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PLAN YEAR: september 1, 2019 – august 31, 2020
elgin isd
What’s inside? EMPLOYEE BENEFITS CENTER
HOW TO ENROLL
S125 PLAN INFORMATION
FLEXIBLE SPENDING ACCOUNTS
AVAILABLE RESOURCES
BENEFITS AT A GLANCE
CONTACT INFORMATION
EMPLOYEE BENEFITs CENTER HTTP://BENEFITS.FFGA.COM/ELGINISD
EDITH BERGMAN, ACCOUNT MANAGER 2009 RR 620 N STE 123, AUSTIN TX 78734
OFFICE: 800-672-9666 | CELL: 619-278-9497
EMAIL: [email protected]
This guide contains a summary of the benefits offered by your employer. If there is a conflict between the terms of this outline of benefits and the actual contracts, the terms of the contracts will prevail. For a more detailed explanation of benefits you may contact
your Account Manager or First Financial Administrators at 1-800-523-8422 or visit http://benefits.ffga.com.
Employee benefits center NEW employee benefits center - your guide to your benefits! We’ve created a custom site just for you! Find detailed information about current and upcoming benefits, voluntary product offerings and employer programs, Section 125 & Flex Information, important contact numbers and links, and downloadable forms and brochures.
http://benefits.ffga.com/elginisd
How to Enroll Your First Financial Account Manager will be on site to assist you in enrolling in your benefits. To find out when your Account Manager will be at your location, view the schedule online or contact your site director. You also have the option to enroll online 24/7 through FFenroll during your enrollment period. To prepare for your enrollment, visit your Employee Benefits Center at http://benefits.ffga.com/elginisd. Once you have reviewed available benefits for the upcoming plan year, visit FFenroll, https://ffga.benselect.com/enroll, to review currently enrolled benefits and dependent information.
ON SITE ENROLLMENT • What to have ready for your enrollment: • Social Security Numbers for all dependents • Any Status/Life Event or address changes • Questions about available benefits
ONLINE ENROLLMENT To enroll online, log in to FFenroll (https://ffga.benselect.com/enroll). For detailed information on how to enroll, visit the how to enroll tab on your Employee Benefits Center
Login and PIN Your login is your social security number (no dashes) and your PIN is the last four digits of your social security number and the last two digits of your birth year (678977) Once you login you will arrive at the Welcome Screen. Click “Next”, then: Verify your personal information Verify all dependent information (ssn/date of birth) **Very Important** View employment information
USEFUL INFORMATION TO KNOW • Write your PIN number down • Contact First Financial at 855‐523‐8422 with any technical questions • No changes will be permitted until annual enrollment, unless you have an IRS S125 qualified event
Section 125 Plan Information and rules
A Section 125 Plan provides a tax-saving way to pay for eligible medical or dependent care expenses. The
funds are automatically deducted from your paycheck on a pre-tax basis.
Here’s How It Works
A Section 125 Plan reduces your taxes and increases your spendable income by allowing you to deduct the
cost of eligible benefits from your earnings before tax. Plus, the plan is available to you at no cost, and you’re
already eligible. All you have to do is enroll.
Is It Right for Me? The savings you may experience with a Section 125 Plan are outlined below. By utilizing the Section 125
Plan, you would have $70 more every month to apply toward insurance benefits or other needs. That’s a
savings of $840 a year!
Flexible Spending Accounts
Medical FSA Medical Flexible Spending Accounts (FSA) allow you to set aside pre-tax payroll deductions each paycheck to pay for out of pocket medical, dental and vision expenses for you and your family. During open enrollment you will estimate the amount you think you will need during the year. This amount will be taken out of each paycheck. Your full annual election will be available to you at the beginning of the plan year. Your employer has chosen the $500 Roll-Over Option for your plan. This option allows you the opportunity to roll over $500 of unclaimed Medical FSA funds into the following plan year. Any amount in excess of $500 will be forfeited under the use-it-or-lose-it rule.
FSA Plan Year is: September 1, 2019 – August 31, 2020 FSA MAX: The maximum you can set aside each year is $2,700.
DEPENDENT CARE FSA With a Dependent Care Flexible Spending Account (FSA), you can set aside part of your pay on a pre-tax basis to pay for eligible dependent care expenses, such as:
• Day Care Centers • Before/After School Care • Mothers-Day-Out Program • Nursery Schools • Babysitters • Nanny • Au Pair • Day Camps
This account allows you to pay for day care expenses for your qualifying dependent/child with pre-tax dollars while you (and your spouse) are working, seeking employment, and/or attending school as a full time student (for at least five months of the year). Eligible dependents must be children under the age of 13 when care is provided or be an adult dependent incapable of self-care and be claimed as an exemption on your tax return. For full plan details, view the FSA Booklet available on the Employee Benefit Center.
Health Savings Account
Health Savings Account (HSA) through First Financial in conjunction with UMB HSAs were created to help control healthcare costs. They provide a savings vehicle that allows you to set aside money to pay for higher deductibles associated with lower monthly premium High Deductible Health Plans (HDHP). The money you save in monthly insurance premiums may be set aside for eligible medical expenses you incur in the future.
How it works: You choose the payroll deduction contributions up to the maximum allowed by the IRS. Your HSA balance rolls over from year-to-year earning interest along the way. The account is portable. Upon retirement or separation of service, you take the HSA with you because it’s your money and your account. When you want to access the funds, use your benefits card to pay your provider directly or simply request reimbursement or distribution on our online portal or mobile app. Be sure to keep receipts for all of your medical expenses, for which you received a reimbursement, for at least three years for tax-reporting purposes.
HSAs Offer a Triple Tax Advantage • The money you put in to the account is deducted from your paycheck before tax • The interest and earnings you make on the account grow tax free • Distributions for eligible medical expenses are tax free
What are the key advantages of an HSA? • No end-of-year forfeiture of funds • Portable account • Provides an excellent savings vehicle for healthcare expenses • No monthly account fees. • Free eStatements when you opt in for electronic delivery
Minimum Health Insurance Plan Deductible
Amounts for the Qualifying HDHP 2019 Individual Coverage $1,350 Family Coverage $2,700
Annual Maximum Contribution Levels 2019 Individual Coverage $3,500 Family Coverage $7,000
Maximums for HDHP Out-of-Pocket Expenses 2019 Individual Coverage $6,750 Family Coverage $13,500
BENEFITS CARD The Benefits Card is available to all employees that participate in Medical FSA, HSA and/or a Dependent Care FSA. The Benefits Card gives you immediate access to your money at the point of purchase. Cards are available for participating employees, their spouse and eligible dependents that are at least 18 years old. To request a card for your spouse or dependent, login to our secure portal at www.ffga.com. The IRS requires validation of most transactions. You must submit receipts for validation of expenses when requested. If you fail to substantiate by providing a receipt to First Financial within 60 days of the purchase or date of service your card will be suspended until the necessary receipt or explanation of benefits from your insurance provider is received.
Online Portal Get account information from our easy-to-use online portal. View your Flex Account balance, find claim forms and view claim status and history. See your HSA account and investment balances in real time and request distributions. Visit www.ffga.com to set up your online account.
FF FLEX MOBILE APP With the FF Flex Mobile App you can submit claims, view account balance & history, see claim status, view alerts, upload receipts and documentation and more! The FF Flex Mobile App is available for Apple® or AndroidTM devices on the App StoreSM or the Google Play StoreTM.
Your Employer ID Number is FFA975. You must have this number or your Flex Benefits Card number to register your account on the FF Flex Mobile App.
FSa and hsa STORE First Financial has partnered with the FSA & HSA Store to bring you an easy to use online store to better understand and manage your FSA. For Flex, visit http://www.ffga.com/fsaextras and for HSA visit www.ffga.com/hsaextras for more details & special deals!
• Shop at FSA Store for eligible items from bandages to wheel chairs and thousands of products in between
• Browse or search for eligible products and services using the FSA Eligibility List • Visit the FSA Learning Center to help find answers to questions you may have about your FSA
FSA and hsa RESOURCES
Visit http://benefits.ffga.com/elginisd for rates and benefit information.
Medical- TRS ActiveCare Aetna is the plan administrator for the TRS-ActiveCare plans.
First Financial Group of America enrolls this product for your district however any product questions or concerns need to be directed to Aetna or your district benefit administrator.
Aetna offers:
• A variety of plan and network options to suit your individual needs
• A Health Concierge available by phone for answers and guidance on care and benefits
• Online services and mobile apps for easy access to health information and tools, wherever you travel.
To get the best view of Aetna resources and plan information, visit www.trsactivecareaetna.com. Please learn about your Aetna medical plan and take advantage of all it offers for your health and well-being.
Dental – ameritas and metlife Oral care can be a significant financial expense. Having dental insurance can help cover the costs. Help keep your family's smiles healthy with dental insurance.
Vision - davis Vision insurance is a way to help cover expenses incurred for eye care services from eye care professionals such as optometrists and ophthalmologists. Regular eye exams can offer more than just measuring your eye sight! They can identify serious eye diseases early, allowing time for treatment. Most people don't realize that eye exams can also reveal the early signs of serious illnesses like diabetes, heart disease and high blood pressure.
Hospital Indemnity – Aflac ***NEW*** Even a small trip to the hospital can have a major impact on your finances. Hospital Indemnity Insurance provides financial assistance to help with out-of-pocket expenses that major medical insurance doesn’t cover.
Benefits at a Glance
Disability – American fidelity ***NEW*** Disability insurance pays a cash benefit and is designed to help protect you if you can’t work due to a covered injury or sickness. It pays a monthly benefit amount based on a percentage of your gross income, so you may continue to pay for everyday living expenses.
CANCER INSURANCE - American fidelity ***NEW*** If cancer touches someone in your family, this plan may help ease the impact on your finances. Benefit payments are made directly to you, allowing you to pay for expenses like copayments, hospital stays, and house and car payments.
Accident Insurance – Aflac ***NEW*** Accidents are inevitable. Even though you can’t always prepare for unforeseen events, you can plan ahead. Accident Insurance is designed to help cover some of the expenses that can result from a covered accident, and benefit payments are made directly to you.
Critical Illness Insurance – Aflac ***NEW*** If you experience an event such as a heart attack or stroke, Critical Illness Insurance may help. It pays a lump sum amount to help with expenses that may not be covered by major medical insurance – house payments, everyday expenses, lost income, and more.
Permanent, Portable Life Insurance - TEXAS LIFE Ensuring your family is financially covered in the event of a loss is an important way of showing them you care about their needs. Life Insurance can help. Portable, Individual Life Insurance policies may help your family in the event of your death. The application process is simple. You only have to answer three health questions, and there are no medical exams required.
GROUP LIFE – Dearborn ***NEW*** Group life insurance allows you to purchase affordable life insurance on yourself, spouse and dependent children. This is term insurance, available as long as you are employed by district. Employees enrolling in the coverage after the first 31 days of their employment will be subject to insurability and must complete a health questionnaire prior to coverage being issued.
