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<br />Evidence Of Insurability <br /> <br />Required: <br />a. For late application for Contributory insurance. <br />b. For reinstatements ifrequired. <br />c. For Members eligible but not insured under the Prior Plan. <br />d. For all Supplemental Life Insurance. <br />e. For Life and AD&D Insurance in excess of $xxx,xxx: (the <br />Guarantee Issue Amount). <br />f. For any increase in Life and AD&D Insurance to an amount <br />which is $50,000 greater than the last amount for which your ' <br />Evidence Of Insurability was approved. <br /> <br />PREMIUM CONTRIBUTIONS <br /> <br />Life and AD&D Insurance: <br />Supplemental Life <br />Insurance: <br />Dependents Life Insurance: <br /> <br />Noncontributory <br /> <br />Contributory <br />Contributory <br /> <br />SCHEDULE OF INSURANCE <br /> <br />Life Insurance: <br /> <br />2 times your Annual Earnings, rounded to the next higher multiple <br />of $1,000, if not already a multiple of $1,000. The maximum <br />amount is $300,000. <br /> <br />AD&D Insurance: <br /> <br />2 times your Annual Earninc.as, rounded to the next higher multiple <br />of $1,000, if not already a multiple of $1,000. The maximum <br />amount is $300,000. <br /> <br />The amount payable for certain Losses will differ. See Accidental Death And Dismemberment <br />Insurance. <br /> <br />Seat Belt Benefit: <br /> <br />The amount of the Seat Belt Benefit is the lesserof(1) $10,000 or(2) <br />the amount of AD&D Insurance payable for loss of life. <br /> <br />Supplemental Life <br />Insurance: <br /> <br />You may apply for Supplemental Life Insurance for you and your <br />Spouse in multiples of $10,000, from $30,000 to $300,000. <br /> <br />Spouse: $ 10,000 <br />Child: 5,000 <br /> <br />The amount of Dependents Life Insurance for your Spouse or Child Dependent may not exceed X% of the <br />amount of your Life Insurance, <br /> <br />Dependents Life Insurance: <br /> <br />Printed 4196 Revised 4196 <br /> <br />-2- <br /> <br />SAMPLE U, AD&D, DU, Sup. U <br />