Life/LTD/STD/Supplemental Life Chart Template
Author: Dominique DiCriscio

Basic Term Life and AD&D Insurance
All active, full-time employees working at least 30 hours per week are eligible for the basic life and accidental death & dismemberment (AD&D) plan. This plan is available to employees at no cost – <CLIENT NAME> pays 100% of the basic life and AD&D premium.

Basic Term Life and AD&D Plan
Benefit Amount	1

Short-Term Disability Insurance
<CLIENT NAME> provides short-term disability insurance to protect a portion of your income in the event you are incapable of working due to a qualified illness or injury. This plan is available to <CLIENT NAME> employees at no cost – <CLIENT NAME> pays 100% of the short-term disability premium.

Short-Term Disability (STD) Plan
Benefits Percent
Benefit Maximum per Week
Duration
Elimination Period—Accident or Sickness

Long-Term Disability Insurance
All active, full-time employees regularly working at least 30 hours per week are eligible for the long-term disability (LTD) plan. This plan is available to employees at no cost – <CLIENT NAME> pays 100% of the LTD premium.

Long-Term Disability (LTD) Plan
Percentage of Income Replaced
Minimum Benefit
Maximum Benefit

Supplemental Employee Term Life and AD&D
All active, full-time employees working at least 30 hours per week are eligible to participate in the supplementary employee term life plan. Since this plan is optional, the employee is responsible for 100% of the premium.

Supplemental Employee Term Life Plan
Benefit Increments
Maximum Amount

Supplemental Spousal Term Life and AD&D
You have the option of purchasing life insurance, for your spouse, at your own expense. Since this plan is optional, the employee is responsible for 100% of the premium.
NOTE: You must purchase Supplemental Employee Term Life Insurance to participate in Supplemental Spousal and/or Child(ren) Term Life plans.

Supplemental Spousal Term Life Plan
Benefit Increments
Maximum Amount

Supplemental Child(ren) Term Life and AD&D
You have the option of purchasing life insurance, for your child(ren), at your own expense. Since this plan is optional, the employee is responsible for 100% of the premium.
NOTE: You must purchase Supplemental Employee Term Life Insurance to participate in Supplemental Spousal and/or Child(ren) Term Life plans.

Supplemental Child(ren) Term Life Plan
Benefit Increments / 15 days old through 6 months old / 6 months old through 18 years old (or 23 if your child(ren) if a full time student)