ACH Recurring Payment Authorization Form | Voluntary Long Term Disability

How would you like to enter your income?*

To calculate your maximum disability coverage, please enter your hourly wage in this box:

The maximum amount of disability coverage you can purchase is:

And the monlthy cost of this coverage to you is:

To calculate your maximum disability coverage, please enter your annual base salary in this box:

The maximum amount of disability coverage you can purchase is:

And the monlthy cost of this coverage to you is:

If you would like to purchase less than your max available benefit, please enter how much coverage you would like in this box:

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"Maximum coverage" minus "less than coverage" (hourly)

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"Maximum coverage" minus "less than coverage" (annual)

The monthly premium for the amount you have chosen is: