CHEIBA
Enrollment Form
Voluntary Life and Dependent Life
Colorado School of Mines - 002252
Name:
Date of Hire
Gender (M or F)
Date of Birth
Age
Hours Worked (Number)
Effective Date
SSN
Annual Salary
Home Address:
(Number and Street)
City
State
Zip Code
SECTION II - BENEFIT SELECTION
Check the boxes that apply for all products:
Employee Voluntary
Elect in $10,000 increments to a maximum of $500,000 or 5x annual earnings, whichever is less.
Life
ONE TIME OPEN ENROLLMENT: You can get up to $60,000 with NO MEDICAL QUESTIONS ASKED,
unless previously denied or age 60 and above at the time of application.
Current Coverage Amount
Smoker
Requesting Coverage
Amount
Non-Smoker
$60,000
Other Benefit
Monthly Premium
Spouse
Elect in $10,000 increments to a maximum of $300,000.
Voluntary Life
ONE TIME OPEN ENROLLMENT: You can get up to $30,000 with NO MEDICAL QUESTIONS ASKED,
unless previously denied or age 60 and above at the time of application.
Spouse Name:
Date of Birth
Current Coverage Amount
Requesting Coverage
Amount
$30,000
Other Benefit
Smoker
Monthly Premium
Non-Smoker
Child(ren)
You may elect in $5,000 increments to a maximum of $25,000.
Voluntary Life
ONE TIME OPEN ENROLLMENT: You can get up to $25,000 with NO MEDICAL QUESTIONS ASKED.
Current Coverage Amount
Requesting Coverage
Amount
$25,000
Other Benefit
Monthly Premium
SECTION III - BENEFICIARY INFORMATION
Please attach a separate sheet if need with additional beneficiaries.
Full Name
Address
Relationship
D.O.B
%
Primary
Contingent
SECTION IV - ELIGIBILITY AND AUTHORIZATION
Employee Signature
Date
Spouse Signature
Date

Now is the time to enroll in Optional Life insurance with
Anthem Blue Cross!
OPEN ENROLLMENT
Unlike your annual benefits enrollment period, CHEIBA Trust
Effective
participants now have a one-time opportunity to enroll in Optional
Life insurance. During this enrollment you can select life insurance
2018
in amounts from $10,000 up to $500,000 or 5 times your annual
earnings, whichever is less.
Please review these important
materials to learn about your
Why buy it now?
Optional Life enrol ment
Everyone thinks, “Oh, I can buy life insurance later.” Here are a few great
opportunity.
reasons to enrol in optional life insurance now, during this one-time
enrollment period.
1. It’s easy – and affordable – to add more coverage now. CHEIBA Trust already provides basic term
life insurance at no cost to you. But this may not be enough for your needs. Now, you can buy more
coverage at a rate you can afford.
2. You coverage is “Guaranteed Issue”. This means you get covered - or increase coverage - up to $60,000
without answering medical questions.
3. Payments are deducted from your paycheck. It’s easy – no bills to pay or checks to write. Premium
payments are deducted right from your paycheck.
4. Optional Life is Portable. If you leave the company for reasons other than retirement or disability this
feature allows you to take your optional life coverage with you by paying the premiums to Anthem. These
premiums are typically lower than an individual policy. Basic life insurance does not have a portability feature.
Everything you need to learn about optional life insurance is included here:
1. Personalized Enrol ment Form – This form lists the optional life insurance coverage amounts available
and the per pay period cost which wil be deducted from your paycheck.
2. Benefit Summary – This gives a detailed description of the features and benefits for the optional life
insurance provided by Anthem Blue Cross
3. Worksheet – The optional life insurance worksheet helps you discover your personal need for this
coverage and determine how much to elect.
4. Rate Chart – This chart will help you calculate the cost of life insurance you choose to purchase that
are different than the amounts listed on your Personalized Enrol ment Form.
5. Insurability Information Request form – **Complete this form only if the amount of life insurance
you choose is over your guaranteed issue amount.
Enrolling in optional life insurance is as easy as 1 – 2 – 3.
Using your Personalized Enrollment Form, follow these three simple steps to make your choices.
1. For each benefit, check either the “Accept” or “Decline” box to indicate your choice. If you check
“Accept,” then check the appropriate box indicating your requested coverage amount.
2. Complete the Employee Beneficiary Designation information section.
3. Sign and date the form and turn it into your Human Resource Representative.
**If you elect an amount over the Guarantee Issue for yourself or your spouse, complete and sign the
Insurability Information Request form and email it to Anthem at LifeDisUW_MEU@anthem.com.
Please do not turn the Insurability Information Request form into HR**

Life insurance


One more way you can protect
your family
No one wants to think about life insurance. It’s one of those
How much life insurance do you need?
unpleasant topics you push to the back of your mind and
promise to think about “later.” But what if “later” came and
Here’s a worksheet to help you estimate how much coverage
your family wasn’t protected?
you’ll need. Just fill out each amount and add them up at
the end. That will give you an idea of the total amount of life
A recent study shows that more than half of U.S. households
insurance your family will need if something happens to you.
would have trouble meeting everyday living expenses within
six months if the primary wage earner died. More than a third

would have trouble within just one month.*
Money you owe
How much will be left for your family to pay?
