AffinityChoice Benefits Selection Tool v4.0 Renaissance Life

AffinityChoice Benefits Selection Tool

CUSTOMIZE YOUR GROUP INSURANCE BENEFITS PACKAGE AND ENROLL
LIFE
INSURANCE
DENTAL
INSURANCE
VISION
INSURANCE
SHORT-TERM DISABILITY
INSURANCE
{employerName} has made AffinityChoice - a custom group insurance benefits package - available to you and will contribute ${emac} per month to help you pay the premium for the benefits you select. {basicLife}of life and accidental death insurance is automatically included at no cost to you.

No health questions or physical exam required if applying during the open enrollment period or within 30 days of hire. Please note that rates for voluntary life insurance and short-term disability are age-banded and will increase as you age.

To get started, please provide your date of birth.
Your Date of Birth:*

MonthDayYear
You must be 18 or older to enroll in AffinityChoice.
- Employer Group Table
- BAL Rate Table
- VOL Rate Table
- DEN Rate Table
- VIS Rate Table
- STD Rate Table

Choose Your Benefits

CREATE AN INSURANCE BENEFITS PACKAGE THAT WORKS BEST FOR YOU AND YOUR FAMILY
Use this form to select the best benefit mix for you and your family. Scroll down to see the calculator at the bottom of the screen which will keep track of your selections and costs. If the total monthly cost of benefits is greater than your employer’s monthly contribution, the difference will be paid via payroll deduction. Once you are happy with your choices, click “Next” to continue to the enrollment form.

	Voluntary Life Insurance
	You can choose up to $50,000 of voluntary life insurance for yourself (in addition to the coverage automatically provided at no cost to you by your employer), up to $25,000 for your spouse and $10,000 per child. Note that premiums increase via age banded rates throughout the life of your policy.

Do you want to enroll for voluntary life insurance in addition to the basic life coverage provided by your employer?*

YesNo
Your Voluntary Life Insurance Amount:*
Would you like life insurance coverage for your spouse/domestic partner?*

YesNo
Spouse/Domestic Partner's Date of Birth*

MonthDayYear
Your spouse must be 18 or older to enroll in AffinityChoice.
Spouse/Domestic Partner's Life Insurance Amount*

Would you like $10,000 of life insurance for each of your Dependent Children (under age 26)?*

YesNo

	Dental Insurance
	Helps pay for check-ups, cleanings and other services. Please select whom you would like to enroll for dental insurance.
	See in-network dentists

Choose a Dental Plan*

	Vision Insurance
	Helps pay for eye exams, frames, lenses and contacts. Please select whom you would like to enroll for vision insurance.
	See in-network vision providers

Choose a Vision Plan*

Short-Term Disability Insurance

Provides benefits to help replace your paycheck for up to {stdPeriod} if you are Disabled due to injury or illness. The benefit is equivalent to 60% of your gross annual income up to $108,333.33. The maximum weekly benefit is $1,250 per week for 26 weeks.

Please Note: this benefit cannot be paid using your employer's monthly contribution.

Would you like short-term disability coverage?*

YesNo
What is your gross annual income?*

BENEFITS SELECTION TOOL Use this tool to calculate your payroll deduction.
SELECTED BENEFITS
Basic Life & AD&D:	{BLADDp}
Employee Life:	{eVOLp}
Spouse Life:	{sVOLp}
Child Life:	{cVOLp}
Dental:	{DENp}
Vision:	{VISp}
Short-Term Disability:	{STDp}
You have used {spentEmployer} of your employer's ${emac} contribution.
YOUR MONTHLY COST
{totalPdisp}
via payroll deduction
All benefits except for Short-Term Disability are eligible for an employer contribution. For a detailed explanation of how your monthly cost is calculated, please click here.

Here's How We Calculate Your Monthly Premium:

Sum of the Premiums for Life, AD&D, Dental & Vision Insurance
LESS
Your Employer’s Monthly Contdibution
PLUS
Short Term Disability Insurance Premium (if selected)

Sum of the Premiums for Life, AD&D, Dental & Vision Insurance

LESS

Your Employer’s Monthly Contdibution

PLUS

Short Term Disability Insurance Premium
(if selected)

The employer contribution may not be applied to pay for short-term disability to ensure that your benefits will not be taxed as income when you receive them.

