Dowqew
Employee Id: T100125
printed on 11, 2019 at 12:21 PM E.T.
This is your confirmation of enrollment. For your reference, you can print this page. You do not need to sign or send this statement to the Benefits Team. If you added or changed a beneficiary(ies), you must print, sign and date the beneficiary form and send the original signed document to the Benefits team. An electronic or scanned version will not be accepted.
Your benefit carrier is Sun life.
For Quebec and Ontario claims/customer service inquires call 1-XXX-XXX-XXXX.
For all other provinces call 1-XXX-XXX-XXXX.
Your Benefits
Coverage effective from: November 22, 2019
| Benefit | Option | Description / Coverage / Category | Annual Cost | Employer-paid | Payroll Deductions Per Pay |
|---|---|---|---|---|---|
| Short-Term Disability (STD) | 1 | 100% of regular base earnings for up to 180 days | $0.00 | $0.00 | $0.00 |
| Long-Term Disability (LTD) | 1 | $4,492.00 per month (taxable) Basic LTD |
$21.56 | $21.56 | $0.00 |
| Health Benefits | 2 | Family | $1,678.00 | $1,678.00 | $0.00 |
| Dental Benefits | 2 | Family | $1,298.00 | $1,298.00 | $0.00 |
| 11Basic Employee Life Insurance | 1 | $10,000.00 Non-Smoker | $4.80 | $0.00 | $0.18 |
| Optional Employee Life Insurance | 77 | $5,000.00 Non-Smoker | $2.40 | $0.00 | $0.09 |
| Optional Spousal Life Insurance | 1 | No Coverage | $0.00 | $0.00 | $0.00 |
| Optional Child Life Insurance | 2 | $5,000.00 Single | $8.70 | $0.00 | $0.33 |
| Basic Employee AD&D Insurance | 1 | $77,000.00 | $0.00 | $0.00 | $0.00 |
| Optional Employee AD&D Insurance | 1 | No Coverage | $0.00 | $0.00 | $0.00 |
| Optional Spousal AD&D Insurance | 1 | No Coverage | $0.00 | $0.00 | $0.00 |
| Optional Child AD&D Insurance | 1 | No Coverage | $0.00 | $0.00 | $0.00 |
| Optional Employee Critical Illness Insurance | 26 | $10,000.00 Non-Smoker | $4.80 | $0.00 | $0.18 |
| Optional Spousal Critical Illness Insurance1 | 2 | $10,000.00 Smoker | $7.20 | $0.00 | $0.28 |
| Employee & Family Assistance Plan | 1 | Family | $0.00 | $0.00 | $0.00 |
| 10Employee Life Insurance | 1 | $5,000.00 Non-Smoker | $2.40 | $1.92 | $0.02 |
| Child Critical Illness | 1 | $10,000.00 Single | $0.00 | $0.00 | $0.00 |
| Additional Employee Critical Illness | 1 | $5,000.00 Non-Smoker | $2.40 | $0.00 | $0.09 |
| Additional Spousal Critical Illness | 1 | $5,000.00 Smoker | $3.60 | $0.00 | $0.14 |
| Dependent Life – Employee Age Based | 1 | $5,000.00 Non-Smoker | $2.40 | $0.00 | $0.09 |
| LTD 40 | 1 | $3,763.00 per month Non-Smoker | $18.06 | $0.00 | $0.69 |
| LTD 41 | 1 | $3,485.00 per month Non-Smoker | $16.73 | $0.00 | $0.64 |
| LTD 42 | 1 | $4,280.00 per month LTD42 Non-Smoker | $20.54 | $0.00 | $0.79 |
| Personal Wellness Credits | 3 | 2 Personal Well-being Days as days off. | $0.00 | $0.00 | $0.00 |
| Sub-Total: | $3,091.59 | $2,999.48 | $3.52 | ||
| Sales Tax: | $0.28 | ||||
| Total: | $3.80 | ||||
Your excess Flex Dollars Allocation
You have $500 in Flex Dollars remaining.
| Benefit | Amount Applied |
|---|---|
| Health Care Expense Account | $500 |
Your Dependents
| Dependent | Benefit | Covered UnderThis Plan | Covered UnderOther Plan | |
|---|---|---|---|---|
| Karen Dow SpouseD.O.B. 04/02/1976 | Smoker | Health Care | No | No |
| Dental Care | Yes | No | ||
| Optional Single or Family AD&D | Yes | |||
| Mark dow Child < 21D.O.B. 06/06/2012 | Health Care | Yes | No | |
| Dental Care | Yes | No | ||
| Optional Single or Family AD&D | Yes | |||
| abc a xyz Child < 21D.O.B. 01/01/2001 | Health Care | Yes | No | |
| Dental Care | Yes | No | ||
| Optional Single or Family AD&D | Yes |
LABEL DEPENDENT MESSAGE ENGLISH in client variables (LL)
Your Beneficiaries
Basic Employee Life
| Pending Beneficiaries (Until the Beneficiary Declaration is signed, dated and received) | |
|---|---|
| Estate | 60 % |
| Karen Dow - Spouse (Revocable)D.O.B. 04/02/1976 | 30 % |
| mark dow - Other (Irrevocable)D.O.B. 03/06/2010 | 10 % |
Optional Spousal Life Insurance
| Pending Beneficiaries (Until the Beneficiary Declaration is signed, dated and received) | |
|---|---|
| Cat C - Other (Revocable)D.O.B. 07/31/2006 | 100 % |
Basic Employee AD&D & Business Travel Accident
| Pending Beneficiaries (Until the Beneficiary Declaration is signed, dated and received) | |
|---|---|
| Estate | 100 % |
| Estate | 60 % |
Optional Single or Family AD&D
| Pending Beneficiaries (Until the Beneficiary Declaration is signed, dated and received) | |
|---|---|
| Estate | 50 % |
| Karen Dow - Spouse (Revocable)D.O.B. 04/02/1976 | 50 % |