Our optional life insurance plans can give your family peace of
mind for their future. While you may not want to think about it,
Mortgage balance
$
there’s actually no better time than now to protect your family.
Car payments
$
Why now?
Loans or credit cards
$
1. It’s easy and more affordable than you might think to
add more life insurance coverage. Your employer may
Long-term costs
offer a basic term life policy, but it may not be enough to
How much do your loved ones need each year?
meet your family’s needs. During your annual open
Utilities $
enrollment, you can buy more coverage at lower rates.
(electricity, water, phone, cable)
And you can keep the policy as long as you make your
monthly payments, no matter where you work.
Medical costs or insurance
$
2. You don’t need a physical exam. During your enrollment
Food, clothing, children’s activities
$
period, you can buy life insurance — up to a certain
amount — without a health exam. You may only need to
Car insurance, repairs, gas
$
answer a few basic medical questions.
Retirement savings
$
3. Payments are taken from your paycheck. No extra bills
or checks to write.
Future plans
How much will your loved ones need for the future?
College $
Other
$
Do you have a plan for protecting your family?
(such as retirement or long-term care)
Having the right coverage can give them —
and you — peace of mind.
Total $
* Life Happens and LIMRA, 2016 Insurance Barometer Study. www.lifehappens.org/industry-resources/agent/barometer2016/.
Life and Disability products underwritten by Anthem Blue Cross Life and Health Insurance Company, an independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the
Blue Cross Association.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross
name and symbol are registered marks of the Blue Cross Association.
28053CAMENABC VPOD 01/17


EMPLOYEE VOLUNTARY GROUP TERM LIFE PREMIUMS
Monthly Premiums For Non- Smokers
CHEIBA Trust
ATTAINED
EMPLOYEE AMOUNTS OF INSURANCE
AGE
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$110,000
$120,000
$130,000
$140,000
$150,000
<25
0.54
1.08
1.62
2.16
2.70
3.24
3.78
4.32
4.86
5.40
5.94
6.48
7.02
7.56
8.10
25 - 29
0.60
1.20
1.80
2.40
3.00
3.60
4.20
4.80
5.40
6.00
6.60
7.20
7.80
8.40
9.00
30 - 34
0.80
1.60
2.40
3.20
4.00
4.80
5.60
6.40
7.20
8.00
8.80
9.60
10.40
11.20
12.00
35 - 39
0.90
1.80
2.70
3.60
4.50
5.40
6.30
7.20
8.10
9.00
9.90
10.80
11.70
12.60
13.50
40 - 44
1.02
2.04
3.06
4.08
5.10
6.12
7.14
8.16
9.18
10.20
11.22
12.24
13.26
14.28
15.30
45 - 49
1.80
3.60
5.40
7.20
9.00
10.80
12.60
14.40
16.20
18.00
19.80
21.60
23.40
25.20
27.00
50 - 54
2.82
5.64
8.46
11.28
14.10
16.92
19.74
22.56
25.38
28.20
31.02
33.84
36.66
39.48
42.30
55 - 59
5.16
10.32
15.48
20.64
25.80
30.96
36.12
41.28
46.44
51.60
56.76
61.92
67.08
72.24
77.40
60 - 64
7.20
14.40
21.60
28.80
36.00
43.20
50.40
57.60
64.80
72.00
79.20
86.40
93.60
100.80
108.00
65 - 69
12.80
25.60
38.40
51.20
64.00
76.80
89.60
102.40
115.20
128.00
140.80
153.60
166.40
179.20
192.00
70 - 74
20.60
41.20
61.80
82.40
103.00
123.60
144.20
164.80
185.40
206.00
226.60
247.20
267.80
288.40
309.00
75 - 79
41.34
82.68
124.02
165.36
206.70
248.04
289.38
330.72
372.06
413.40
454.74
496.08
537.42
578.76
620.10
ATTAINED
EMPLOYEE AMOUNTS OF INSURANCE
AGE
$160,000
$170,000
$180,000
$190,000
$200,000
$210,000
$220,000
$230,000
$240,000
$250,000
$260,000
$270,000
$280,000
$290,000
$300,000
<25
8.64
9.18
9.72
10.26
10.80
11.34
11.88
12.42
12.96
13.50
14.04
14.58
15.12
15.66
16.20
25 - 29
9.60
10.20
10.80
11.40
12.00
12.60
13.20
13.80
14.40
15.00
15.60
16.20
16.80
17.40
18.00
30 - 34
12.80
13.60
14.40
15.20
16.00
16.80
17.60
18.40
19.20
20.00
20.80
21.60
22.40
23.20
24.00
35 - 39
14.40
15.30
16.20
17.10
18.00
18.90
19.80
20.70
21.60
22.50
23.40
24.30
25.20
26.10
27.00
40 - 44
16.32
17.34
18.36
19.38
20.40
21.42
22.44
23.46
24.48
25.50
26.52
27.54
28.56
29.58
30.60
45 - 49
28.80
30.60
32.40
34.20
36.00
37.80
39.60
41.40
43.20
45.00
46.80
48.60
50.40
52.20
54.00
50 - 54
45.12
47.94
50.76
53.58
56.40
59.22
62.04
64.86
67.68
70.50
73.32
76.14
78.96
81.78
84.60
55 - 59
82.56
87.72
92.88
98.04
103.20
108.36
113.52
118.68
123.84
129.00
134.16
139.32
144.48
149.64
154.80
60 - 64
115.20
122.40
129.60
136.80
144.00
151.20
158.40
165.60
172.80
180.00
187.20
194.40
201.60
208.80
216.00
65 - 69
204.80
217.60
230.40
243.20
256.00
268.80
281.60
294.40
307.20
320.00
332.80
345.60
358.40
371.20
384.00
70 - 74
329.60
350.20
370.80
391.40
412.00
432.60
453.20
473.80
494.40
515.00
535.60
556.20
576.80
597.40
618.00
75 - 79
661.44
702.78
744.12
785.46
826.80
868.14
909.48
950.82
992.16
1,033.50
1,074.84
1,116.18
1,157.52 1,198.86
1,240.20
ATTAINED
EMPLOYEE AMOUNTS OF INSURANCE
AGE
$310,000
$320,000
$330,000
$340,000
$350,000
$360,000
$370,000
$380,000
$390,000
$400,000
$410,000
$420,000
$430,000
$440,000
$450,000
<25
16.74
17.28
17.82
18.36
18.90
19.44
19.98
20.52
21.06
21.60
22.14
22.68
23.22
23.76
24.30
25 - 29
18.60
19.20
19.80
20.40
21.00
21.60
22.20
22.80
23.40
24.00
24.60
25.20
25.80
26.40
27.00
30 - 34
24.80
25.60
26.40
27.20
28.00
28.80
29.60
30.40
31.20
32.00
32.80
33.60
34.40
35.20
36.00
35 - 39
27.90
28.80
29.70
30.60
31.50
32.40
33.30
34.20
35.10
36.00
36.90
37.80
38.70
39.60
40.50
40 - 44
31.62
32.64
33.66
34.68
35.70
36.72
37.74
38.76
39.78
40.80
41.82
42.84
43.86
44.88
45.90
45 - 49
55.80
57.60
59.40
61.20
63.00
64.80
66.60
68.40
70.20
72.00
73.80
75.60
77.40
79.20
81.00
50 - 54
87.42
90.24
93.06
95.88
98.70
101.52
104.34
107.16
109.98
112.80
115.62
118.44
121.26
124.08
126.90
55 - 59
159.96
165.12
170.28
175.44
180.60
185.76
190.92
196.08
201.24
206.40
211.56
216.72
221.88
227.04
232.20
60 - 64
223.20
230.40
237.60
244.80
252.00
259.20
266.40
273.60
280.80
288.00
295.20
302.40
309.60
316.80
324.00
65 - 69
396.80
409.60
422.40
435.20
448.00
460.80
473.60
486.40
499.20
512.00
524.80
537.60
550.40
563.20
576.00
70 - 74
638.60
659.20
679.80
700.40
721.00
741.60
762.20
782.80
803.40
824.00
844.60
865.20
885.80
906.40
927.00
75 - 79
1,281.54
1,322.88
1,364.22 1,405.56
1,446.90 1,488.24
1,529.58
1,570.92 1,612.26
1,653.60
1,694.94
1,736.28
1,777.62 1,818.96
1,860.30
ATTAINED
EMPLOYEE AMOUNTS OF INSURANCE
Child Coverage*
AGE
$460,000
$470,000
$480,000
$490,000
$500,000
$1.50 per $5,000 increments to $25,000 maximum
<25
24.84
25.38
25.92
26.46
27.00
25 - 29
27.60
28.20
28.80
29.40
30.00
* Child coverage from 15 days to age 26.