Your Information

PLEASE COMPLETE THE FOLLOWING FIELDS
EVEN THOUGH YOU ARE DECLINING ALL VOLUNTARY INSURANCE, THE FOLLOWING INFORMATION IS REQUIRED BECAUSE YOUR EMPLOYER IS STILL PROVIDING BASIC LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE AT NO COST TO YOU.
Your Name*

First NameMiddle NameLast Name
Street Address*
Please enter your street address.
City*
Please enter your city's name.
State of Residence*
Please select your state.
Zip Code*
Please enter your 5 digit zip code.
Your S.S.N.*
Your Phone Number*
Please enter a valid phone number.
Your Email*
example@example.com
Your Sex*

MaleFemale
Marital Status*

MarriedDomestic PartnershipSingleDivorcedWidowed
Your Occupation*
Hours Worked Per Week*

❌ Are you sure you work {weeklyHours} hours per week?
Hire Date*

MonthDayYear
Date

Spouse / Domestic Partner Information

PLEASE COMPLETE THE FOLLOWING FIELDS

Definition of Spouse: Your lawful Spouse and any other person required to be covered as Your Spouse by the Policyholder or under the civil union, domestic partnership, marriage or other family or domestic relations laws, including the case law, of any applicable State law.

Spouse / Domestic Partner Name:*

First NameLast Name
Spouse / Domestic Partner's Sex:*

MaleFemale
Spouse or Domestic Partner?*

SpouseDomestic Partner
Spouse / Domestic Partner's S.S.N.*
Does your Spouse / Domestic Partner have any other dental insurance coverage?*

YesNo
What is the name of the dental insurance carrier?*

Child(ren) Information

PLEASE COMPLETE THE FOLLOWING FIELDS
Please indicate how many children you wish to insure:*
Name of Child 1*
Date of Birth of Child 1*

MonthDayYear
Date
Sex of Child 1*
Name of Child 2*
Date of Birth of Child 2*

MonthDayYear
Date
Sex of Child 2*
Name of Child 3*
Date of Birth of Child 3*

MonthDayYear
Date
Sex of Child 3*
Name of Child 4*
Date of Birth of Child 4*

MonthDayYear
Date
Sex of Child 4*
Name of Child 5*
Date of Birth of Child 5*

MonthDayYear
Date
Sex of Child 5*
Do any of the children have other dental coverage?*

YesNo
Which of the children have coverage what is the name of their dental insurance carrier?*
Please provide the name, date of birth, and sex of each of your children:

Authorization for Electronic Communication

PLEASE review THE FOLLOWING section
If you check the Email box below, future information will be sent to you electronically using the e-mail address provided on this application form. You may withdraw this authorization at any time.

If you authorize electronic communication, email will be used to:
- confirm your coverage,
- deliver your certificate of insurance, and
- communicate with you about policy administration.
Please communicate with me by:

E-mailRegular Mail

Review

your insurance choices and associated costs are summarized below. you can make changes, or continue to enrollment.

Applicant Information
Applicant's Name:	{name}
Occupation	{occupation}
Email:	{email}
Telephone:	{phone}
Address:	{resAddress} {resCity}, {resState} {resZip}
Employer:	{employerName}
Employer Contribution:	{emac}

Benefits
Basic Life & AD&D:	{bvlMessage}
Employee Voluntary Life:	{evlMessage}
Spouse/Domestic Partner Voluntary Life:	{svlMessage}
Child(ren) Voluntary Life:	{cvlMessage}
Dental Plan:	{denMessage}
Vision Plan:	{visMessage}
Short-Term Disability:	{stdMessage}

Payroll Deduction:	{totalPdisp}
Effective Date: The effective date of your insurance will be the first of the month following: (1) Satisfaction of the plan’s eligibility waiting period, if any, and (2) Completion of the advance payroll deduction of your first month’s premium.

Are you happy with your benefits selections?*

Everything looks good - I'm ready to enrollI'd like to make some changes

Sign and Date

your insurance choices and associated costs are summarized below. you can make changes, or continue to enrollment.
By my signature below, I confirm that I have been offered insurance underwritten by {insurer} and have elected to enroll for one or more coverages as indicated above. Further, I authorize my employer to make payroll deductions (if applicable) for the insurance coverage(s) for which I have applied.

ELECTRONIC TRANSACTIONS, SIGNATURES AND RECORDS CONSENT STATEMENT

IT IS CRITICAL THAT YOU READ AND AGREE TO THIS CONSENT STATEMENT BEFORE SUBMITTING THIS ELECTRONIC APPLICATION. IF YOU DO NOT ACCEPT THESE TERMS AND CONDITIONS OF THIS CONSENT STATEMENT, YOU ARE NOT AUTHORIZED TO SUBMIT THIS APPLICATION ELECTRONICALLY.

Click on the "I Agree" button at the end of the online enrollment form only if you agree to:
- Enter into any electronic transactions on the Affinity Choice Web Site, in connection with online enrollment, beneficiary designations and similar transactions ("Transactions");
- Provide electronic signatures ("Signatures") on the Affinity Choice Web Site, in connection with agreeing to, consenting with and entering into any such Transactions; and
- Receive electronic delivery of records generated in connection with your Transactions and Signatures on the Affinity Choice Web Site ("Records"). These Records will also include electronic delivery of written consumer information and notifications to which you are legally entitled.
Your consent is required before submitting any information through the Affinity Choice Web Site and utilizing any of the Transactions, Signatures and Records functions incorporated within the Affinity Choice Web Site. Your employer and/or employee benefit plan may also involve the use of Records, Transactions and Signatures. At any time after you have provided your consent, you may revoke or modify your consent by calling Customer Service at 1-804-273-9797.

