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EMPLOYER NAME: KITTITAS COUNTY <br />GROUP LIFE PLANS / ACCIDENTAL DEATH DISMEMBERMENT PLANS <br />Employers are required to enroll all eligible employees. Basic Life is 100% employer paid. <br />I. STANDARD INSURANCE COMPANY I BASIC LIFE PLANS <br />0 $12,000 ❑ $15,000 ❑ $20,000 0 $24,000 0 $36,000 ❑ $40,000 ❑ $48,000 ❑ $50,000 <br />❑ 1x Annual Salary I $50k max ❑ 1x Annual Salary 1$1001k max ❑ 1x Annual Salary I $150k max <br />❑ Other Plan: <br />❑ $1,000 Basic Life Dependent Benefit (100% participation, employer paid) <br />11. STANDARD INSURANCE COMPANY I VOLUNTARY PLANS ........ ❑ CHECK TO DECLINE COVERAGE <br />® Voluntary Term Life (VTL) (by employee election, employee paid) <br />® Voluntary Accidental Death & Dismemberment (VAD&D) (by employee election, employee paid) <br />GROUP DISABILITY PLANS <br />Base LTD may be purchased for employees not enrolled in WCIF medical plans by checking the applicable box below. If <br />elected, this is an employer paid benefit that requires 100% employee participation. Must have Base LTD in place to <br />offer voluntary Buy -Up LTD. <br />1. STANDARD INSURANCE COMPANY I DISABILITY PLANS ......... ❑ CHECK TO DECLINE COVERAGE <br />❑ Base Long Term Disability (Base LTD) for Non -Medical Participants (100% participation, employer paid) <br />® Voluntary Buy -Up Long Term Disability (Buy -Up LTD) (by employee election, employee paid) <br />® Voluntary Short Term Disability (VSTD) <br />(by employee election, 2 waiting periods available to coincide with Base or Buy -Up LTD, employee paid) <br />EMPLOYEE ASSISTANCE PROGRAM (EAP) <br />EAP may be purchased for employees not enrolled in WCIF medical plans by checking the applicable box below. If elected, this <br />is an employer paid benefit that requires 100% employee participation. This plan features a special "Stand -Alone" option for <br />employees who are not otherwise benefit eligible. <br />1. MAGELLAN HEALTH SERVICES ................................. ® CHECK TO DECLINE COVERAGE <br />❑ Standard EAP Coverage (100% participation for all benefit -eligible employees, employer paid) <br />❑ Stand -Alone EAP Coverage (100% participation for all employees) <br />When Stand -Alone Coverage is offered to otherwise non benefit eligible employees, do you want these <br />employees included in the monthly combined bill? <br />❑ Yes (if YES, a census will need to be provided to BSI) ❑ No <br />2017GMA2 Page 6 of 9 (092116JM) <br />