ID Theft Protection – ilock360Protect yourself and your family from the fastest growing crime in the US: Identity Theft. A low monthly cost provides protection by scouring the dark web for any compromised accounts and restores your identity with 24/7/365 support. This protection saves you money and time by relying on a service to handle all the details involved when your identity is stolen. Semi-Monthly Payroll DeductionsCoverage Plan Plus PremiumEmployee $4.00 $7.50Employee + Spouse $7.50 $11.00Employee + Children $6.50 $10.00Employee + Family $10.00 $13.50
Long-Term Disability Income InsuranceELGIN ISD
Plan Benefit HighlightsEligibilityAll permanent employees in covered group working 20 hours or more per week. Regarding your eligibility, we may require proof of good health and will rely on answers given on your application to determine if coverage can be issued. Regardless of your health at the time of application, if coverage is approved and issued, claims incurred while coverage is in force will be subject to all terms of the Policy including any Pre-Existing Condition limitation.
Benefits are PayableBenefits are payable up to age 65 for a covered Injury or Sickness. After age 65, the benefit period will be extended to the greater of 12 months or your Social Security Normal Retirement Age.
Disability Benefit Monthly amounts of the Disability Benefits are available from $200 to $10,000 in $100 increments based on 662/3% of your Monthly Compensation and will not exceed the amount for which premium is being paid. If applicable, the insured’s Disability Benefit will be reduced by Deductible Sources of Income.
Physician Expense BenefitInjury - $150.00 per InjuryIf you need personal treatment by a Physician due to an Injury, we will pay the amount shown above provided no other claim has been paid under the Policy. You are not required to miss one full day of work in order to receive the Injury benefit.
Hospital Confinement BenefitA Hospital Confinement Benefit will be paid each day you are confined as a patient in a Hospital due to an Injury or Sickness, for up to 60 days. The amount payable is 1 times the Disability Benefit which will be pro-rated on a daily basis. This benefit will not be reduced by Deductible Sources of Income. The Hospital confinement must be at least 18 continuous hours in duration. This benefit will begin on your first day of Hospital confinement. The remainder of your elimination period will be waived (APPLIES ONLY TO PLANS 1-3).
Hospital- the term “Hospital” shall not include an institution used by you as a place for rehabilitation; a place for rest or for the aged; a nursing or convalescent home; a long-term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative, or ambulatory patients.
Waiver of PremiumNo premium payments are required while you are receiving payments under the plan after disability payments have been received for 90 consecutive days. We will require proof annually that you remain disabled during that time.
Donor BenefitIf you are disabled as a result of being an organ or tissue donor, we will pay your benefit as any other sickness under the terms of the plan.
Offsets With Other Sources of Income Deductible Sources of Income include, Other group disability income, Governmental or other retirement system, whether due to disability, normal retirement or voluntary election of retirement benefits, United States Social Security Act or similar plan or act, including any amounts due your dependent(s) on account of your disability, State Disability, Unemployment compensation, Sick leave or other salary or wage continuance plans provided by the Employer which extend beyond 365 calendar days from the date of disability. We reserve the right to estimate these Deductible Sources of Income that you may receive as defined in your Certificate.
Minimum Disability BenefitThe minimum Monthly Disability Benefit is 10% of the Monthly Disability Benefit or $100.00, whichever is greater.
If You Are Disabled Due to a Covered Disability and Not WorkingFor the first 12 months you are disabled due to a covered disability and not working, we will pay the disability benefit described in the benefit schedule. After 12 months, your disability payment will be the disability benefit less any deductible sources of income you receive or are entitled to receive. No disability payment will be provided for any period in which you are not under the regular and appropriate care of a physician.Disability or disabled for the first 24 months of disability means that you are unable to perform the material and substantial duties of your regular occupation. After that, disability means you are unable to perform the material and substantial duties of any gainful occupation for wage or profit for which you are reasonably qualified by training, education, or experience.
Return To Work Incentives: Disabled and WorkingIf you are disabled and working, you may be eligible to continue to receive a percentage of your disability payment in addition to your disability earnings. If your disability earnings exceed 80% of your monthly compensation, payments will stop and your claim will end.
• Family Care BenefitIf you are disabled and working and have one or more eligible family members, you may be eligible for a family care benefit. This benefit is for expenses incurred upto 25% of your monthly disability benefit. Your disability earnings, gross disability benefit, and family care benefit cannot exceed 100% of your monthly compensation. Payment of this benefit ends when you cease to be eligible for benefits under theDisabled and Working provision of the policy.
• Worksite AccommodationAs a part of our claims evaluation process, if worksite modifications may assist your return to work, we will evaluate your claim for appropriate action.
Mental Illness Limited Benefit If you are disabled due to a mental illness, benefits will be provided for up to 2 years, not to exceed the maximum disability period.
Alcoholism and Drug Addiction Limited BenefitIf you are disabled due to alcoholism or drug addiction, a limited benefit of up to 15 days for each disability will be paid. Benefits will not be paid beyond the maximum benefit period. If drug addiction is sustained at the hands of, or while under the regular and appropriate care of a physician in the course of treatment for injury or sickness, it will be covered the same as any other sickness.
Step 1: Calculate the disability Benefit you qualify for based upon your salary.
__________________ / 12 = ___________________ x 0.662/3 = ___________________________Annual Salary Monthly Salary Monthly Disability Benefit (Rounded down to nearest $100)
Step 2: Calculate your Monthly Premium based upon your plan selection.
PLAN BENEFITS BEGIN MONTHLY PREMIUM
Plan 1 On the 8th day of Disability due to a covered injury or Sickness. *$3.74
Plan 2 On the 15th day of Disability due to a covered injury or Sickness. *$3.18
Plan 3 On the 31st day of Disability due to a covered injury or Sickness. *$2.64
Plan 4 On the 61st day of Disability due to a covered injury or Sickness. *$1.62
Plan 5 On the 91st day of Disability due to a covered injury or Sickness. *$1.20
Plan 6 On the 151st day of Disability due to a covered injury or Sickness. *$0.78
________________ / 100 = _________________ x _________________= $__________________Monthly Benefit Rate from Above Monthly Premium Cost
Example Calculation:
Making $42,000 per year ($3,500 month), you would qualify for $2,300 per month:
$42,000 / 12 = $3,500 x 0.662/3 = $2,300 Monthly Disability Benefit
$2,300 / 100 = 23 x $0.50 = $11.50 per month
*Per $100 Covered Monthly Benefit Rates Based on 12 Deductions per Year
American Fidelity Assurance Company
G120-314 MCH#9837 014427-T1, 014428-T2, 014429-T3, 014407-T4, 014408-T5, 014410-T6
View and print your policies plus file a claim at americanfidelity.com
SB-32576(FF)-0419
800-654-8489 • americanfidelity.com
View and print your policies plus file a claim at americanfidelity.com
American Fidelity’s Online Service Center provides you convenient, secure 24/7 access to manage your account or file a claim.
Special Conditions Limited BenefitIf you are disabled due to special conditions and under the regular and appropriate care of a physician, benefits will be provided for up to 2 years. Special conditions mean: chronic fatigue syndrome; fibromyalgia; any disease, disorder, accident or injury of the neck or back not resulting in hemiplegia, paraplegia, or quadriplegia; environmental allergic illness including, but not limited to sick building syndrome and multiple chemical sensitivity; and self-reported symptoms. Self-reported symptoms are symptoms that the insured tells their physician that are not verifiable using tests, procedures or clinical examinations. Examples include: headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness, or loss of energy.
Pre-Existing Condition LimitationIf Disability is caused by or resulting from a Pre-Existing Condition and begins before you have been continuously covered under the Policy for 12 months, no disability benefit will be payable. Any increase in benefits will be subject to this pre-existing condition limitation. A new pre-existing condition period must be satisfied with respect to any increase applied for and approved by us.
Pre-existing condition means a disease, Injury, Sickness, physical condition or mental illness for which you: had treatment; incurred expense; took medication; received care or services including diagnostic testing or related measures; or received a diagnosis or advice from a physician, during the 3-month period immediately before your effective date of coverage. The term pre-existing condition will also include conditions which are related to such disease, injury, sickness, physical condition, or mental illness.
ExclusionsThe Policy does not cover any loss, fatal or non-fatal, resulting from:• Intentionally self-inflicted injury while sane or insane.• An act of war, declared or undeclared.• Injury sustained or Sickness contracted while in the service of the armed forces of
any country.• Committing a felony.• Penal incarceration. We will not pay benefits for Disability or any other loss during
any period for which you are incarcerated in a penal or correctional institution for a period of 30 consecutive days or longer.
• Injury or Sickness arising out of and in the course of any occupation for wage or profit or for which you are entitled to Workers’ Compensation.
The term “entitled to Workers’ Compensation” shall also include Workers’ Compensation claim settlements that occur via compromise and release. Further, no benefits will be paid under this Policy for any period during which you are entitled to Workers’ Compensation benefits.
Your coverage may be continued for up to 1 year during a leave of absence approved in writing by your employer. Coverage will continue as long as the group policy remains in force, the premiums are paid and you remain eligible for the coverage under the policy. Your coverage will end when you no longer qualify as an insured, you retire, you are not on active employment, or your employment terminates. Your coverage can be terminated or premiums may be increased on any premium due date with 31 days advance notice.