30 - 34
36.80
37.60
38.40
39.20
40.00
35 - 39
41.40
42.30
43.20
44.10
45.00
40 - 44
46.92
47.94
48.96
49.98
51.00
45 - 49
82.80
84.60
86.40
88.20
90.00
50 - 54
129.72
132.54
135.36
138.18
141.00
55 - 59
237.36
242.52
247.68
252.84
258.00
60 - 64
331.20
338.40
345.60
352.80
360.00
65 - 69
588.80
601.60
614.40
627.20
640.00
70 - 74
947.60
968.20
988.80 1,009.40
1,030.00
75 - 79
1,901.64
1,942.98
1,984.32 2,025.66
2,067.00

SPOUSE VOLUNTARY GROUP TERM LIFE PREMIUMS
Monthly Premiums For Non- Smokers
CHEIBA Trust
ATTAINED
SPOUSE AMOUNTS OF INSURANCE
AGE
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$110,000
$120,000
$130,000
$140,000
$150,000
<25
0.54
1.08
1.62
2.16
2.70
3.24
3.78
4.32
4.86
5.40
5.94
6.48
7.02
7.56
8.10
25 - 29
0.60
1.20
1.80
2.40
3.00
3.60
4.20
4.80
5.40
6.00
6.60
7.20
7.80
8.40
9.00
30 - 34
0.80
1.60
2.40
3.20
4.00
4.80
5.60
6.40
7.20
8.00
8.80
9.60
10.40
11.20
12.00
35 - 39
0.90
1.80
2.70
3.60
4.50
5.40
6.30
7.20
8.10
9.00
9.90
10.80
11.70
12.60
13.50
40 - 44
1.02
2.04
3.06
4.08
5.10
6.12
7.14
8.16
9.18
10.20
11.22
12.24
13.26
14.28
15.30
45 - 49
1.80
3.60
5.40
7.20
9.00
10.80
12.60
14.40
16.20
18.00
19.80
21.60
23.40
25.20
27.00
50 - 54
2.82
5.64
8.46
11.28
14.10
16.92
19.74
22.56
25.38
28.20
31.02
33.84
36.66
39.48
42.30
55 - 59
5.16
10.32
15.48
20.64
25.80
30.96
36.12
41.28
46.44
51.60
56.76
61.92
67.08
72.24
77.40
60 - 64
7.20
14.40
21.60
28.80
36.00
43.20
50.40
57.60
64.80
72.00
79.20
86.40
93.60
100.80
108.00
65 - 69
12.80
25.60
38.40
51.20
64.00
76.80
89.60
102.40
115.20
128.00
140.80
153.60
166.40
179.20
192.00
70 - 74
20.60
41.20
61.80
82.40
103.00
123.60
144.20
164.80
185.40
206.00
226.60
247.20
267.80
288.40
309.00
75 - 79
41.34
82.68
124.02
165.36
206.70
248.04
289.38
330.72
372.06
413.40
454.74
496.08
537.42
578.76
620.10
ATTAINED
SPOUSE AMOUNTS OF INSURANCE
AGE
$160,000
$170,000
$180,000
$190,000
$200,000
$210,000
$220,000
$230,000
$240,000
$250,000
$260,000
$270,000
$280,000
$290,000
$300,000
<25
8.64
9.18
9.72
10.26
10.80
11.34
11.88
12.42
12.96
13.50
14.04
14.58
15.12
15.66
16.20
25 - 29
9.60
10.20
10.80
11.40
12.00
12.60
13.20
13.80
14.40
15.00
15.60
16.20
16.80
17.40
18.00
30 - 34
12.80
13.60
14.40
15.20
16.00
16.80
17.60
18.40
19.20
20.00
20.80
21.60
22.40
23.20
24.00
35 - 39
14.40
15.30
16.20
17.10
18.00
18.90
19.80
20.70
21.60
22.50
23.40
24.30
25.20
26.10
27.00
40 - 44
16.32
17.34
18.36
19.38
20.40
21.42
22.44
23.46
24.48
25.50
26.52
27.54
28.56
29.58
30.60
45 - 49
28.80
30.60
32.40
34.20
36.00
37.80
39.60
41.40
43.20
45.00
46.80
48.60
50.40
52.20
54.00
50 - 54
45.12
47.94
50.76
53.58
56.40
59.22
62.04
64.86
67.68
70.50
73.32
76.14
78.96
81.78
84.60
55 - 59
82.56
87.72
92.88
98.04
103.20
108.36
113.52
118.68
123.84
129.00
134.16
139.32
144.48
149.64
154.80
60 - 64
115.20
122.40
129.60
136.80
144.00
151.20
158.40
165.60
172.80
180.00
187.20
194.40
201.60
208.80
216.00
65 - 69
204.80
217.60
230.40
243.20
256.00
268.80
281.60
294.40
307.20
320.00
332.80
345.60
358.40
371.20
384.00
70 - 74
329.60
350.20
370.80
391.40
412.00
432.60
453.20
473.80
494.40
515.00
535.60
556.20
576.80
597.40
618.00
75 - 79
661.44
702.78
744.12
785.46
826.80
868.14
909.48
950.82
992.16
1,033.50
1,074.84
1,116.18
1,157.52 1,198.86
1,240.20
Child Coverage*
$1.50 per $5,000 increments to $25,000 maximum
* Child coverage from 15 days to age 26.