Fraud Warning:

{fraudWarning}
Your Signature:*
Signature Date:*

MonthDayYear
Date
Fraud Warnings

Form Calculations
System Date

MonthDayYear
Today's Date
Basic AD&D and Voluntary Life Calculations
Employee Age
Spouse Age
Total Employer Contribution
Basic Life and AD&D Premium
Employee Voluntary Life Premium
Spouse Voluntary Life Premium
Child(ren)'s Voluntary Life Premium
Dental Premium
Vision Premium
Short-Term Disability Premium

Voluntary Life Rates
Employer Name
Employer Code
Employer State
State Code
State Rating Area
Rate Code

Basic Life and Accidental Death & Dismemberment
Basic Life & AD&D Coverage
Employer's Monthly Base Contribution
Basic Life & AD&D Coverage Added to Contribution?
Basic Life (Per $1,000 of Coverage)

Rates apply to employee basic life
BAL Ages 18-24
BAL Ages 25-29
BAL Ages 30-34
BAL Ages 35-39
BAL Ages 40-44
BAL Ages 45-49
BAL Ages 50-54
BAL Ages 55-59
BAL Ages 60-64
BAL Ages 65-69
BAL Life Ages 70-74
BAL Ages 75-79
BAL Ages 80+
Basic Accidental Death & Dismember (Per $1,000 of Coverage)

Rates apply to employee basic accidental death & dismemberment
Basic AD&D Rate

Voluntary Life
Voluntary Life Insurance (Per $1,000 of Coverage)

Rates apply to employee voluntary life and spouse/domestic partner voluntary life.
VOL Ages 18-24
VOL Ages 25-29
VOL Ages 30-34
VOL Ages 35-39
VOL Ages 40-44
VOL Life Ages 45-49
VOL Ages 50-54
VOL Ages 55-59
VOL Ages 60-64
VOL Ages 65-69
VOL Life Ages 70-74
VOL Ages 75-79
VOL Ages 80+
CHLD Life All Ages
CHLD Life Volume
Spouse Life Key
Spouse Life Max

Child Life

Dental
Employee Only (Dental)
Employee + Spouse (Dental)
Employee + Children (Dental)
Employee + Family (Dental)

Vision
Employee Only (Vision)
Employee + Spouse (Vision)
Employee + Children (Vision)
Employee + Family (Vision)

Short-Term Disability
Fixed Variables
Underwriting Threshold
Hardcoded at the field level. Any income equal to or greater than this amount should simply use this amount instead,
Underwriting Threshold (Helper)
Converts Underwriting Threshold to a Number
Underwriting Percentage
Hardcoded at the field level.
Max Weekly Benefit
Hardcoded at the field level.
Income (Helper)
This field converts the amount a user enters for their annual income to a number.

It's important for calculating STD weekly benefits.
Income (For Rating STD)
Converts income back to a currency for math and display.
Weekly STD Benefit
Rates
STD Ages 18-24
STD Ages 25-29
STD Ages 30-34
STD Ages 35-39
STD Ages 40-44
STD Ages 45-49
STD Ages 50-54
STD Ages 55-59
STD Ages 60-64
STD Ages 65-69
STD Ages 70-74
STD Ages 75-79
STD Ages 80+

Premium Calculations
Step 1. Total Premium (Excl. STD)
Step 2. Total Premium (Excl. STD) - Total Employer Contribution
Step 3. Total Premium (Incl. STD)
Step 4. Total Premium (Incl. STD) - Total Employer Contribution
Unspent Employer Funds
Spent Employer Funds
Check

# of Lives
# Basic Life Insureds
Hardcoded to 1 as there will always be 1 life insured via Basic Life Insurance
# Employee Life Insureds
# Spouse Life Insureds
# Child Life Insureds
# Dental Insureds
# Vision Insureds
# Short-Term Disability Insureds
Should be Empty:

AffinityChoice Benefits Selection Tool

Choose Your Benefits

Voluntary Life Insurance

Dental Insurance

Vision Insurance

Short-Term Disability Insurance

Here's How We Calculate Your Monthly Premium:

Your Information

Spouse / Domestic Partner Information

Child(ren) Information

Life Insurance Beneficiary Information

Authorization for Electronic Communication

Review

Sign and Date

Form Calculations

General

Messages

Voluntary Life Rates

Basic Life and Accidental Death & Dismemberment

Voluntary Life

Child Life

Dental

Vision

Short-Term Disability

Fixed Variables

Rates

Premium Calculations

# of Lives