Monthly Premiums
Monthly SalaryMonthly
Disability Benefit
Plan 1 (8th)
Plan 2 (15th)
Plan 3 (31st)
Plan 4 (61st)
Plan 5 (91st)
Plan 6 (151st)
$300.00 - $449.99 $200.00 $7.48 $6.36 $5.28 $3.24 $2.40 $1.56
$450.00 - $599.99 $300.00 $11.22 $9.54 $7.92 $4.86 $3.60 $2.34
$600.00 - $749.99 $400.00 $14.96 $12.72 $10.56 $6.48 $4.80 $3.12
$750.00 - $899.99 $500.00 $18.70 $15.90 $13.20 $8.10 $6.00 $3.90
$900.00 - $1,049.99 $600.00 $22.44 $19.08 $15.84 $9.72 $7.20 $4.68
$1,050.00 - $1,199.99 $700.00 $26.18 $22.26 $18.48 $11.34 $8.40 $5.46
$1,200.00 - $1,349.99 $800.00 $29.92 $25.44 $21.12 $12.96 $9.60 $6.24
$1,350.00 - $1,499.99 $900.00 $33.66 $28.62 $23.76 $14.58 $10.80 $7.02
$1,500.00 - $1,649.99 $1,000.00 $37.40 $31.80 $26.40 $16.20 $12.00 $7.80
$1,650.00 - $1,799.99 $1,100.00 $41.14 $34.98 $29.04 $17.82 $13.20 $8.58
$1,800.00 - $1,949.99 $1,200.00 $44.88 $38.16 $31.68 $19.44 $14.40 $9.36
$1,950.00 - $2,099.99 $1,300.00 $48.62 $41.34 $34.32 $21.06 $15.60 $10.14
$2,100.00 - $2,249.99 $1,400.00 $52.36 $44.52 $36.96 $22.68 $16.80 $10.92
$2,250.00 - $2,399.99 $1,500.00 $56.10 $47.70 $39.60 $24.30 $18.00 $11.70
$2,400.00 - $2,549.99 $1,600.00 $59.84 $50.88 $42.24 $25.92 $19.20 $12.48
$2,550.00 - $2,699.99 $1,700.00 $63.58 $54.06 $44.88 $27.54 $20.40 $13.26
$2,700.00 - $2,849.99 $1,800.00 $67.32 $57.24 $47.52 $29.16 $21.60 $14.04
$2,850.00 - $2,999.99 $1,900.00 $71.06 $60.42 $50.16 $30.78 $22.80 $14.82
$3,000.00 - $3,149.99 $2,000.00 $74.80 $63.60 $52.80 $32.40 $24.00 $15.60
$3,150.00 - $3,299.99 $2,100.00 $78.54 $66.78 $55.44 $34.02 $25.20 $16.38
$3,300.00 - $3,449.99 $2,200.00 $82.28 $69.96 $58.08 $35.64 $26.40 $17.16
$3,450.00 - $3,599.99 $2,300.00 $86.02 $73.14 $60.72 $37.26 $27.60 $17.94
$3,600.00 - $3,749.99 $2,400.00 $89.76 $76.32 $63.36 $38.88 $28.80 $18.72
$3,750.00 - $3,899.99 $2,500.00 $93.50 $79.50 $66.00 $40.50 $30.00 $19.50
$3,900.00 - $4,049.99 $2,600.00 $97.24 $82.68 $68.64 $42.12 $31.20 $20.28
$4,050.00 - $4,199.99 $2,700.00 $100.98 $85.86 $71.28 $43.74 $32.40 $21.06
$4,200.00 - $4,349.99 $2,800.00 $104.72 $89.04 $73.92 $45.36 $33.60 $21.84
$4,350.00 - $4,499.99 $2,900.00 $108.46 $92.22 $76.56 $46.98 $34.80 $22.62
$4,500.00 - $4,649.99 $3,000.00 $112.20 $95.40 $79.20 $48.60 $36.00 $23.40
$4,650.00 - $4,799.99 $3,100.00 $115.94 $98.58 $81.84 $50.22 $37.20 $24.18
$4,800.00 - $4,949.99 $3,200.00 $119.68 $101.76 $84.48 $51.84 $38.40 $24.96
$4,950.00 - $5,099.99 $3,300.00 $123.42 $104.94 $87.12 $53.46 $39.60 $25.74
$5,100.00 - $5,249.99 $3,400.00 $127.16 $108.12 $89.76 $55.08 $40.80 $26.52
$5,250.00 - $5,399.99 $3,500.00 $130.90 $111.30 $92.40 $56.70 $42.00 $27.30
$5,400.00 - $5,549.99 $3,600.00 $134.64 $114.48 $95.04 $58.32 $43.20 $28.08
$5,550.00 - $5,699.99 $3,700.00 $138.38 $117.66 $97.68 $59.94 $44.40 $28.86
$5,700.00 - $5,849.99 $3,800.00 $142.12 $120.84 $100.32 $61.56 $45.60 $29.64
$5,850.00 - $5,999.99 $3,900.00 $145.86 $124.02 $102.96 $63.18 $46.80 $30.42
$6,000.00 - $6,149.99 $4,000.00 $149.60 $127.20 $105.60 $64.80 $48.00 $31.20
This insert must be used in conjunction with SB-32576(FF).
Your maximum benefit amount is based upon 662/3% of your gross monthly compensation. Benefit amounts start at $200 and go up to a Maximum Monthly Disability Benefit of $10,000. The benefit will not exceed the amount for which premium has been paid.
Long-Term Disability Income InsuranceELGIN ISD
American Fidelity Assurance Company
Long-Term Disability Income InsuranceYour maximum benefit amount is based upon 662/3% of your gross monthly compensation. Benefit amounts start at $200 and go up to a Maximum Monthly Disability Benefit of $10,000. The benefit will not exceed the amount for which premium has been paid.
This insert must be used in conjunction with SB-32576(FF).
G120-314 MCH#9837 014427-T1, 014428-T2, 014429-T3, 014407-T4, 014408-T5, 014410-T6SB-32576(FF)(RATE)(INSERT)-0419
800-654-8489 • americanfidelity.com
Monthly Premiums
Monthly SalaryMonthly
Disability Benefit
Plan 1 (8th)
Plan 2 (15th)
Plan 3 (31st)
Plan 4 (61st)
Plan 5 (91st)
Plan 6 (151st)
$6,150.00 - $6,299.99 $4,100.00 $153.34 $130.38 $108.24 $66.42 $49.20 $31.98
$6,300.00 - $6,449.99 $4,200.00 $157.08 $133.56 $110.88 $68.04 $50.40 $32.76
$6,450.00 - $6,599.99 $4,300.00 $160.82 $136.74 $113.52 $69.66 $51.60 $33.54
$6,600.00 - $6,749.99 $4,400.00 $164.56 $139.92 $116.16 $71.28 $52.80 $34.32
$6,750.00 - $6,899.99 $4,500.00 $168.30 $143.10 $118.80 $72.90 $54.00 $35.10
$6,900.00 - $7,049.99 $4,600.00 $172.04 $146.28 $121.44 $74.52 $55.20 $35.88
$7,050.00 - $7,199.99 $4,700.00 $175.78 $149.46 $124.08 $76.14 $56.40 $36.66
$7,200.00 - $7,349.99 $4,800.00 $179.52 $152.64 $126.72 $77.76 $57.60 $37.44
$7,350.00 - $7,499.99 $4,900.00 $183.26 $155.82 $129.36 $79.38 $58.80 $38.22
$7,500.00 - $7,649.99 $5,000.00 $187.00 $159.00 $132.00 $81.00 $60.00 $39.00
$7,650.00 - $7,799.99 $5,100.00 $190.74 $162.18 $134.64 $82.62 $61.20 $39.78
$7,800.00 - $7,949.99 $5,200.00 $194.48 $165.36 $137.28 $84.24 $62.40 $40.56
$7,950.00 - $8,099.99 $5,300.00 $198.22 $168.54 $139.92 $85.86 $63.60 $41.34
$8,100.00 - $8,249.99 $5,400.00 $201.96 $171.72 $142.56 $87.48 $64.80 $42.12
$8,250.00 - $8,399.99 $5,500.00 $205.70 $174.90 $145.20 $89.10 $66.00 $42.90
$8,400.00 - $8,549.99 $5,600.00 $209.44 $178.08 $147.84 $90.72 $67.20 $43.68
$8,550.00 - $8,699.99 $5,700.00 $213.18 $181.26 $150.48 $92.34 $68.40 $44.46
$8,700.00 - $8,849.99 $5,800.00 $216.92 $184.44 $153.12 $93.96 $69.60 $45.24
$8,850.00 - $8,999.99 $5,900.00 $220.66 $187.62 $155.76 $95.58 $70.80 $46.02
$9,000.00 - $9,149.99 $6,000.00 $224.40 $190.80 $158.40 $97.20 $72.00 $46.80
$9,150.00 - $9,299.99 $6,100.00 $228.14 $193.98 $161.04 $98.82 $73.20 $47.58
$9,300.00 - $9,449.99 $6,200.00 $231.88 $197.16 $163.68 $100.44 $74.40 $48.36
$9,450.00 - $9,599.99 $6,300.00 $235.62 $200.34 $166.32 $102.06 $75.60 $49.14
$9,600.00 - $9,749.99 $6,400.00 $239.36 $203.52 $168.96 $103.68 $76.80 $49.92
$9,750.00 - $9,899.99 $6,500.00 $243.10 $206.70 $171.60 $105.30 $78.00 $50.70
$9,900.00 - $10,049.99 $6,600.00 $246.84 $209.88 $174.24 $106.92 $79.20 $51.48
$10,050.00 - $10,199.99 $6,700.00 $250.58 $213.06 $176.88 $108.54 $80.40 $52.26
$10,200.00 - $10,349.99 $6,800.00 $254.32 $216.24 $179.52 $110.16 $81.60 $53.04
$10,350.00 - $10,499.99 $6,900.00 $258.06 $219.42 $182.16 $111.78 $82.80 $53.82
$10,500.00 - $10,649.99 $7,000.00 $261.80 $222.60 $184.80 $113.40 $84.00 $54.60
$10,650.00 - $10,799.99 $7,100.00 $265.54 $225.78 $187.44 $115.02 $85.20 $55.38
$10,800.00 - $10,949.99 $7,200.00 $269.28 $228.96 $190.08 $116.64 $86.40 $56.16
$10,950.00 - $11,099.99 $7,300.00 $273.02 $232.14 $192.72 $118.26 $87.60 $56.94
$11,100.00 - $11,249.99 $7,400.00 $276.76 $235.32 $195.36 $119.88 $88.80 $57.72
$11,250.00 - And Over $7,500.00 $280.50 $238.50 $198.00 $121.50 $90.00 $58.50
E M P L O Y E R B E N E F I T S O L U T I O N S F O R Y O U R I N D U S T R Y
Focus on the fight.A cancer diagnosis may be both a physical and emotional drain. But thanks to advances in medicine and procedures to treat cancer, more and more people are beating the disease. However, with the arrival of these advances also comes the continuing rise in the cost of cancer treatment.
AF™ Limited Benefit Group Cancer Insurance offers a solution to help you and your family focus on fighting the disease.
AF™ Group Cancer Insurance Plan Highlights
• Helps cover expenses for the treatment of cancer, transportation, hospitalization, and more.
• Benefits paid directly to you to be used however you see fit.
• Portable to take with you even if you leave employment.
• Coverage options available for you, your spouse, and your children under age 26.
Cancer Insurance BenefitsWith over 25 benefits specifically designed to help with the financial impact of being diagnosed, AF™ Group Cancer Insurance may help pay for expenses not covered by your major medical insurance.
Example cancer insurance benefits include:
Diagnostic and PreventionAnnual benefit to help pay for covered diagnostic testing or screening. This benefit also qualifies for our AFQuickClaims®.
Travel ExpensesThis benefit may help pay for qualified transportation and lodging for the patient and family.
Did You Know?New cancer cases in America are diagnosed at the rate of about 4,626 per day.
American Cancer Society: Cancer Facts and Figures 2017, pg. 4.
