Form 5-301a - Basic And Optional Life Insurance Enrollment Or Change - Alaska Department Of Administration Page 2
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1
2INSTRUCTIONS
BASIC LIFE AND AD&D INSURANCE
The State of Alaska provides Basic Life and Accidental Death and Dismemberment (AD&D) Insurance free of charge to
permanent and long-term nonpermanent, full-time, and seasonal employees and their families. The benefi t pays $2,000
to your benefi ciaries in the event of your death plus an additional $5,000 if your death is accidental. Benefi ts are also
available if you are dismembered by accidental causes or if your spouse or child dies.
Permanent or long-term nonpermanent part-time employees who want to participate in Basic Life must elect coverage
within the fi rst 31 consecutive calendar days of employment. They must also be enrolled in a State Group Health Plan.
Part-time employees pay one-half of the health and life premium cost. Part-time employees who do not enroll within the
fi rst 31 days of employment may apply for coverage, subject to approval by the insurance carriers.
For more detailed information regarding the Basic Life Insurance and AD&D plans, please refer to your Employee Group
Insurance Information Booklet.
OPTIONAL LIFE AND AD&D INSURANCE
Optional Life Premiums
✫Premium Per $1000
You may choose to enroll in Optional Life for a very low cost. The
Age
amount of Optional Life available to you is equal to your annual
Under 30 .................. --------- $0.08
income rounded to the next highest $1,000. The maximum available
30-39 .................... --------- $0.08
is $60,000 ($100,000 for Supervisory and Confi dential Unit
40-44 .................... --------- $0.12
employees). The plan pays double the face value if your death is
45-49 .................... --------- $0.14
accidental. This plan does not cover your dependents.
50-54 .................... --------- $0.20
You may enroll in the Optional Life Insurance within 30 consecutive
55-59 .................... --------- $0.28
calendar days from the date you were hired as a permanent or long-
60-64 .................... --------- $0.38
term nonpermanent employee. If you do not enroll within that time,
65-69 .................... --------- $0.54
you may enroll during the annual open enrollment period or within
70-74 .................... --------- $1.14
30 days of a change in your marital or family status such as marriage,
75-79 .................... --------- $2.10
divorce, death, or birth or adoption of a child.
80-84 .................... --------- $2.98
85 & Over ................. --------- $4.54
For more detailed information regarding the Optional Life Insurance
and AD&D plans, please refer to your Employee Group Insurance
Information Booklet.
BENEFICIARY DESIGNATION
The benefi ciary designation section names the people you want to receive the benefi ts you have elected in the event of
your death. It may also be used to change those names at any time. The section has space for three benefi ciaries. If
necessary, you may attach additional forms. This section must be completed listing all intended benefi ciaries each time
this form is used.
1. Enter the benefi ciary's name, address and relationship to you.
2. Indicate which benefi ts this benefi ciary should receive if you die. Check Optional Life only if you are enrolled in the
program.
3. Indicate whether this benefi ciary is primary or contingent. Primary benefi ciaries receive the benefi t fi rst if you die.
Contingent benefi ciaries receive the benefi t if the primary benefi ciary has died.
4. Indicate the percentage of the benefi ts that you would like this benefi ciary to receive. The total percentage given to
primary benefi ciaries must equal 100%. The total percentage given to contingent benefi ciaries must equal 100%.
5. List as many benefi ciaries as you like, following the instructions for the fi rst benefi ciary in #1 through #4 above.
5-301a (Rev. 6/10)
g:/publications/forms/benefi ts/5-301a.indd
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