All eligible active employees working or more hours per week, their spouse, unmarried children ages 14 days to 19 years (25 if
a full time student), and handicapped children over the age of 19 are eligible for coverage.
Dependent cover
age is available only if the employee elects coverage. Dependents may not be insured if they are confined to a medical facility.
If the employee is not actively at work on the effective date of coverage, the insurance will become effective on the date of the employee’s return
to active employment.
The premium for your coverage is paid by you.
Issue Age pricing means that your rates (and your spouse’s if applicable) do not change with age.
After the initial rate guarantee period, the employer is subject to an annual review and possible rate changes.
Employee and spouse coverage reduces upon the attainment of age and
periodically thereafter in accordance with the following
schedule:
to % of the original benefit at age
to % of the original benefit at age
to % of the original benefit at age
Dependent children coverage terminates upon notice that all dependent children are no longer eligible. All insurance benefits shall terminate
upon the employee’s retirement or termination of employment.
see other side
No medical underwriting will be required unless you apply for coverage over the Guaranteed Issue amount, apply beyond the initial
31 day eligibility period, or have been previously declined coverage by Boston Mutual.
Guaranteed Issue Amounts
AGE EMPLOYEE SPOUSE
All life insurance coverage for dependent children is guaranteed issue if applied for during the initial 31 day eligibility period.
, sold in increments of
, sold in increments of
. Coverage cannot exceed times base annual salary.
. Coverage cannot exceed % of employee coverage
Employ
ee coverage maximum of
Spouse coverage maximum of
amount elected.
Child coverage: Age 14 days to 1 year:
Age 1 to 19 years: (age 25 for full-time students)
A spouse or child who is also an employee cannot be insured as a dependent. If both spouses are insured as employees of the same group, their
children can be insured as dependents of one spouse only.
Voluntary Term Life and Accidental Death &
Dismemberment Benefit Summary
(Issue Age Pricing)
BOSTON MUTUAL LIFE INSURANCE COMPANY – 120 Royall Street Canton, MA 02021 www.bostonmutual.com
Policy Series GRTP 04/99 335-3946 3/18
32b
Designed for the Employees of
GUARANTEED ISSUE
COST OF COVERAGE
ELIGIBILITY & BENEFIT FEATURES
REDUCTIONS IN BENEFITS
Town of Greenfield
20
$500,000
$10,000
7
$150,000
$5,000
50
$5,000 or $10,000
Under Age 60
$150,000
$35,000
Ages 60 - 69
$80,000
$25,000
Ages 70 & Over
$10,000
$0
70
65
70
50
75
25
80
This information is a summary of benefits; this summary is not your certificate nor does it constitute coverage for claim.
Any discrepancies between this summary and the master policy will be resolved by the language issued in the master policy.
For complete details of coverage and availability, please refer to your certificate or contact your benefits administrator.
Accidental Death & Dismemberment: The Voluntary Life Insurance benefit is doubled if death is the result of a covered
accident. Dismemberment benefits are payable for loss of eyesight or limbs according to the policy provisions.
Portability: If you leave your employer prior to age , the coverage is portable for you, your spouse under age and
all eligible dependent children. You may elect to exercise this option in accordance with the provisions as defined by the
policy. The coverage would not include Waiver of Premium or Group Voluntary AD&D.
Conversion: Employees have 31 days from the date of termination to convert the voluntary life insurance to an individual
permanent life insurance policy without evidence of insurability. The premium will be based on Boston Mutual’s usual rate
for the insured’s age on the date of conversion. Coverage will not include Waiver of Premium or Voluntary AD&D.
Waiver of Premium: If you become totally disabled prior to age 60 and remain totally disabled for the period stated in
the policy, Boston Mutual will continue your insurance without any further payment of premiums subject to the provisions
of the contract.
Accelerated Death Benefit: This provision enables an employee diagnosed and certified by a Doctor with a terminal
illness, resulting in a life expectancy of twelve months or less, to receive a portion of the life insurance benefit prior to death.
The remaining benefit will be paid to the beneficiary. To be eligible, the employee must have purchased at least $10,000 in
voluntary life coverage.
Also Included: Education Benefit, Seat Belt Benefit, and Repatriation of Remains Benefit. These benefits pertain to the
accidental death & dismemberment only.
Under the AD&D coverage, benefits are not payable for losses caused by or contributed to by: intentionally self-inflicted
injuries; suicide or attempted suicide; riot or war; diseases; ptomaine or bacterial infection; drug and/or alcohol abuse;
commission of an assault or felony by an employee; accident while serving on active duty; travel or flight in any aircraft
or device which can fly above the earth’s surface (does not apply to commercial flights); or injury which occurred before the
employee was insured by this policy. All exclusion details are stated in the master policy and certificate which may be reviewed
through your benets administrator.
ADDITIONAL FEATURES
EXCLUSIONS
60
60