EMPLOYEE VOLUNTARY GROUP TERM LIFE PREMIUMS
Monthly Premiums For Smokers
CHEIBA Trust
ATTAINED
EMPLOYEE AMOUNTS OF INSURANCE
AGE
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$110,000
$120,000
$130,000
$140,000
$150,000
<25
0.84
1.68
2.52
3.36
4.20
5.04
5.88
6.72
7.56
8.40
9.24
10.08
10.92
11.76
12.60
25 - 29
0.84
1.68
2.52
3.36
4.20
5.04
5.88
6.72
7.56
8.40
9.24
10.08
10.92
11.76
12.60
30 - 34
0.84
1.68
2.52
3.36
4.20
5.04
5.88
6.72
7.56
8.40
9.24
10.08
10.92
11.76
12.60
35 - 39
1.20
2.40
3.60
4.80
6.00
7.20
8.40
9.60
10.80
12.00
13.20
14.40
15.60
16.80
18.00
40 - 44
1.86
3.72
5.58
7.44
9.30
11.16
13.02
14.88
16.74
18.60
20.46
22.32
24.18
26.04
27.90
45 - 49
3.42
6.84
10.26
13.68
17.10
20.52
23.94
27.36
30.78
34.20
37.62
41.04
44.46
47.88
51.30
50 - 54
5.52
11.04
16.56
22.08
27.60
33.12
38.64
44.16
49.68
55.20
60.72
66.24
71.76
77.28
82.80
55 - 59
9.84
19.68
29.52
39.36
49.20
59.04
68.88
78.72
88.56
98.40
108.24
118.08
127.92
137.76
147.60
60 - 64
12.00
24.00
36.00
48.00
60.00
72.00
84.00
96.00
108.00
120.00
132.00
144.00
156.00
168.00
180.00
65 - 69
19.32
38.64
57.96
77.28
96.60
115.92
135.24
154.56
173.88
193.20
212.52
231.84
251.16
270.48
289.80
70 - 74
30.60
61.20
91.80
122.40
153.00
183.60
214.20
244.80
275.40
306.00
336.60
367.20
397.80
428.40
459.00
75 - 79
56.64
113.28
169.92
226.56
283.20
339.84
396.48
453.12
509.76
566.40
623.04
679.68
736.32
792.96
849.60
ATTAINED
EMPLOYEE AMOUNTS OF INSURANCE
AGE
$160,000
$170,000
$180,000
$190,000
$200,000
$210,000
$220,000
$230,000
$240,000
$250,000
$260,000
$270,000
$280,000
$290,000
$300,000
<25
13.44
14.28
15.12
15.96
16.80
17.64
18.48
19.32
20.16
21.00
21.84
22.68
23.52
24.36
25.20
25 - 29
13.44
14.28
15.12
15.96
16.80
17.64
18.48
19.32
20.16
21.00
21.84
22.68
23.52
24.36
25.20
30 - 34
13.44
14.28
15.12
15.96
16.80
17.64
18.48
19.32
20.16
21.00
21.84
22.68
23.52
24.36
25.20
35 - 39
19.20
20.40
21.60
22.80
24.00
25.20
26.40
27.60
28.80
30.00
31.20
32.40
33.60
34.80
36.00
40 - 44
29.76
31.62
33.48
35.34
37.20
39.06
40.92
42.78
44.64
46.50
48.36
50.22
52.08
53.94
55.80
45 - 49
54.72
58.14
61.56
64.98
68.40
71.82
75.24
78.66
82.08
85.50
88.92
92.34
95.76
99.18
102.60
50 - 54
88.32
93.84
99.36
104.88
110.40
115.92
121.44
126.96
132.48
138.00
143.52
149.04
154.56
160.08
165.60
55 - 59
157.44
167.28
177.12
186.96
196.80
206.64
216.48
226.32
236.16
246.00
255.84
265.68
275.52
285.36
295.20
60 - 64
192.00
204.00
216.00
228.00
240.00
252.00
264.00
276.00
288.00
300.00
312.00
324.00
336.00
348.00
360.00
65 - 69
309.12
328.44
347.76
367.08
386.40
405.72
425.04
444.36
463.68
483.00
502.32
521.64
540.96
560.28
579.60
70 - 74
489.60
520.20
550.80
581.40
612.00
642.60
673.20
703.80
734.40
765.00
795.60
826.20
856.80
887.40
918.00
75 - 79
906.24
962.88
1,019.52 1,076.16
1,132.80 1,189.44
1,246.08
1,302.72 1,359.36
1,416.00
1,472.64
1,529.28
1,585.92 1,642.56
1,699.20
ATTAINED
EMPLOYEE AMOUNTS OF INSURANCE
AGE
$310,000
$320,000
$330,000
$340,000
$350,000
$360,000
$370,000
$380,000
$390,000
$400,000
$410,000
$420,000
$430,000
$440,000
$450,000
<25
26.04
26.88
27.72
28.56
29.40
30.24
31.08
31.92
32.76
33.60
34.44
35.28
36.12
36.96
37.80
25 - 29
26.04
26.88
27.72
28.56
29.40
30.24
31.08
31.92
32.76
33.60
34.44
35.28
36.12
36.96
37.80
30 - 34
26.04
26.88
27.72
28.56
29.40
30.24
31.08
31.92
32.76
33.60
34.44
35.28
36.12
36.96
37.80
35 - 39
37.20
38.40
39.60
40.80
42.00
43.20
44.40
45.60
46.80
48.00
49.20
50.40
51.60
52.80
54.00
40 - 44
57.66
59.52
61.38
63.24
65.10
66.96
68.82
70.68
72.54
74.40
76.26
78.12
79.98
81.84
83.70
45 - 49
106.02
109.44
112.86
116.28
119.70
123.12
126.54
129.96
133.38
136.80
140.22
143.64
147.06
150.48
153.90
50 - 54
171.12
176.64
182.16
187.68
193.20
198.72
204.24
209.76
215.28
220.80
226.32
231.84
237.36
242.88
248.40
55 - 59
305.04
314.88
324.72
334.56
344.40
354.24
364.08
373.92
383.76
393.60
403.44
413.28
423.12
432.96
442.80
60 - 64
372.00
384.00
396.00
408.00
420.00
432.00
444.00
456.00
468.00
480.00
492.00
504.00
516.00
528.00
540.00
65 - 69
598.92
618.24
637.56
656.88
676.20
695.52
714.84
734.16
753.48
772.80
792.12
811.44
830.76
850.08
869.40
70 - 74
948.60
979.20
1,009.80 1,040.40
1,071.00 1,101.60
1,132.20
1,162.80 1,193.40
1,224.00
1,254.60
1,285.20
1,315.80 1,346.40
1,377.00
75 - 79
1,755.84
1,812.48
1,869.12 1,925.76
1,982.40 2,039.04
2,095.68
2,152.32 2,208.96
2,265.60
2,322.24
2,378.88
2,435.52 2,492.16
2,548.80
ATTAINED
EMPLOYEE AMOUNTS OF INSURANCE
Child Coverage*
AGE
$460,000
$470,000
$480,000
$490,000
$500,000
$1.50 per $5,000 increments to $25,000 maximum
<25
38.64
39.48
40.32
41.16
42.00
25 - 29
38.64
39.48
40.32
41.16
42.00
* Child coverage from 15 days to age 26.
