Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 4424 n  DEPENDENT LIFE INSURANCE – SPOUSE AND/OR DEPENDENT CHILD •  Dependent Life Insurance is an optional term insurance policy that permanent employees may purchase for coverage on their eligible dependents: • spouse • a biological or adopted child or stepchild up to age 26. • You, as the employee, are the beneficiary. •  You cannot purchase dependent life insurance for a spouse who is also a WSSC employee or a child who is already covered by another WSSC employee. •  Dependent Life Insurance coverage on your spouse is an amount, elected by you, which is a multiple of $10,000 with a maximum dependent life benefit of $100,000. The cost of this coverage is based on your age and coverage amount. Age Semi-monthly rate per $10,000 in coverage Age Semi-monthly rate per $10,000 in coverage under 30 $0.15 50-54 $0.76 30-34 $0.17 55-59 $1.20 35-39 $0.22 60-64 $1.91 40-44 $0.31 65-69 $3.28 45-49 $0.46 70-74 $6.28 •  Dependent Life Insurance on your eligible children is offered in the amount of $10,000. The semi-monthly rate for $10,000 in coverage will be $0.72. •  Employees already enrolled in Dependent Life who wish to increase their benefit amount must have their eligi- ble dependents complete a Statement of Health form. See the Statement of Health section below. •  Employees who are not currently enrolled in Dependent Life Insurance but wish to enroll during Open Enroll- ment for the 2017 Plan year, must have their eligible dependents complete a Statement of Health. •  Enrollment in Dependent Life is not automatic. You must elect Dependent Life and the coverage amount in One-Source. n  STATEMENT OF HEALTH •  The Statement of Health form is available on the WSSC Intranet and One-Source. •  Send the completed form to HR, attn: Open Enrollment and it will be sent to MetLife for review. Your new policy and premium deduction will not take effect until MetLife approves your application; this will occur after January 1, 2017. Do not send your form directly to MetLife.  Please Note: If you are requesting a new insurance policy or an increase that requires completion of a state- ment of health form, your request will be pending until we are notified by MetLife that the request has been approved.           Life Insurance: Basic, Supplemental & Dependent PLEASE ENTER THE ADDRESS, DATE OF BIRTH AND SOCIAL SECURITY NUMBERS OF ALL YOUR BENEFICIARIES INTO ONE-SOURCE. THIS ENSURES THAT THE RIGHT PERSON RECEIVES YOUR BENEFIT.