AF™ Limited Benefit Group Cancer Insurance
Choose Your Coverage
TREATMENT BENEFITS BASIC ENHANCED PLUS
Radiation Therapy/Chemotherapy/Immunotherapy Benefit (per 12-month period) (actual charges)
$10,000 $15,000
Administrative/Lab Work Benefit (per calendar month) $50 $75
Hormone Therapy Benefit (per treatment - max 1 treatment/calendar month)
$50 $50
Experimental Treatment Benefit
Paid in the same manner and under the
same maximums as any other treatment
Blood, Plasma, and Platelets Benefit ($10,000 Basic, $15,000 Enhanced Plus per calendar year max)
$200/day $300/day
Medical Imaging Benefit (per image - max 2 per calendar year) $200 $300
Surgical Benefit
$20 surgical unit/
Max per operation:
$2,000
$40 surgical unit/
Max per operation:
$4,000
Anesthesia Benefit 25% of the amount paid for covered surgery
Second and Third Surgical Opinion Benefit(per diagnosis) $300 $300
Outpatient Hospital or Ambulatory Surgical Center Benefit
$200/day of surgery
$600/day of surgery
Bone Marrow or Stem Cell Transplant Benefit
Patient Provided (per calendar year)Donor Provided (per calendar year)
$500$1,500
$1,500$4,500
Prosthesis and Orthotic Benefit and Related Services
Surgical (1/site; lifetime max 2/covered person)Non-surgical (1/site; lifetime max 3/covered person)
Hair Prosthesis (once per life)
$1,000
$100
$100
$2,000
$200
$200
Hospital Confinement BenefitDay 1-30Day 31+
$100/day$200/day
$300/day$600/day
U.S. Government/Charity Hospital Benefit (paid in lieu of most benefits) (inpatient and outpatient)
$100/day $300/day
Extended Care Facility Benefit(up to the same number of days of paid hospital confinement)
$100/day $300/day
Home Health Care(up to the same number of days of paid hospital confinement)
$100/day $300/day
Hospice Care Benefit ($18,000 lifetime max for Basic; $54,000 lifetime max for Enhanced Plus)
$100/day $300/day
Inpatient Special Nursing Services Benefit $100/day $300/day
Dread Disease Benefit(paid per day while hospital confined)
Day 1-30Day 31+
$100/day$200/day
$300/day$600/day
Unless otherwise indicated, benefits are for a specified indemnity amount listed in the above schedule and are subject to applicable maximums. Refer to Plan Benefit Highlights for more complete Benefit Descriptions and limits on the Cancer Insurance Plan.
BASIC ENHANCED PLUS
Individual $15.80 $31.62
Family $26.86 $53.80
TREATMENT BENEFITS BASIC ENHANCED PLUS
Donor Benefit $1,000/donation
Drugs and Medicine BenefitInpatient (payable per confinement)Outpatient ($50/prescription/calendar month up to max shown)
$50$50
$200$100
Attending Physician Benefit(while hospital confined) $50/day $50/day
Transportation & Lodging Benefit(Patient & Family Member)Transportation ($1,500 max per round trip; max 12 trips/calendar year)
Lodging (per day up to 90 days per calendar year)
Coach fare or $.50/mile by car
$50
Coach fare or $.50/mile by car
$75
Ambulance BenefitGround (per trip, up to 2 per confinement)Air (per trip, up to 2 per confinement)
$200$2,000
$200$2,000
Physical or Speech Therapy Benefit (per visit up to 4 per calendar month - lifetime max of $1,000)
$50 $50
Diagnostic and Prevention Benefit (one per calendar year) $25 $75
Cancer Screening Follow-Up Benefit (one per calendar year) $25 $75
Waiver of Premium(employee only)
After 90 days of continuous disability
Internal Cancer Diagnosis Benefit(paid once/Covered Person/Lifetime; Benefits reduce 50% at age 70)
$2,500 $5,000
Heart Attack or Stroke Diagnosis Benefit(paid once/covered person/lifetime; benefits reduce 50% at age 70)
N/A $5,000
Hospital Intensive Care Unit Benefit(per day; max 30 days/confinement; benefits reduce 50% at age 70)
Ambulance
$600
$100
Monthly Premium
The premium and amount of benefits provided vary depending upon the plan selected.
Plan Benefit Highlights
Only loss for cancer Unless otherwise indicated, benefits are payable only for loss pays only for loss resulting from definitive Cancer diagnosis or treatment including direct extension, metastatic spread, or recurrence. Proof must be submitted to support each claim. The Policy also covers other conditions or diseases directly caused by Cancer or the treatment of Cancer. The Policy does not cover any other disease, sickness, or incapacity, even though after contracting Cancer it may have been aggravated or affected by Cancer or the treatment of Cancer except for conditions specifically covered under the Dread Disease Benefit or Hospital Intensive Care Unit Benefit; or Heart Attack or Stroke Diagnosis Benefit, if included.
Cancer Means a disease which is manifested by autonomous growth (malignancy) in which there is uncontrolled growth, function, or spread (local or distant) of cells in any part of the body. This includes cancer in situ and malignant melanoma. It does not include other conditions which may be considered precancerous or having malignant potential such as: leukoplakia; hyperplasia; acquired immune deficiency syndrome (AIDS); polycythemia; actinic keratosis; aplastic anemia; atypia; non-malignant monoclonal gammopathy; or pre-malignant lesions, benign tumors or polyps.
Such Cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. Pathologic interpretation of the histology of skin lesions will be accepted from dermatologists certified by the American Board of Dermatopathology. Diagnosis must be made based on a microscopic examination of fixed tissue, or preparations from the hemic system (either during life or post-mortem). The pathologist establishing the diagnosis shall base his judgment solely on the criteria of malignancy as accepted by the American Board of Pathology or the Osteopathic Board of Pathology after a study of the histocytologic architecture or pattern of the suspect tumor, tissue and/or specimen.
Radiation Therapy, Chemotherapy or Immunotherapy Benefit We will pay the actual charges up to the benefit listed in the schedule per 12 month period. If Proof of Loss regarding actual charges for treatment is not submitted, we will pay the daily amount shown in your certificate for each day treatment is received, up to the actual charges maximum per 12-month period. Upon receipt of actual charges Proof of Loss, we will pay the difference, up to the maximum per 12-month period. Actual charges are the amount actually paid by or on behalf of the Covered Person and accepted by the provider for services provided.
This benefit does not cover other related procedures such as treatment planning, treatment management or consultation, design and construction of treatment devices, radiation dosimetry calculation, lab tests, x-rays, scans, medical supplies and equipment used in administration (IV solutions, needles, dressings, pumps, catheters, etc.).
Administrative and Lab Work Benefit Paid only if the Covered Person is also receiving the Radiation Therapy, Chemotherapy or Immunotherapy Benefit during the same calendar month.
Hormone Therapy Benefit Drugs and medicines covered under the Drugs and Medicine Benefit or the Radiation Therapy, Chemotherapy or Immunotherapy Benefit are not included. This benefit does not cover associated administrative processes.
Experimental Treatment Benefit Benefits for experimental treatment prescribed by a physician for treatment of Cancer will be provided the same as non-experimental treatment. Coverage for treatments received outside of the United States or its territories is not provided.
Blood, Plasma and Platelets Benefit Laboratory processes are not included. Colony stimulating factors are not covered. Benefits for blood, plasma and platelets are only provided under this benefit.
Medical Imaging Benefit Payable for a Covered Person who has been diagnosed with Cancer who receives either an MRI, CT scan, CAT scan, PET scan, or RAIU (thyroid) test when performed at the request of a physician.
Surgical Benefit Payable when a surgical operation is performed for covered diagnosed Cancer, Skin Cancer, or reconstructive surgery due to Cancer. Benefits are calculated up to a maximum benefit by multiplying the surgical unit value assigned to the procedure, as shown in the most current Physician’s Relative Value Table, by the unit dollar amount shown in your certificate schedule. Two or more surgical procedures performed through the same incision will be considered one operation and benefits will be limited to the most expensive procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer are not covered under this benefit. Bone marrow surgeries, surgeries to implant a permanent prosthetic device, surgeries required for administration of Radiation Therapy, Chemotherapy or Immunotherapy are not covered under this benefit.
Anesthesia Benefit Services of an anesthesiologist for Skin Cancer or surgical prosthesis implantation are not covered.
Second and Third Surgical Opinion Benefit Payable once per diagnosis of Cancer for a second surgical opinion, and a third if the second disagrees with the first. Surgical opinions for reconstructive, Skin Cancer, or prosthesis surgeries are not covered.
Outpatient Hospital or Ambulatory Surgical Center Benefit Surgical procedures for Skin Cancer are not covered.
Bone Marrow or Stem Cell Transplant Benefit Harvesting of bone marrow or stem cells from a donor are not covered under this benefit.
Prosthesis and Orthotic Benefit and Related Services Payable for a Prosthetic or Orthotic Device and, if surgery required, its surgical implantation. Prosthetic related supplies such as special bras or ostomy pouches and supplies are not covered. Benefits for a hair prothesis will only be covered under the Hair Prosthesis Benefit.
Covered benefits under this provision are limited to the most appropriate model of Prosthetic Device or Orthotic Device that adequately meets the medical needs of the Covered Person as determined by the Covered Person’s treating Physician or podiatrist and prosthetist or orthotist, as applicable. The Prosthesis Benefit will include repair and replacement of a Prosthetic Device or Orthotic Device, unless the repair or replacement is necessitated by misuse by the Covered Person.
Hospital Confinement Benefit Pays when the Covered Person requires Hospital confinement for at least 18 continuous hours. Hospital shall not include an institution, or part thereof, used by the Covered Person as a place for rehabilitation; a hospice unit, including any bed designated as a hospice or swing bed; a place for rest or for the aged; a nursing or convalescent home; a long-term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.
U.S. Government or Charity Hospital Benefit Payable when an itemized list of services is not available and the Covered Person is confined in a charity Hospital or a Hospital owned or operated by the U.S. government as a result of Cancer or Dread Disease or covered under a Diagnostic Related Group where no charges are made to the Covered Person for treatment of Cancer or Dread Disease. This benefit will be paid in lieu of most benefits listed on the schedule.
Extended Care Facility Benefit Pays a daily benefit for physician authorized confinement that begins within 14 days after a Hospital confinement.
Home Health Care Benefit Pays a daily benefit for physician authorized private nursing care that begins within 14 days of a hospital confinement. This benefit does not include nutrition counseling, medical social services, medical supplies, prosthesis or orthopedic appliances, rental or purchase of durable medical equipment, drugs or medicines, child care, meals or housekeeping services, or physical or speech therapy.
G926 SeriesSB-32483(TX)(FFGA) - 0119
American Fidelity Assurance Company 9000 Cameron Parkway, Oklahoma City, Oklahoma 73114800-662-1113 • americanfidelity.com
This product may contain limitations, exclusions, and waiting periods. This brochure highlights important features of the policy. Please refer to your certificate for complete details. If you reside in a state other than your employers state domicile, where required by law, policy provisions and benefits may vary. This product is inappropriate for people who are eligible for Medicaid coverage.
Plan Benefit Highlights Hospice Care Benefit Pays a daily benefit when a physician determines terminal illness with life expectancy of 6 months or less and approves hospice care at home or in a hospice facility. This benefit does not include well baby care, volunteer services, meals, housekeeping services, or family support after the death.
Inpatient Special Nursing Services Benefit Pays a daily benefit when receiving physician authorized special nursing care (other than that regularly furnished by a Hospital) of at least 8 consecutive hours during a 24 hour period.
