Effective Date of Premium Changes due to change in Age (i.e., EE moves into next age band category with new rate) This includes premium changes due to age for cases that are step-rated. Choices: -the date -first of the month coinciding w/next following - Policy Ann Date - Specific Month/Date w/next following - Other define Earnings Definition For choices 6) or 7): What is included in the W2? For choices 3), 4), or 7): What is the time period for averaging? 2 years, 3 years? For choices 3) or 4): What is averaged and who does it apply to? See below for a description of the Earnings Definitions. (Please indicate the number and the details of the definition.) Choices: Standard Standard & Hourly Standard & Average Standard, Hourly & Average Not Applicable Prior Year W2 Average W2 Other Earnings based on: Note: Earnings definition may or may not always match the Minimum Hours Requirement on Page 1 regarding Scheduled or Actual. Enter based on Earnings Definition. Choices: - Scheduled Hours - Actual Hours Worked Earnings Determination (determination date must be the same as the EARNINGS CHANGE) "The Day" for the "Earnings Determination". This means that the employee's benefit will be determined by his/her wages on the day just before the date of the loss. Choices: the date first of the month following Policy Anniversary Date Specific MM/DD Other (provide details) Premium Grace Period Enter the Premium Grace Period: - 60 days (Default) Default: 60 Days EOI Approval Effective Date Required to match the Individual Effective Date on the plan. There are to be "No" variations.
Accelerated Death Benefit* (*state requirements may apply to some areas) Reliance standard benefit: 75% to $500,000 Expected within 12 months If other than the above percentage and amount, please describe. Continuation during FMLA Does employee have continued coverage with paid premium during FMLA? (Yes/No) Continuation of Coverage Applicable to GL and VAR only RSL Standard: 12 months – Illness or Injury 1 month – lay-off or leave of absence Does the employee have continued coverage with paid premium for a leave of absence? Any time period that differ or are different Suicide Limitation Applicable to GL only. Automatically added on contributory coverage Suicide Exclusion Applicable to AD&D product only. Automatically applicable if the case has AD&D otherwise N/A Portability RSL Standard: - available on GL (if included, both life and AD&D coverage may be ported, if AD&D is on the policy) - NOT available VAR Confirm if the Portability provision has been added to this Plan. (Yes or No) Special Note: As a standard, portability is not available to retirees. If we must do this, it requires a filing. Supplemental AD&D Benefit Coverage Amount Enter the Supplemental Coverage Amount. List by Class. How is Supplemental AD&D Benefit elected? Options: -AD&D must match what the employee is insured for under the GL - Automatically enrolled for GL amount
Dependent Coverage Requirement What coverage does the employee have to be insured for in to cover dependents? Choices: -Basic Only -Supp Only -Basic and Supp Spouse Benefit Coverage Amount Provide coverage amounts. Include maximum and minimum benefit amounts. Also include limits on whether Dependent cannot have more than 50% of coverage. Spouse/Child units or Example Spouse/Child Life Unit: Spouse $10,000 Chile $3,000 (birth to age 26* regardless of FTS) -OR- Example Stand-Alone: Spouse $5,000 increments Child $2,000 increments Spouse Benefit Reduction Schedule A) Enter Spouses Reduction Schedule, does this? -Matches employees reduction or Special (include reduction if different from employee's) B) Is the reduction based on the spouse's or employee's age? A) B) A) B) Dependent Accelerated Benefit* requirements may apply to some areas) Reliance standard benefit: 75% to $500,000 Expected death within 12 months If other than the above percentage and amount, please describe. Dependent Waiver of Premium RSL standard: If EE is approved for WOP, dependents’ premium is also waived. Default: Yes, if EE WOP is approved. Dependent Portability RSL standard: - available on GL (if included, both life and AD&D coverage may be ported, if AD&D is on the policy) - NOT available VAR Confirm if the Portability provision has been added to this Plan. (Yes or No) Special Note: As a standard, portability is not available to retirees or retiree’s dependents. If we must do this, it requires a filing. ALSO, Spouse cannot port unless the Employee ports