30 - 34
38.64
39.48
40.32
41.16
42.00
35 - 39
55.20
56.40
57.60
58.80
60.00
40 - 44
85.56
87.42
89.28
91.14
93.00
45 - 49
157.32
160.74
164.16
167.58
171.00
50 - 54
253.92
259.44
264.96
270.48
276.00
55 - 59
452.64
462.48
472.32
482.16
492.00
60 - 64
552.00
564.00
576.00
588.00
600.00
65 - 69
888.72
908.04
927.36
946.68
966.00
70 - 74
1,407.60
1,438.20
1,468.80 1,499.40
1,530.00
75 - 79
2,605.44
2,662.08
2,718.72 2,775.36
2,832.00

SPOUSE VOLUNTARY GROUP TERM LIFE PREMIUMS
Monthly Premiums For Smokers
CHEIBA Trust
ATTAINED
SPOUSE AMOUNTS OF INSURANCE
AGE
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$110,000
$120,000
$130,000
$140,000
$150,000
<25
0.84
1.68
2.52
3.36
4.20
5.04
5.88
6.72
7.56
8.40
9.24
10.08
10.92
11.76
12.60
25 - 29
0.84
1.68
2.52
3.36
4.20
5.04
5.88
6.72
7.56
8.40
9.24
10.08
10.92
11.76
12.60
30 - 34
0.84
1.68
2.52
3.36
4.20
5.04
5.88
6.72
7.56
8.40
9.24
10.08
10.92
11.76
12.60
35 - 39
1.20
2.40
3.60
4.80
6.00
7.20
8.40
9.60
10.80
12.00
13.20
14.40
15.60
16.80
18.00
40 - 44
1.86
3.72
5.58
7.44
9.30
11.16
13.02
14.88
16.74
18.60
20.46
22.32
24.18
26.04
27.90
45 - 49
3.42
6.84
10.26
13.68
17.10
20.52
23.94
27.36
30.78
34.20
37.62
41.04
44.46
47.88
51.30
50 - 54
5.52
11.04
16.56
22.08
27.60
33.12
38.64
44.16
49.68
55.20
60.72
66.24
71.76
77.28
82.80
55 - 59
9.84
19.68
29.52
39.36
49.20
59.04
68.88
78.72
88.56
98.40
108.24
118.08
127.92
137.76
147.60
60 - 64
12.00
24.00
36.00
48.00
60.00
72.00
84.00
96.00
108.00
120.00
132.00
144.00
156.00
168.00
180.00
65 - 69
19.32
38.64
57.96
77.28
96.60
115.92
135.24
154.56
173.88
193.20
212.52
231.84
251.16
270.48
289.80
70 - 74
30.60
61.20
91.80
122.40
153.00
183.60
214.20
244.80
275.40
306.00
336.60
367.20
397.80
428.40
459.00
75 - 79
56.64
113.28
169.92
226.56
283.20
339.84
396.48
453.12
509.76
566.40
623.04
679.68
736.32
792.96
849.60
ATTAINED
SPOUSE AMOUNTS OF INSURANCE
AGE
$160,000
$170,000
$180,000
$190,000
$200,000
$210,000
$220,000
$230,000
$240,000
$250,000
$260,000
$270,000
$280,000
$290,000
$300,000
<25
13.44
14.28
15.12
15.96
16.80
17.64
18.48
19.32
20.16
21.00
21.84
22.68
23.52
24.36
25.20
25 - 29
13.44
14.28
15.12
15.96
16.80
17.64
18.48
19.32
20.16
21.00
21.84
22.68
23.52
24.36
25.20
30 - 34
13.44
14.28
15.12
15.96
16.80
17.64
18.48
19.32
20.16
21.00
21.84
22.68
23.52
24.36
25.20
35 - 39
19.20
20.40
21.60
22.80
24.00
25.20
26.40
27.60
28.80
30.00
31.20
32.40
33.60
34.80
36.00
40 - 44
29.76
31.62
33.48
35.34
37.20
39.06
40.92
42.78
44.64
46.50
48.36
50.22
52.08
53.94
55.80
45 - 49
54.72
58.14
61.56
64.98
68.40
71.82
75.24
78.66
82.08
85.50
88.92
92.34
95.76
99.18
102.60
50 - 54
88.32
93.84
99.36
104.88
110.40
115.92
121.44
126.96
132.48
138.00
143.52
149.04
154.56
160.08
165.60
55 - 59
157.44
167.28
177.12
186.96
196.80
206.64
216.48
226.32
236.16
246.00
255.84
265.68
275.52
285.36
295.20
60 - 64
192.00
204.00
216.00
228.00
240.00
252.00
264.00
276.00
288.00
300.00
312.00
324.00
336.00
348.00
360.00
65 - 69
309.12
328.44
347.76
367.08
386.40
405.72
425.04
444.36
463.68
483.00
502.32
521.64
540.96
560.28
579.60
70 - 74
489.60
520.20
550.80
581.40
612.00
642.60
673.20
703.80
734.40
765.00
795.60
826.20
856.80
887.40
918.00
75 - 79
906.24
962.88
1,019.52 1,076.16
1,132.80 1,189.44
1,246.08
1,302.72 1,359.36
1,416.00
1,472.64
1,529.28
1,585.92 1,642.56
1,699.20
Child Coverage*
$1.50 per $5,000 increments to $25,000 maximum
* Child coverage from 15 days to age 26.

Colorado Insurability Information Request