Dread Disease Benefit Covered Dread Diseases are: Addison’s Disease; Amyotrophic Lateral Sclerosis; Cystic Fibrosis; Diphtheria; Encephalitis; Grand Mal Epilepsy; Legionnaire’s Disease; Meningitis; Multiple Sclerosis; Muscular Dystrophy; Myasthenia Gravis; Niemann-Pick Disease; Osteomyelitis; Poliomyelitis; Reye’s Syndrome; Rheumatic Fever; Rocky Mountain Spotted Fever; Sickle Cell Anemia; Systemic Lupus Erythematosus; Tay-Sach’s Disease; Tetanus; Toxic Epidermal; Toxic Shock Syndrome; Tuberculosis; Tularemia; Typhoid Fever; Whipple’s Disease.
Donor Benefit Blood donor expenses are not covered.
Drugs and Medicine Benefit Pays a benefit for anti-nausea and pain medication for treatment of Cancer. It does not include associated administrative processes or drugs or medicines covered under the Radiation Therapy, Chemotherapy or Immunotherapy Benefit or the Hormone Therapy Benefit.
Transportation and Lodging Benefits Pays a benefit for transportation by scheduled bus, plane or train, or by car and outpatient lodging for Radiation Therapy, Chemotherapy, or Immunotherapy treatment, Bone Marrow or Stem Cell Transplant, or surgery in a Hospital not available locally and at least 50 miles from the Covered Person’s residence. Payable for the Covered Person and one adult family member. If traveling in the same car or lodging in the same room, the benefit is payable only for the Covered Person.
Ambulance Benefit If air and ground ambulance services are both required on the same day, we will only pay the higher benefit amount. Covered Person must be admitted as an inpatient and hospital confined for at least 18 consecutive hours.
Waiver of Premium Premium waived if you are disabled due to Cancer for longer than 90 continuous days. This benefit does not apply if your spouse or children become disabled.
Physical or Speech Therapy Benefit Therapy must be provided by a caregiver licensed in physical or speech therapy.
Diagnostic and Prevention Benefit Pays for a generally medically recognized screening test to detect Internal Cancer. This benefit is not payable for any test covered under the Medical Imaging Benefit.
Cancer Screening Follow Up Benefit Payable for one follow-up invasive screening test when a Covered Person receives abnormal results from a covered screening test. For tests involving an incision or surgery, payable only for tests that result in a negative diagnosis of Cancer.
Internal Cancer Diagnosis Benefit Payable if a physician diagnoses the Covered Person with Internal Cancer after coverage is in force for that person.
Heart Attack or Stroke Diagnosis Benefit Payable if a physician diagnoses the Covered Person as having a Heart Attack or Stroke after coverage is in force for that person. This benefit is payable only for the first to occur of either the Heart Attack or Stroke.
Pre-existing condition Means a Specified Disease for which the Covered Person: (a) had treatment; or (b) received advice from a Physician, during the 12-month period immediately before the Covered Person’s Effective Date of coverage.
Pre-existing condition limitation No benefit will be payable for any loss which is caused by or resulting from a Pre-Existing Condition which occurs before a Covered Person has been continuously covered under the Policy for 12 consecutive months. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. Increases or changes in coverage will be subject to an additional Pre-Existing Condition Limitation.
Hospital intensive care unit benefit limitations No benefits will be payable during the first 2 years of coverage for confinement caused by any heart condition that was diagnosed or treated prior to 30 days following the Effective Date of coverage. (The heart condition causing confinement need not be the same condition diagnosed or treated prior to the Effective Date).
Exclusions We will not pay benefits resulting from or caused by: (a) intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; (b) alcoholism or drug addiction; (c) war or acts of war, declared or undeclared, while serving in the military or an auxiliary unit thereto; (d) military service for any country at war; (e) participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; or (f ) participation in, or attempting to participate in, a felony, riot or insurrection (A felony is as defined by the law of the jurisdiction in which the activity takes place.)
Benefits are also not payable for services performed by a Physician who is related to the Covered Person.
Termination of Insurance Your coverage may be continued for up to 1 year during a leave of absence approved in writing by your employer. Coverage will continue as long as the group policy remains in force, the premiums are paid and you remain eligible for the coverage under the policy. Your coverage will end when you no longer qualify as an insured, you retire, you are not on active employment, your employment terminates, or you die. Your dependent’s coverage will end if your coverage ends, premiums are not paid, they no longer meet the definition of a dependent or the policy is modified to exclude dependents. Your coverage can be terminated or premiums may be increased on any premium due date with 60 days advance written notice.
AF™ Limited Benefit Group Cancer Insurance
Aflac Group Accident Insurance Accident protection made for you.
IV (4/19)AGC1901050
Underwritten by:Continental American Insurance Company (CAIC)In California, coverage is underwritten byContinental American Life Insurance Company.
This plan does not contain comprehensive adult wellness benefits as defined by law.
AFLAC GROUP ACCIDENT INSURANCE Policy Series C70000
Just because an accident can change your health, doesn’t mean it should change your lifestyle too.Accidents can happen in an instant affecting you or a loved one. Aflac is designed to help families plan for the
health care bumps ahead and take some of the uncertainty and financial insecurity out of getting better.
Protection for the unexpected, that’s the benefit of the Aflac Group Accident Plan.
After an accident, you may have expenses you’ve never thought about. Can your finances handle them? It’s
reassuring to know that an accident insurance plan can be there for you in your time of need to help cover
expenses such as:
• Ambulance rides
• Emergency room visits
• Surgery and anesthesia
• Prescriptions
• Major Diagnostic Testing
• Burns
Plan Features
• Benefits are paid directly to you, unless otherwise assigned.
• Coverage is guaranteed-issue (which means you may qualify for coverage without having to answer
health questions).
• Benefits are paid regardless of any other medical insurance.
What you need, when you need it.
Group accident insurance pays cash
benefits that you can use any way
you see fit.
HIGH LOW
INIT IAL TRE ATMENT (once per accident, within 7 days after the accident, not payable for telemedicine services) Payable when an insured receives initial treatment for a covered accidental injury. This benefit is payable for initial treatment received under the care of a doctor when an insured visits the following:
Hospital emergency room with X-Ray / without X-Ray $150/$100 $100/$50
Urgent care facility with X-Ray / without X-Ray $150/$100 $100/$50Doctor’s office or facility (other than a hospital emergency room or urgent care) with X-Ray / without X-Ray $100/$75 $50/$25
AMBUL ANCE (within 90 days after the accident) Payable when an insured receives transportation by a professional ambulance service due to a covered accidental injury.
$300 Ground
$1,000 Air
$200 Ground$750 Air
MAJOR DIAGNOSTIC TESTING (once per accident, within 6 months after the accident) Payable when an insured requires one of the following exams: Computerized Tomography (CT/CAT scan), Magnetic Resonance Imaging (MRI), or Electroencephalography (EEG) due to a covered accidental injury. These exams must be performed in a hospital, a doctor’s office, a medical diagnostic imaging center or an ambulatory surgical center.
$200 $100
EMERGENCY ROOM OBSERVATION (within 7 days after the accident) Payable when an insured receives treatment in a hospital emergency room, and is held in a hospital for observation without being admitted as an inpatient because of a covered accidental injury.
$100Each 24
hour period
$50 Less than 24 hours,
but at least 4 hours
$50Each 24
hour period
$25 Less than 24 hours,
but at least 4 hours
PRESCRIPTIONS (2 times per accident, within 6 months after the accident) Payable for a prescription filled that - due to a covered accidental injury - is ordered by a doctor, dispensed by a licensed pharmacist and medically necessary for the care and treatment of the insured (in Alaska, Massachusetts and Montana prescriptions do not have to be medically necessary). This benefit is not payable for therapeutic devices or appliances; experimental drugs; drugs, medicines or insulin used by or administered to a person while he is confined to a hospital, rest home, extended-care facility, convalescent home, nursing home or similar institution; or immunization agents, biological sera, blood or blood plasma. This benefit is not payable for pain management techniques for which a benefit is paid under the Pain Management Benefit (if available).
$5 $5
BLOOD/PL ASMA /PL ATELETS (3 times per accident, within 6 months after the accident) Payable for each day that an insured receives blood, plasma or platelets due to a covered accidental injury.
$400 $300
PAIN MANAGEMENT (once per accident, within 6 months after the accident) Payable when an insured, due to a covered accidental injury, is prescribed and receives a nerve ablation and/or block, or an epidural injection administered into the spine. This benefit is only payable for pain management techniques (as shown above) that are administered in a hospital or doctor’s office. This benefit is not payable for an epidural administered during a surgical procedure.
$100 $50
CONCUSSION (once per accident, within 6 months after the accident) Payable when an insured is diagnosed by a doctor with a concussion due to a covered accident.
$400 $200
TR AUMATIC BR AIN INJURY (once per accident, within 6 months after the accident) Payable when an insured is diagnosed by a neurologist with Traumatic Brain Injury (TBI) due to a covered accident. To qualify as TBI, the neurological deficit must require treatment by a neurologist and a prescribed course of physical, speech and/or occupational therapy under the direction of a neurologist.
$1,500 $1,250
GROUP ACCIDENT INSURANCE
COMA (once per accident) Payable when an insured is in a coma lasting 30 days or more as the result of a covered accident. For the purposes of this benefit, Coma means a profound state of unconsciousness caused by a covered accident.
$10,000 $5,000
EMERGENCY DENTAL WORK (once per accident, within 6 months after the accident) Payable when an insured’s natural teeth are injured as a result of a covered accident.
$50 Extraction
$200 Repair with a
crown
$25 Extraction
$100 Repair with a
crown
BURNS (once per accident, within 6 months after the accident) Payable when an insured is burned in a covered accident and is treated by a doctor. We will pay according to the percentage of body surface burned. First degree burns are not covered.
Second Degree
Less than 10% $50 $25
At least 10% but less than 25% $100 $50
At least 25% but less than 35% $250 $125
35% or more $500 $250
Third Degree
Less than 10% $500 $250
At least 10% but less than 25% $2,500 $1,250
At least 25% but less than 35% $5,000 $2,500
35% or more $10,000 $5,000
EYE INJURIES Payable for eye injuries if, because of a covered accident, a doctor removes a foreign body from the eye, with or without anesthesia.
$300 $200
FR ACTURES (once per accident, within 90 days after the accident) Payable when an insured fractures a bone because of a covered accident and is treated by a doctor. If the fracture requires open reduction, 200% of the benefit is payable for that bone. For multiple fractures (more than one bone fractured in one accident), we will pay a maximum of 200% of the benefit amount for the bone fractured that has the highest dollar amount. For a chip fracture (a piece of bone that is completely broken off near a joint), we will pay 25% of the amount for the affected bone. This benefit is not payable for stress fractures.
Up to $3,000
based on a schedule
Up to $1,500
based on a schedule
DISLOCATIONS (once per accident, within 90 days after the accident) Payable when an insured dislocates a joint because of a covered accident and is treated by a doctor. If the dislocation requires open reduction, 200% of the benefit for that joint is payable. We will pay benefits only for the first dislocation of a joint. We will not pay for recurring dislocations of the same joint. If the insured dislocated a joint before the effective date of his certificate and then dislocates the same joint again, it will not be covered by the plan. For multiple dislocations (more than one dislocated joint in one accident), we will pay a maximum of 200% of the benefit amount for the joint dislocated that has the highest dollar amount. For a partial dislocation (joint is not completely separated, including subluxation), we will pay 25% of the amount for the affected joint.
