24 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 $15,000. The semi-monthly rate for $15,000 in coverage will be $1.08. •  Employees already enrolled in Dependent Life who wish to increase their benefit amount must have their eligible 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 Enrollment for the 2018 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, 2018. 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 statement 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.