Please keep a copy of this form/notice for your records.
Medical Evidence Underwriting Unit
Group no.
LifeDisUW_MEU@anthem.com
Evidence required because of:
This evidence is provided for:
Over guaranteed issue amount Late entrant Change of benefits
An effective date under a new group A post group effective date addition
SECTION 1: GENERAL INFORMATION
Last name
First name
M.I.
Date of birth (MM/DD/YYYY)
Social Security no.
Work phone no.
Home phone no.
Email address
Employee address
City
State
ZIP code
State of birth Height
Weight
Name of employer
Employer address
SECTION 2: DEPENDENT INFORMATION — Complete for all dependents (if any) to be covered under this program.
Last name, first name, M.I.
Sex
Date of birth
State of
(MM/DD/YYYY)
birth
Social Security no.
Relationship
Height
Weight
M
F
Spouse
M
F
M
F
M
F
SECTION 3: MEDICAL AND ACTIVITIES QUESTIONNAIRE
Complete the following medical questions for all persons to be covered: For the purpose of the following questions, the term “medical or social practitioner” includes
but is not limited to: a doctor, nurse, psychologist, psychiatrist, social worker, chiropractor, podiatrist, therapist, pathologist, dentist, optometrist, osteopath, Christian
Science practitioner, or any person affiliated with a self-help program such as Alcoholics Anonymous, a substance abuse program, or a weight loss program.
1. Are you or any of your dependents currently pregnant?
Yes No 4. Have you or any of your dependents ever been diagnosed by,
If yes, who? _________________________________
or received treatment from, a member of the medical profession
for Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related
Expected due date:
(MM/DD/YYYY)
Complex (ARC) or tested positive for antibodies to the Human
2. Have you or any of your dependents smoked or used tobacco
Immune Deficiency virus?
Yes
No
in the last five years?
Yes No 5. In the past three years have you or any of your dependents been
If yes, who? _________________________________
prescribed medication?
Yes
No
Type: _____________________________________
6. In the past 10 years have you or any of your dependents had
Quit date (if applicable):
(MM/DD/YYYY)
an inpatient admission and/or outpatient surgery?
Yes
No
3. In the past 10 years, have you or any of your dependents ever:
a. Had high blood pressure or high cholesterol?
Yes No 7. During the past three years, have you or any of your dependents
If yes, who? ______________________________
sought medical treatment, or been advised by a medical or social
practitioner to seek treatment for any condition not indicated by
Last three readings: _________________________
the answers to the preceding six questions?
Yes
No
b. Had heart disease, cancer, diabetes, arthritis, or asthma?
Yes No 8. Have you or any of your dependents ever been rated or declined
c. Had counseling by a medical or social practitioner for an
for, or refused reinstatement or renewal of, life or health
emotional, mental or nervous condition?
Yes No
insurance? If yes, name of person, date and reason:
Yes
No
d. Been treated for alcohol or chemical dependency, or been
________________________________________
convicted for driving while intoxicated?
Yes No 9. In the past three years, have you or any of your dependents been
engaged in or contemplate during the next 12 months being
engaged in sports or hobbies such as aviation, scuba diving,
sky diving, racing, or similar activities?