Up to $3,000
based on a schedule
Up to $1,500
based on a schedule
L ACER ATIONS (once per accident, within 7 days after the accident) Payable when an insured receives a laceration in a covered accident and the laceration is repaired by a doctor. For multiple lacerations, we will pay a maximum of 200% of the benefit for the largest single laceration requiring stitches. Lacerations requiring stitches (including liquid skin adhesive):
Under 5 centimeters $50 $25
5-15 centimeters $200 $100
Over 15 centimeters $400 $200
Lacerations not requiring stitches $25 $12.50
OUTPATIENT SURGERY AND ANESTHESIA (per day / performed in hospital or ambulatory surgical center, within one year after the accident) Payable for each day that, due to a covered accidental injury, an insured has an outpatient surgical procedure performed by a doctor in a hospital or ambulatory surgical center. Surgical procedure does not include laceration repair. If an outpatient surgical procedure is covered under another benefit in the plan, we will pay the higher benefit amount.
$400 $200
FACILIT IES FEE FOR OUTPATIENT SURGERY (surgery performed in hospital or ambulatory surgical center, within one year after the accident) Payable once per each eligible Outpatient Surgery and Anesthesia Benefit (in a hospital or ambulatory surgical center).
$100 $25
OUTPATIENT SURGERY AND ANESTHESIA (per day / performed in a doctor’s office, urgent care facility, or emergency room; maximum of two procedures per accident, within one year of the accident)Payable for each day that, due to a covered accidental injury, an insured has an outpatient surgical procedure performed by a doctor in a doctor’s office, urgent care facility or emergency room. Surgical procedure does not include laceration repair. If an outpatient surgical procedure is covered under another benefit in this plan, we will pay the higher benefit amount.
$50 $25
INPATIENT SURGERY AND ANESTHESIA (per day / within one year after the accident) Payable for each day that, due to a covered accidental injury, an insured has an inpatient surgical procedure performed by a doctor. The surgery must be performed while the insured is confined to a hospital as an inpatient. If an inpatient surgical procedure is covered under another benefit in the plan, we will pay the higher benefit amount.
$1,500 $1,000
TR ANSPORTATION (greater than 100 miles from the insured’s residence, 3 times per accident, within 6 months after the accident) Payable for transportation if, because of a covered accident, an insured is injured and requires doctor-recommended hospital treatment or diagnostic study that is not available in the insured’s resident city.
$400 Plane
$200 Any ground
transportation
$200 Plane
$100 Any ground
transportation
Surgical Procedures may include, but are not limited to, surgical repair of: ruptured disc, tendons/ligaments, hernia, rotator cuff, torn knee cartilage, skin grafts, joint replacement, internal injuries requiring open abdominal or thoracic surgery, exploratory surgery (with or without repair), etc., unless otherwise noted due to an accidental injury.
AFTER CARE BENEFITS HIGH LOW
APPLIANCES (within 6 months after the accident)Payable if, as a result of an injury received in a covered accident, a doctor advises the insured to use a listed medical appliance as an aid in personal locomotion. Cane, Ankle Brace $40 $20
Walker, Crutches, Leg Brace, Cervical Collar, Walking Boot, Wheelchair, Knee Scooter, Body Jacket, Back Brace
$100 $50
ACCIDENT FOLLOW-UP TRE ATMENT (maximum of 3 per accident, within 6 months after the accident provided initial treatment is within 7 days of the accident)Payable for doctor-prescribed follow-up treatment for injuries received in a covered accident. Follow-up treatments do not include physical, occupational or speech therapy. Chiropractic or acupuncture procedures are also not considered follow-up treatment.
$50 $25
POST-TR AUMATIC STRESS DISORDER (PTSD) (once per accident, within 6 months after the accident)Payable if the insured is diagnosed with PTSD, a mental health condition triggered by a covered accident. An insured must meet the diagnostic criteria for PTSD, stipulated in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV-TR), and be under the active care of either a psychiatrist or Ph.D.-level psychologist.
$200 $100
SUCCESSOR INSURED BENEFITIf spouse coverage is in force at the time of the employee’s death, the surviving spouse may elect to continue coverage. Coverage would continue according to the existing plan and would also include any dependent child coverage in force at the time.
REHABILITATION UNIT (maximum of 31 days per confinement, no more than 62 days total per calendar year for each insured)Payable for each day that, due to a covered accidental injury, an insured receives treatment as an inpatient at a rehabilitation facility. For this benefit to be payable, the insured must be transferred to the rehabilitation facility for treatment following an inpatient hospital confinement. We will not pay the rehabilitation facility benefit for the same days that the hospital confinement benefit is paid. We will pay the highest eligible benefit.
$100 per day
$50 per day
THER APY (maximum of 10 per accident, beginning within 90 days after the accident provided initial treatment is within 7 days after the accident)Payable if because of injuries received in a covered accident, an insured has doctor-prescribed therapy treatment in one of the following categories: physical therapy provided by a licensed physical therapist, occupational therapy provided by a licensed occupational therapist, or speech therapy provided by a licensed speech therapist.
$25 $15
CHIROPR ACTIC OR ALTERNATIVE THER APY (maximum of 6 per accident, beginning within 90 days after the accident provided initial treatment is within 7 days after the accident)Payable if because of injuries received in a covered accident, an insured receives acupuncture or chiropractic treatment.
$30 $15
HOSPITALIZATION BENEFITS HIGH LOW
HOSPITAL ADMISSION (once per accident, within 6 months after the accident)Payable when an insured is admitted to a hospital and confined as an inpatient because of a covered accidental injury. This benefit is not payable for confinement to an observation unit, for emergency room treatment or for outpatient treatment.
$1,000 per
confinement
$500 per
confinement
HOSPITAL CONFINEMENT (maximum of 365 days per accident, within 6 months after the accident)Payable for each day that an insured is confined to a hospital as an inpatient because of a covered accidental injury. If we pay benefits for confinement and the insured is confined again within 6 months because of the same accidental injury, we will treat this confinement as the same period of confinement.This benefit is payable for only one hospital confinement at a time even if caused by more than one covered accidental injury. This benefit is not payable for confinement to an observation unit or a rehabilitation facility.
$200 per day
$100per day
HOSPITAL INTENSIVE CARE (maximum of 30 days per accident, within 6 months after the accident) Payable for each day an insured is confined in a hospital intensive care unit because of a covered accidental injury. We will pay benefits for only one confinement in a hospital intensive care unit at a time, even if it is caused by more than one covered accidental injury.If we pay benefits for confinement in a hospital intensive care unit and an insured becomes confined to a hospital intensive care unit again within 6 months because of the same accidental injury, we will treat this confinement as the same period of confinement.This benefit is payable in addition to the Hospital Confinement Benefit.
$200 per day
$100 per day
INTERMEDIATE INTENSIVE CARE STEP-DOWN UNIT (maximum of 30 days per accident, within 6 months after the accident)Payable for each day an insured is confined in an intermediate intensive care step-down unit because of a covered accidental injury.We will pay benefits for only one confinement in an intermediate intensive care step-down unit at a time, even if it is caused by more than one covered accidental injury.If we pay benefits for confinement in an intermediate intensive care step-down unit and an insured becomes confined to an intermediate intensive care step-down unit again within 6 months because of the same condition, we will treat this confinement as the same period of confinement.This benefit is payable in addition to the Hospital Confinement Benefit.
$100 per day
$50 per day
FAMILY MEMBER LODGING (greater than 100 miles from the insured’s residence, maximum of 30 days per accident, within 6 months after the accident)Payable for each night’s lodging in a motel/hotel/rental property for an adult member of the insured’s immediate family. For this benefit to be payable:• The insured must be confined to a hospital for treatment of a covered accidental injury;• The hospital and motel/hotel must be more than 100 miles from the insured’s residence; and• The treatment must be prescribed by the insured’s treating doctor.
$200 per day
$100 per day
LIFE CHANGING EVENTS BENEFITS
DISMEMBERMENT (once per accident, within 6 months after the accident)Payable if an insured loses a hand or foot or experiences loss of sight as the result of a covered accident.Dismemberment means:• Loss of a hand -The hand is removed at or above the wrist joint; • Loss of a foot -The foot is removed at or above the ankle; • Loss of a finger/toe - The finger or toe is removed at or above the joint where it is attached to the hand or foot; or• Loss of sight - At least 80% of the vision in one eye is lost (such loss of sight must be permanent and irrecoverable).If the Dismemberment Benefit is paid and the insured later dies as a result of the same covered accident, we will pay the appropriate death benefit (if available), less any amounts paid under this benefit.
SINGLE LOSS (the loss of one hand, one foot, or the sight of one eye) HIGH LOW
Employee $12,500 $5,000
Spouse $5,000 $2,500
Child(ren) $2,500 $1,250
DOUBLE LOSS (the loss of both hands, both feet, the sight of both eyes, or a combination of any two)
Employee $25,000 $10,000
Spouse $10,000 $5,000
Child(ren) $5,000 $2,500
LOSS OF ONE OR MORE FINGERS OR TOES
Employee $1,250 $500
Spouse $500 $250
Child(ren) $250 $125
PARTIAL DISMEMBERMENT (INCLUDES AT LEAST ONE JOINT OF A FINGER OR A TOE)
Employee $125 $62.50
Spouse $125 $62.50
Child(ren) $125 $62.50
PAR ALYSIS (once per accident, diagnosed by a doctor within six months after the accident)Payable if an insured has permanent loss of movement of two or more limbs for more than 90 days (in Utah, 30 days) as the result of a covered accidental injury.Paraplegia
Quadriplegia
$5,000
$10,000
$2,500
$5,000
PROSTHESIS (once per accident, up to 2 prosthetic devices and one replacement per device per insured)*Payable when an insured receives a prosthetic device, prescribed by a doctor, as a result of a covered accidental injury. Prosthetic Device/Prosthesis means an artificial device designed to replace a missing part of the body. This benefit is not payable for hearing aids, wigs, or dental aids (to include false teeth), repair or replacement of prosthetic devices* and /or joint replacements.
* We will pay this benefit again once to cover the replacement of a prosthesis for which a benefit has been paid, provided the replacement takes place within three years of the initial benefit payment.
$1,500 $500
RESIDENCE/ VEHICLE MODIFICATION (once per accident, within one year after the accident)Payable for a permanent structural modification to an insured’s primary residence or vehicle when the insured suffers total and permanent or irrevocable loss of one of the following, due to a covered accidental injury:• The sight of one eye;• The use of one hand/arm; or• The use of one foot/leg.
$1,000 $500
ACCIDENTAL DEATH RIDER HIGH LOW
ACCIDENTAL DE ATH BENEFIT (within 90 days after the accident*)Payable if a covered accidental injury causes the insured to die.
