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Okaloosa County BOCC — October 21, 2014 — Symetra - Final Payment Request — reading text
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Explanation: Adjustments
Current Account Balance
as of
Gross Premium/Fees Due $ 2,056.74
Make Check Payable to: Symetra Life Insurance Company
Return Statement &
Premium/Fees to:
Symetra Life Insurance Company
Benefit Accounting Services
C/O Wells Fargo
PO Box 1491
Minneapolis MN 55480-1491
Prepared By
Date
Last Payment Received
Coverages or Rates listed incorrectly? Address Change? Call 1-800-426-7784
LG-12024 6/12
Symetra Life Insurance Company - Group Division - 777 108th Ave NE - Suite 1200, Bellevue, WA 98004 - www.symetra.com
Mailing Address: PO Box 34690 - Seattle, WA 98124-1690 - Phone (800) 426-1690 - TTY/TDD (800) 833-6388
Okaloosa County 01-016209-00
Employee Supplemental Life Worksheet
**Please enter total headcount and Inforce for each age band
Age Band Headcount Inforce
Under 25 0
25 to 29
30 to 34 1 100,000.00
35 to 39
40 to 44 1 125,000.00
45 to 49 2 250,000.00
50 to 54 2 125,000.00
55 to 59 2 125,000.00
60 to 64 1 50,000.00
65 to 69 0
70 to 74 0
fo = 0
Grand Total: y) 775000
Rate
0.0700
0.0700
0.0800
0.1100
0.1600
0.2900
0.4500
0.6100
1.0200
1.5900
2.5700
5.1200
Okaloosa County 01-016209-00
Employee Supplemental Life Worksheet
**Please enter total headcount and Inforce for each age band
Age Band Headcount Inforce
Under 25 1 250,000.00
25 to 29
30 to 34 5 1,000,000.00
35 to 39 5 750,000.00
40 to 44 5 950,000.00
45 to 49 4 525,000.00
50 to 54
55 to 59 2 175,000.00
60 to 64
65 to 69
70 to 74
fox
Grand Total: 22 3650000
Rate
0.0700
0.0700
0.0800
0.1100
0.1600
0.2900
0.4500
0.6100
1.0200
1.5900
2.5700
5.1200
Okaloosa County 01-016209-00
Employee Supplemental Spouse Life Worksheet
*“Please enter total headcount and Inforce for each age band
Age Band Headcount
Under 25 0
25 to 29 0
30 to 34
35 to 39
40 to 44 25,000.00
45 to 49 2 50,000.00
50 to 54 1 25,000.00
55 to 59 1 12,500.00
60 to 64 1 25,000.00
65 to 69 0
70 to 74 0
15 e 0
Grand Total: 5 137500
Rate
0.0700
0.0700
0.0800
0.1100
0.1600
0.2900
0.4500
0.6100
1.0200
1.5900
2.5700
5.1200
Okaloosa County 01-016209-00
Employee Supplemental Spouse Life Worksheet
™Please enter total headcount and Inforce for each age band
Age Band
Under 25
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75+
Grand Total:
Headcount Inforce
1 25,000.00
3 75,000.00
1 25,000.00
2 50,000.00
0
2 50,000.00
9 225000
Rate
0.0700
0.0700
0.0800
0.1100
0.1600
0.2900
0.4500
0.6100
1.0200
1.5900
2.5700
5.1200