Yes
No
Please list: __________________________________
IMPORTANT NOTICE: No person, including an employee or agent of Anthem Life has the authority to change or omit any of these medical questions.
Si usted necesita ayuda en Español para entender este documento, puede solicitarlo sin ningun costo adicional llamando al número de servicio al cliente que se encuentra en este documento.
Life and Disability products underwritten by Anthem Life Insurance Company. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
A-0711-EOI
60133COMENLIC Rev. 6/16 1 of 2
645133 32641COEENLIC Disability and Life Employer EOI FR 10 12

SECTION 3: MEDICAL AND ACTIVITIES QUESTIONNAIRE (continued)
Explain any “Yes” answers below. If additional space is necessary, attach a separate page including your signature and date.
Question
Dates of
Any remaining
Name of medication
Name and address of
no.
Name of individual
Name of illness
or injury
treatment
effects
and dosage
physician/hospital
SECTION 4: NOTICE OF EXCHANGE OF INFORMATION
To proposed Insured and other persons proposed to be Insured, if any — information regarding your insurability will be treated as confidential. We or our reinsurer(s)
may, however, make a brief report on this information to MIB, Inc., a non-profit membership organization of insurance companies that operates an information
exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such
a company, MIB may, upon request, supply such company with the information in its file. Upon receipt of a request from you, MIB will arrange disclosure of any
information it may have in your file. If you question the accuracy of this information in MIB’s file, you may contact MIB and seek a correction in accordance with the
procedures set forth in the Federal Fair Credit Reporting Act. The address of MIB’s information office is: 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts
02184-8734; and telephone number is 1-866-692-6901.
SECTION 5: AGREEMENT AND AUTHORIZATION
1. I authorize the release of any medical records or information concerning claims, conditions or treatment of myself and for any dependents listed herein,
by any provider of health services, pharmacy related service organization, medical or medically-related facility, or the MIB, Inc., to Anthem Life Insurance
Company (Anthem Life), its affiliates, and any administrators, reinsurers, agents, or other entity providing services on behalf of Anthem Life. This
information will be used for purposes which include but are not limited to: processing this application for enrollment; group risk classification; detecting
or preventing fraud or misrepresentation; internal and external audits; administration of claims; and quality improvement programs. Anthem Life will
advise such entities that such information must be kept confidential to the extent necessary or as otherwise provided by law, and should not be used
for any unlawful purpose. This information includes any records or knowledge about medical history, including sensitive services such as mental health,
psychiatric, substance abuse, reproductive health, information relating to HIV virus or AIDS, sexually transmitted or other communicable diseases contained
in such records, including but not limited to, all records of office visits, examinations, treatment, evaluation, diagnostic and laboratory testing, reports,
consultations, hospital records, prescription history, records for treatment of substance abuse, psychiatric counseling, notes, correspondence, insurance
and billing information for treatment or services rendered by any provider. I understand that Anthem Life may collect personal information about me from
outside sources, and that both personal and privileged information may be collected and disclosed to third parties without my further authorization, and
may no longer be protected by Federal privacy laws. I also understand that I have a right to see and correct personal information that Anthem Life collects
about me, and that I may receive a more detailed description of my rights under this law by writing to Anthem Life.
2. These coverages will become effective on the date established by the provisions of the group contract and certificates issued thereunder.
3. I am responsible for the timely notification to my employer of any changes that would make me or a dependent ineligible for coverage.
4. I understand that Anthem Life reserves the right to accept or decline the application and that no right whatsoever is created by this information request.
I acknowledge that I have read the foregoing provisions and I expressly accept such provisions as a condition of coverage. I also acknowledge receipt and
understanding of the Notice of Exchange of Information explained above. I represent that the answers given to all questions on this information request
are true and accurate to the best of my knowledge and I understand they are being relied on by the insurer in reviewing the application for insurance.
I understand that any misstatements or failure to report new medical information prior to my effective date may result in a material change to coverage
or premium rates. Any material misrepresentation or significant omission found in this information request may result in denial of benefits or rescission or
cancellation of my coverage(s). This authorization, for purposes of processing this information request form, is valid from the date signed for a period of
thirty months unless revoked by me in writing, which I may do at any time by contacting Anthem Life. A photocopy is as valid as the original.
Applicant signature
Date (MM/DD/YYYY)
X
Spouse signature (If to be covered)
Date (MM/DD/YYYY)
X
This Authorization may be revoked at any time by the Applicant by sending a written revocation to us at: Anthem, P.O. Box 182361, Columbus, OH, 43218-2361.
Such revocation must be signed and dated by the Applicant and spouse, if the spouse is to be covered. Revocation of this Authorization may result in denial of
coverage or denial of a claim.
REFUSAL OF AUTHORIZATION — I refuse authorization to disclose health care information. I understand that such refusal may result in denial of coverage
or denial of a claim.
Applicant signature
Date (MM/DD/YYYY)
X
Spouse signature (If to be covered)
Date (MM/DD/YYYY)
X
Fraud Warning: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding
or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of
an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding
or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado
division of insurance within the department of regulatory agencies.
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