coverage, please complete section 5. Children's Term Rider l 2,500 l 5,000 SECTION 3: Spouse Information 3 Always show name 3 Fully Complete for Coverage Name (First, Middle, Last) Social Security Number Home Address (Street/PO Box) Gender l F l M City Date of Birth (mm/dd/yyyy) State ZIP Code Has spouse been hospitalized, advised to seek medical treatment, or received disability bene<ts during the last 6 months? l Yes l No If yes, submit supplemental application. AE-1115 1 ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... ............................................................................................................................... ............................................................... AE-1115 2 SECTION 4: Spouse Certi\xccate Information Spouse Coverage Minimum - $5,000 Maximum - Less than Age 55: one times employee 9s annual base salary up to $30,000 in $5,000 increments Maximum - Ages 55 and Over: $15,000 Term Life Universal Life Spouse Coverage Amount $ Spouse Coverage Amount $ Bene<ciary Relationship Bene<ciary Relationship Address Percentage Address Percentage Bene<ciary Relationship Bene<ciary Relationship Address Percentage Address Percentage Children 9s Coverage Please note you can not add children 9s coverage to the spouse certi<cate if children 9s coverage has already been added to employee certi<cate. Children 9s coverage is only available on the term certi<cate, unless only universal life coverage is selected. If selecting children 9s coverage, please complete section 5. Children 9s Term Rider l 2,500 l 5,000 SECTION 5: Children Information 3 Complete only if dependent children 9s insurance chosen List eligible dependent children as de<ned in the plan. Child 9s Name Social Security Date of Birth Issue Gender Relationship First, Middle, Last Number (mm/dd/yyyy) Age M or F to Employee The bene<ciary of children 9s term insurance is the employee, if living, otherwise the estate of the covered child. I certify that the information on this application is true and complete and that I am Actively at Work/Positive Pay Status on the date of my signature below. I understand that if I have selected insurance for myself, it will begin on the Certi<cate Is- sue Date; provided I am Actively at Work/Positive Pay Status on that date. Dependent Spouse and/or Dependent Children 9s Coverage, if selected, will begin on the Certi<cate Issue Date; provided: (1) I am Actively at Work/Positive Pay Status on that date; and (2) my Dependent Spouse and/or Dependent Child(ren) is/ are able to engage in normal activities on the date the coverage is to become effective. I understand that I, as the Employee, am the owner of all coverages applied for. I authorize my Employer to deduct the proper premiums for this insurance from my earnings. Any person who, knowingly and with intent to defraud or deceive any insurance company, submits an insurance application or \xcles a claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties, depending upon state law. Employee Signature __________________________________________________Date ________________________ FOR HOME OFFICE USE ONLY DEDUCTION AMOUNT: E ________________ S ________________ C _______________ TD ________________ Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. ................................

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