Announcing Voluntary Accidental Death and Dismemberment Insurance

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					P.O. Drawer 27727                                  Announcing Voluntary Accidental
Raleigh, NC 27611
                                                   Death and Dismemberment Insurance
Tel (919) 833-6436 / 1-800-222-2758
Fax (919) 829-5829                                 For SEANC Members and Their Families
                                                   $25,000 to $500,000 Accidental Death & Dismemberment Insurance
                                                            Underwritten by Reliance Standard Life Insurance Company
New Travel Assistance                              If you enroll for dependent coverage:
Services Program Included                          • In the event there are no eligible dependent children, your spouse will be insured for 50% of
                                                      your Principal Sum.
                                                   • In the event there are eligible dependent children, your spouse will be insured for 40% of
Affordable group rates                                your Principal Sum and each child for 10%.
                                                   • In the event there is no spouse, each eligible dependent child will be insured for 15% of your
Payroll deduction                                     Principal Sum.
                                                 		Coverage/Cost
Insure your dependents                             Member                                                   Member only                                       Member & Family
                                                   Amount                                                   Cost/Monthly                                       Cost/Monthly
No health evidence                                   $25,000                                                     $0.95                                              $1.40
required                                             $50,000                                                     $1.90                                              $2.80
                                                    $100,000                                                     $3.80                                              $5.60
                                                    $150,000                                                     $5.70                                              $8.40
                                                    $200,000                                                     $7.60                                            $11.20
                                                    $250,000                                                     $9.50                                            $14.00
                                                    $300,000                                                   $11.40                                             $16.80
                                                    $350,000                                                   $13.30                                             $19.60
                                                    $400,000                                                   $15.20                                             $22.40
To enroll, fill out the attached
enrollment card and mail to the                     $450,000                                                   $17.10                                             $25.20
address above.                                      $500,000                                                   $19.00                                             $28.00

Reliance Standard Life Insurance Company                                                                                         Personal Accident Enrollment Form
Policyholder	                                                                                                              Policy	No.
                    State Employees Association of NC                                                                                     VAR 200127
Proposed	Insured’s	Name	                                                    Social	Security	#	                                                 Date	of	Birth
	                                                                           																																										--									--	           																																			/											/

Street	                                                        City	                                                       State	                              ZIP
	                                                              	

Proposed Insured’s Principal Sum     Monthly Premium           Beneficiary                                                 Relationship                        Certified Effective Date to
	                                                              	                                                           	                                   be	completed	@	processing

										Member	           Member	&	Family	Plan	        Please Note: An Eligible Person may not have coverage both as an Insured Person and as an             State	Department/Agency	           	
										Only	             (Including	Insured)          Insured Dependent. Only one Insured spouse may cover the eligible children as Insured
                                                         Dependents.	If	insurance	is	in	force	for	an	Insured	Dependent,	any	newly	eligible	Dependents	
                                                         will be automatically covered.

q I request to purchase this accident insurance coverage. I authorize the Policyholder to deduct from my salary of
   wages, if applicable, the necessary premium for this insurance coverage.
q I have been offered and have declined to purchase this accident insurance coverage.
With my signature: (1) I verify that the information provided on this enrollment form is accurate and complete, and (2) I make the necessary authorization for
voluntary payroll deduction in the amount of premium indicated above.

Date	Signed	                                                   Signature	of	Proposed	Insured

GEF 00070-0299          Revision 11/07