$50,000 Employee
$25,000 Spouse
$10,000 Child
$25,000 Employee
$12,500 Spouse
$5,000 Child
ACCIDENTAL COMMON-CARRIER DE ATH BENEFITPayable if the insured:• Is a fare-paying passenger on a common carrier;• Is injured in a covered accident; and• Dies within 90 days* after the covered accident.
*In Oregon and Utah, within 180 days after the accident; in Pennsylvania, there is no limitation on the number of days.
$100,000 Employee
$50,000 Spouse
$20,000 Child
$50,000 Employee
$25,000 Spouse
$10,000 Child
ORGANIZED ATHLETIC ACTIV IT Y RIDER BOTH PLANS
ORGANIZED ATHLETIC ACTIV IT Y BENEFIT We will pay an additional percentage of the benefit amount payable under the Aflac Group Accident plan for covered accidental injuries sustained while participating in an organized athletic event.
10%
INITIAL ACCIDENT EXCLUSIONSEXCLUSIONSPlan exclusions apply to all riders unless otherwise noted.We will not pay benefits for accidental injury, disability or death contributed to, caused by, or resulting from*:
• War – voluntarily participating in war, any act of war, or military conflicts, declared or undeclared, or voluntarily participating or serving in the military, armed forces or an auxiliary unit thereto, or contracting with any country or international authority. (We will return the prorated premium for any period not covered by the certificate when the insured is in such service.) War also includes voluntary participation in an insurrection, riot, civil commotion or civil state of belligerence. War does not include acts of terrorism.
− In California: voluntarily participating in war, any act of war, or military conflicts, declared or undeclared, or voluntarily participating or serving in the military, armed forces, or an auxiliary unit thereto or contracting with any country or international authority. (We will return the prorated premium for any period not covered by the certificate when the insured is in such service.) War also includes voluntary participation in an insurrection or riot.
− In Idaho: participating in any war or act of war, declared or undeclared, or participating or serving in the armed forces or units auxiliary thereto. War also includes participation in a riot or an insurrection.
− In Illinois: the statement “war does not include acts of terrorism” is deleted. − In Michigan: voluntarily participating in war or any act of war. War also
includes voluntary felonious participation in an insurrection, riot, civil commotion or civil state of belligerence. War does not include acts of terrorism.
− In North Carolina: War – voluntarily participating in war, any act of war, or military conflicts, declared or undeclared, or voluntarily participating or serving in the military, armed forces or an auxiliary unit thereto, or contracting with any country or international authority. (We will return the prorated premium for any period not covered by the certificate when the insured is in such service.) War also includes civil participation in an active riot. War does not include acts of terrorism.
• Suicide – committing or attempting to commit suicide, while sane or insane. − In Montana: committing or attempting to commit suicide, while sane − In Illinois, Michigan and Minnesota: this exclusion does not apply
• Sickness – having any disease or bodily/mental illness or degenerative process. We also will not pay benefits for:
− Allergic reactions − Any bacterial, viral, or microorganism infection or infestation or any
condition resulting from insect, arachnid or other arthropod bites or stings. In Illinois: any bacterial infection, except an infection which results from an accidental injury or an infection which results from accidental, involuntary or unintentional ingestion of a contaminated substance; any viral or microorganism infection or infestation; or any condition resulting from insect, arachnid or other arthropod bites or stings. In North Carolina: any viral or microorganism infestation or any condition resulting from insect, arachnid or other arthropod bites or stings
− An error, mishap or malpractice during medical, diagnostic, or surgical treatment or procedure for any sickness
− Any related medical/surgical treatment or diagnostic procedures for such illness
• Self-Inflicted Injuries – injuring or attempting to injure oneself intentionally. − In Idaho: intentionally self-inflicting injury. − In Montana: injuring or attempting to injure oneself intentionally,
while sane − In Michigan: this exclusion does not apply
• Racing – riding in or driving any motor-driven vehicle in a race, stunt show or speed test in a professional or semi-professional capacity.
− In Idaho: this exclusion does not apply • Illegal Occupation – voluntarily participating in, committing or attempting to commit a felony or illegal act or activity, or voluntarily working at or being engaged in, an illegal occupation or job.
− In California, Nebraska and Tennessee: voluntarily participating in,
committing, or attempting to commit a felony; or voluntarily working at, or being engaged in, an illegal occupation or job.
− In Illinois and Pennsylvania: committing or attempting to commit a felony or being engaged in an illegal occupation
− In Michigan: voluntarily participating in, committing or attempting to commit a felony, or being engaged in an illegal occupation
− In Idaho and South Dakota: this exclusion does not apply • Sports – participating in any organized sport in a professional or semi-professional capacity for pay or profit.
− In California and Idaho: participating in any organized sport in a professional capacity for pay or profit
• Cosmetic Surgery – having cosmetic surgery or other elective procedures that are not medically necessary or having dental treatment except as a result of a covered accident.
− In Alaska, Massachusetts and Montana: having cosmetic surgery, other elective procedures or dental treatment except as a result of a covered accident.
− In California: having cosmetic surgery or other elective procedures that are not medically necessary (“cosmetic surgery” does not include reconstructive surgery when the service is related to or follows surgery resulting from a covered accident); or having dental treatment except as a result of a covered accident.
− In Idaho: having cosmetic surgery or other elective procedures that are not medically necessary or having dental treatment except as a result of a covered accident. Cosmetic surgery shall not include reconstructive surgery because of a Congenital Anomaly of a covered dependent child.
• Felony (In Idaho only) – participation in a felonyFor 24-Hour Coverage, the following exclusions will not apply:An injury arising from any employment. An injury or sickness covered by worker’s compensation.In North Carolina: services or supplies for the treatment of an occupational injury or sickness which are paid under the North Carolina workers’ compensation act only to the extent such services or supplies are the liability of the employee, employer, or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ Compensation Act.*“Contributed to” language doesn’t apply in Illinois
DEFINITIONSAccidental Injury means accidental bodily damage to an insured resulting from an unforeseen and unexpected traumatic event. This must be the direct result of an accident and not the result of disease or bodily infirmity. A Covered Accidental Injury is an accidental injury that occurs while coverage is in force. A Covered Accident is an accident that occurs on or after an insured’s effective date while coverage is in force, and that is not specifically excluded by the plan.Ambulatory Surgical Center is defined as a licensed surgical center consisting of an operating room; facilities for the administration of general anesthesia; and a post-surgery recovery room in which the patient is admitted and discharged within a period of less than 24 hours.Dependent Child or Dependent Children means your or your spouse’s natural children, step-children, grandchildren who are in your legal custody and residing with you, foster children, children subject to legal guardianship, legally adopted children, or children placed for adoption, who are younger than age 26 (and in Louisiana, unmarried). Newborn children may be automatically covered from the moment of birth for 60 days. Newly adopted children (and foster children in North Carolina and Florida) may also be automatically covered for 60 days. See certificate for details.Doctor is a person who is duly qualified as a practitioner of the healing arts acting within the scope of his license, and is licensed to practice medicine; prescribe and administer drugs; or to perform surgery, or is a duly qualified
medical practitioner according to the laws and regulations in the state in which treatment is made.In Montana, for purposes of treatment, the insured has full freedom of choice in the selection of any licensed physician, physician assistant, dentist, osteopath, chiropractor, optometrist, podiatrist, psychologist, licensed social worker, licensed professional counselor, acupuncturist, naturopathic physician, physical therapist, speech-language pathologist, audiologist, licensed addiction counselor, or advanced practice registered nurse.A Doctor does not include the insured or an insured’s family member. In South Dakota however, a doctor who is an employee’s family member may treat the insured if that doctor is the only doctor in the area and acts within the scope of his practice. For the purposes of this definition, family member includes the employee’s spouse as well as the following members of the employee’s immediate family son, daughter, mother, father, sister, and brother. This includes step-family members and family-members-in-law. The term Hospital specifically excludes any facility not meeting the definition of hospital as defined in this plan, including but not limited to:
• A nursing home, • An extended-care facility, • A skilled nursing facility, • A rest home or home for the aged,
• A rehabilitation facility, • A facility for the treatment of alcoholism or drug addiction, or
• An assisted living facility. Spouse is your legal wife, husband, or partner in a legally recognized union. Refer to your certificate for details. Telemedicine Service means a medical inquiry with a doctor via audio or video communication that assists with a patient’s assessment, diagnosis, and consultation.Treatment is the consultation, care, or services provided by a doctor. This includes receiving any diagnostic measures and taking prescribed drugs and medicines. Treatment does not include telemedicine services.Urgent Care is a walk-in clinic that delivers ambulatory, outpatient care in a dedicated medical facility for illnesses or injuries that require immediate care but that are not serious enough to require a visit to an emergency room.
HOSPITALIZATION BENEFITS Hospital Intensive Care Unit means a place that meets all of the following criteria:
• Is a specifically designated area of the hospital called a hospital intensive care unit;
• Provides the highest level of medical care;
• Is restricted to patients who are critically ill or injured and who require intensive comprehensive observation and care;
• Is separate and apart from the surgical recovery room and from rooms, beds and wards customarily
used for patient confinement; • Is permanently equipped with special life-saving equipment for the care of the critically ill or injured;
• Is under close observation by a specially trained nursing staff assigned exclusively to the hospital intensive care unit 24 hours a day; and
• Has a doctor assigned to the hospital intensive care unit on a full-time basis.
The term Hospital Intensive Care Unit specifically excludes any type of facility not meeting the definition of hospital intensive care unit as defined in this plan, including but not limited to private monitored rooms, surgical recovery rooms, observation units and the following step-down units:
• A progressive care unit; • A sub-acute intensive care unit; or • An intermediate care unit.
Intermediate Intensive Care Step-Down Unit means any of the following: • A progressive care unit; • A sub-acute intensive care unit; • An intermediate care unit; or • A pre- or post-intensive care unit.
An intermediate intensive care step-down unit is not a hospital intensive care unit as defined in this plan.
AFTER CARE BENEFITS Psychiatrist is a doctor of medicine who specializes in the diagnosis and treatment of mental disorders. Psychologist is a clinical, mental health professional who works with patients. A psychologist is not a doctor of medicine who typically provides medical interventions and drug therapies, but provides analysis and counseling.Rehabilitation Facility is a unit or facility providing coordinated multidisciplinary physical restorative services. These services must be provided to inpatients under a doctor’s direction. The doctor must be knowledgeable and experienced in rehabilitative medicine. Beds must be set up in a unit or facility specifically designated and staffed for this service. This is not a facility for the treatment of alcoholism or drug addiction.
ACCIDENTAL DEATH RIDER Common Carrier means:
• An airline carrier that is licensed by the United States Federal Aviation Administration and operated by a licensed pilot on a regular schedule between established airports;
• A railroad train that is licensed and operated for passenger service only; or • A boat or ship that is licensed for passenger service and operated on a regular schedule between established ports.
ORGANIZED ATHLETIC ACTIVITY RIDEREXCLUSIONSThe Organized Athletic Activity Benefit is not payable for accidental injuries that are caused by or occur as a result of an insured’s participating in any sport or sporting activity for wage, compensation, or profit, including officiating, coaching, or racing any type vehicle in an organized event (in Idaho, in a professional capacity).
