Request a Quote for Group Policy Life Insurance

	NOTE: Accidental death and Dismemberment coverage is indicated throughout this form as "AD&D." PECG members receive the following insurance coverage automatically as part of their PECG membership at no additional cost to themselves: Basic Life (providing $5,000 in coverage) Basic AD&D providing $1,500 in coverage) Additional insurance coverage under the group plan through Standard Insurance Company can be applied for as indicated below. (Please note that you must be a PECG member to apply for and purchase supplemental insurance under the PECG group plan.)

1.

All coverages in this section are under PECG Group Plan Policy No. 608009. To learn more about these coverages click here for the brochure.

	SUPPLEMENTAL LIFE - provides $26,000 of life insurance coverage, and is a prerequisite for specifying any other coverages in this section.
	SUPPLEMENTAL PLUS LIFE - for those interested in more insurance than Supplemental Life alone provides, you can add additional life insurance coverage by specifying Supplemental Plus Life in any multiple of $15,000, up to a maximum of $495,000.

2.	Please select your desired amount of SUPPLEMENTAL PLUS LIFE coverage:

3.

Please specify any other coverages you are interested in below:

	SUPPLEMENTAL AD&D - Provides $26,000 of AD&D insurance at the very nominal cost of $1.00 per month until age 65 (50 cents per month from age 65-69).
	SUPPLEMENTAL PLUS AD&D - Provides AD&D insurance in an amount that must match your dollar amount of coverage selected for Supplemental Plus Life above.
	BASIC DEPENDENTS LIFE - Provides dependents' life coverage at a flat rate of $1.50 per month for your dependents as follows: Spouse ($5,000); each child six months of age or older ($5,000); and each child under six months ($500). (Please consult the brochure for the definition of a qualifying dependent.)
	SUPPLEMENTAL PLUS DEPENDENTS LIFE - Supplemental Plus Dependents Life is available for your spouse only, and provides coverage in an amount you specify that is (a) in multiples of $15,000 up to $255,000, and (b) in an amount 50 percent or lower than the combined totals of the PECG member's Basic Life ($1,500), Supplemental Life ($26,000), and Supplemental Plus Life insurance.

4.	Please select your desired amount of SUPPLEMENTAL PLUS DEPENDENTS LIFE coverage. (Note that Supplemental Plus Life is required when specifying this coverage.)

5.

Spouse's Date of Birth (required if specifying Supplemental Plus Dependents Life coverage)

MM/DD/YYYY