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GGFM-ER-8514 Maxwell Health Employer Information Form 02/24 <br /> Life insurance <br />Sun Life plan .................................................................................................................................................... Yes No <br />If “Yes,” please fill in the portion of the premium cost that you, as the employer, will be contributing (if applicable). <br />If “No,” skip to “Non-Sun Life Plan Information: Life insurance” section. <br />A.Employer contributions: <br /> Employee basic life __________ % <br /> Employee basic AD&D __________ % <br /> Dependent basic life __________ % <br />If the Optional/Voluntary Life and AD&D coverage is anything but 100% employee paid, please indicate the <br />percentage(s) here: __________________________________________ <br />If Employee’s contribute to the premium please make a selection below: <br /> Pre-tax Post-tax (Standard) <br />Value-added services: <br />If you purchased employee life, you are eligible to receive one of three value-added services packages offered by Sun <br />Life. Please make your selection below. If no selection is made, you will automatically be enrolled in Self Care+. Self <br />Care+ is not available in VT. <br /> Self Care+ <br />Offers employees and their families (age 13+) 24/7 access to digital tools such as mindfulness activities, guided <br />journals, blogs, and meditations to help them build resilience and improve their mental health. Service provided by <br />AbleTo and is not insurance. <br /> Emergency Travel Assistance & ID Theft <br />Emergency Travel Assistance provides medical, dental and personal emergency assistance for employees and <br />dependents traveling 100+ miles from home. Identity Theft Protection offers prevention and resolution tools to <br />safeguard data and restore its integrity if it is used fraudulently. These services are provided by Assist America <br />and are not insurance. <br /> Online Will Preparation & Claimant Support Services <br />Online Will Preparation provides step-by-step guidance online to create a legally binding will. Claimant Support <br />Services connects claimants and beneficiaries to professional grief, financial and legal counseling. These services <br />are provided by ComPsych and are not insurance. <br />B.Please indicate below how you would like Sun Life to calculate the spouse age for Dependent Voluntary Life insurance. <br /> Measured based on age of spouse <br /> Measured based on age of employee (standard) <br />The option selected above will be used to calculate the spouse age for age reduction changes and age banded <br />premium (step-rate) changes. Spouse information will be required on the final census. <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />X <br />X <br />0 <br />X <br />X <br />X <br />X <br />100 <br />100 <br />X <br />Self Care+ is only available for Effective dates of 4/1/23 or later