This benefit is also not payable for accidental injuries that occur during or are due to physical education classes (except in Idaho).
DEFINITION Organized Athletic Activity means an athletic competition or supervised organized practice for an athletic competition. Organized Athletic Activities take place on a regularly occurring and scheduled basis, often during a pre-determined season. The competition must be governed by a set of written rules and officiated by someone certified to act in that capacity. The competition must also be overseen by a legal entity such as a public school system or sports conference. The legal entity must have a set of bylaws and competition must take place on a regulation playing surface. Participation must be on an amateur basis.
YOU MAY CONTINUE YOUR COVERAGEYour coverage may be continued with certain stipulations. See certificate for details.
TERMINATION OF COVERAGEYour insurance may terminate when the plan is terminated; the 31st day after the premium due date if the premium has not been paid; or the date you no longer belong to an eligible class. If your coverage terminates, we will provide benefits for valid claims that arose while your coverage was in force.
Notice to Consumer: The coverages provided by Continental American Insurance Company (CAIC) represent supplemental benefits only. They do not constitute comprehensive health insurance coverage and do not satisfy the requirement of minimum essential coverage under the Affordable Care Act. CAIC coverage is not intended to replace or be issued in lieu of major medical coverage.
$6.58
$10.98
$13.49
$17.89
Initial Accident Treatment Category Custom
Hospitalization Category Custom
After Care Category Custom
Life-Changing Events Category Custom
Included Riders:Accidental Death - Custom
Organized Athletic Activity
Provisions: Group Attributes:24 hour (on and off job) protection Situs State: TX
Rate Guarantee: 3 Years Group Size: 650
Portability: Process 1
Please note: Premiums shown are accurate as of publication. They are subject to change.
Published: Jan-19 Series C70000 - TX AC70000-190117-165526-001Jt2aY-000fJHXY-0Cq4JTVr-25750 Product Code: AC190117-165526
Family
Group Accident
Elgin ISD - Semimonthly (24pp/yr)
Coverage Rates
Employee
Employee & Dependent Spouse
Employee & Dependent Child(ren)
$3.46
$5.80
$7.14
$9.48
Initial Accident Treatment Category Custom
Hospitalization Category Custom
After Care Category Custom
Life-Changing Events Category Custom
Included Riders:Accidental Death - Custom
Organized Athletic Activity
Provisions: Group Attributes:24 hour (on and off job) protection Situs State: TX
Rate Guarantee: 3 Years Group Size: 650
Portability: Process 1
Please note: Premiums shown are accurate as of publication. They are subject to change.
Published: Jan-19 Series C70000 - TX AC70000-190117-162031-001Jt2aY-000fJHXY-0Cq4JTVr-49799 Product Code: AC190117-162031
Family
Group Accident
Elgin ISD - Semimonthly (24pp/yr)
Coverage Rates
Employee
Employee & Dependent Spouse
Employee & Dependent Child(ren)
Aflac Group Critical Illness AdvantageINSURANCE – PLAN INCLUDES BENEFITS FOR CANCER AND HEALTH SCREENING
We help take care of your expenses while you take care of yourself.
®
IV (3/19)AGC1801292 R1
The plan does not contain comprehensive adult wellness benefits as defined by law.
What you need, when you need it.
Group critical illness insurance pays
cash benefits that you can use any
way you see fit.
AFLAC GROUP CRITICAL ILLNESS ADVANTAGE CIG
Aflac can help ease the financial stress of surviving a critical illness.
Chances are you may know someone who’s been diagnosed with a critical
illness. You can’t help notice the difference in the person’s life—both physically
and emotionally. What’s not so obvious is the impact a critical illness may have on
someone’s personal finances.
That’s because while a major medical plan may pay for a good portion of the
costs associated with a critical illness, there are a lot of expenses that may not be
covered. And, during recovery, having to worry about out-of-pocket expenses is the
last thing anyone needs.
That’s the benefit of an Aflac Group Critical Illness plan.
It can help with the treatment costs of covered critical illnesses, such as a heart
attack or stroke.
More importantly, the plan helps you focus on recuperation instead of the
distraction of out-of-pocket costs. With the Critical Illness plan, you receive cash
benefits directly (unless otherwise assigned)—giving you the flexibility to help pay
bills related to treatment or to help with everyday living expenses.
CIG For more than 60 years, Aflac has been dedicated to helping provide individuals and families peace of mind and financial security when they’ve needed it most. The Aflac Group Critical Illness plan is just another innovative way to help make sure you’re well protected.
Here’s why the Aflac Group Critical Illness plan may be right for you.
How it works
Amount payable based on $10,000 Initial Diagnosis Benefit.
Aflac Group Critical Illness
Advantage coverage is selected.
You experience chest pains
and numbness in the left arm.
You visit the emergency
room.
A physician determines
that you have suffered a
heart attack.
Aflac Group Critical Illness Advantage pays an Initial Diagnosis Benefit of
$10,000
The Aflac Group Critical Illness plan benefits include:
• Critical Illness Benefit payable for:
– Cancer
– Heart Attack (Myocardial Infarction)
– Stroke
– Kidney Failure (End-Stage Renal Failure)
– Major Organ Transplant
– Bone Marrow Transplant (Stem Cell Transplant)
– Sudden Cardiac Arrest
– Coronary Artery Bypass Surgery
– Non-Invasive Cancer
– Skin Cancer
– Coma
– Severe Burn
– Paralysis
– Loss of Speech/Sight/Hearing
• Health Screening Benefit
Features:
• Benefits are paid directly to you, unless otherwise assigned.
• Coverage is available for you, your spouse, and dependent children.
• Coverage may be continued (with certain stipulations). That means you can take it with you if you change jobs or retire.
But it doesn’t stop there. Having group critical illness insurance from Aflac means that you may have added financial resources to help with medical costs or ongoing living expenses.
For more information, ask your insurance agent/producer, call 1.800.433.3036, or visit aflacgroupinsurance.com.
COVERED CRITICAL ILLNESSES:
CANCER (Internal or Invasive) 100%
HEART ATTACK (Myocardial Infarction) 100%
STROKE (Ischemic or Hemorrhagic) 100%
MAJOR ORGAN TRANSPLANT 100%
KIDNEY FAILURE (End-Stage Renal Failure) 100%
BONE MARROW TRANSPLANT (Stem Cell Transplant) 100%
SUDDEN CARDIAC ARREST 100%
SEVERE BURN* 100%
PARALYSIS** 100%
COMA** 100%
LOSS OF SPEECH / SIGHT / HEARING** 100%
NON-INVASIVE CANCER 25%
CORONARY ARTERY BYPASS SURGERY 25%
INITIAL DIAGNOSISWe will pay a lump sum benefit upon initial diagnosis of a covered critical illness when such diagnoses is caused by or solely attributed to an underlying disease. Cancer diagnoses are subject to the cancer diagnosis limitation. Benefits will be based on the face amount in effect on the critical illness date of diagnosis.
ADDITIONAL DIAGNOSISWe will pay benefits for each different critical illness after the first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation.
REOCCURRENCEWe will pay benefits for the same critical illness after the first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation.
CHILD COVERAGE AT NO ADDITIONAL COSTEach dependent child is covered at 50 percent of the primary insured’s benefit amount at no additional charge. Children-only coverage is not available.
Benefits Overview
*This benefit is only payable for a burn due to, caused by, and attributed to, a covered accident.**These benefits are payable for loss due to a covered underlying disease or a covered accident.
COVERED HEALTH SCREENING TESTS INCLUDE:
• Blood test for triglycerides • Bone marrow testing • Breast ultrasound • CA 15-3 (blood test for breast cancer) • CA 125 (blood test for ovarian cancer) • CEA (blood test for colon cancer) • Chest X-ray • Colonoscopy • DNA stool analysis • Fasting blood glucose test • Flexible sigmoidoscopy
• Hemocult stool analysis • Mammography • Pap smear • PSA (blood test for prostate cancer) • Serum cholesterol test to determine level of HDL
and LDL • Serum protein electrophoresis (blood test for
myeloma) • Spiral CT screening for lung cancer • Stress test on a bicycle or treadmill • Thermography
SKIN CANCER BENEFITWe will pay $250 for the diagnosis of skin cancer. We will pay this benefit once per calendar year.
WAIVER OF PREMIUMIf you become totally disabled due to a covered critical illness prior to age 65, after 90 continuous days of total disability, we will waive premiums for you and any of your covered dependents. As long as you remain totally disabled, premiums will be waived up to 24 months, subject to the terms of the plan.
SUCCESSOR INSURED BENEFITIf spouse coverage is in force at the time of the primary insured’s death, the surviving spouse may elect to continue coverage. Coverage would continue at the existing spouse face amount and would also include any dependent child coverage in force at the time.
HEALTH SCREENING BENEFIT (Employee and Spouse only)We will pay $100 for health screening tests performed while an insured’s coverage is in force. We will pay this benefit once per calendar year.
This benefit is only payable for health screening tests performed as the result of preventive care, including tests and diagnostic procedures ordered in connection with routine examinations. This benefit is payable for the covered employee and spouse. This benefit is not paid for dependent children.
OPTIONAL BENEFITS RIDER
BENIGN BRAIN TUMOR 100%
ADVANCED ALZHEIMER’S DISEASE 25%
ADVANCED PARKINSON’S DISEASE 25%
These benefits will be paid based on the face amount in effect on the critical illness date of diagnosis. We will pay the optional benefit if the insured is diagnosed with one of the conditions listed in the rider schedule if the date of diagnosis is while the rider is in force.
The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions.
PROGRESSIVE DISEASE RIDER:
AMYOTROPHIC LATERAL SCLEROSIS (ALS OR LOU GEHRIG’S DISEASE) 100%
SUSTAINED MULTIPLE SCLEROSIS 100%
This benefit is paid based on your selected Progressive Disease Benefit amount. We will pay the benefit shown upon diagnosis of one of the covered diseases if the date of diagnosis is while the rider is in force.
SPECIFIED DISEASES RIDER (These benefits will be paid based at 25% of the face amount in effect on the critical illness date of diagnosis.)
Addison’s Disease, Cerebrospinal Meningitis, Diphtheria, Huntington’s Chorea, Legionnaire’s Disease, Malaria, Muscular Dystrophy, Myasthenia Gravis, Necrotizing Fasciitis, Osteomyelitis, Poliomyelitis (Polio), Rabies, Sickle Cell Anemia, Systemic Lupus, Systemic Sclerosis (Scleroderma), Tetanus, Tuberculosis
LIMITATIONS AND EXCLUSIONS
All limitations and exclusions that apply to the plan also apply to the riders unless amended by the riders.
Cancer Diagnosis Limitation Benefits are payable for cancer and/or non-invasive cancer as long as the insured:
• Is treatment-free from cancer for at least 12 months before the diagnosis date; and • Is in complete remission prior to the date of a subsequent diagnosis, as evidenced
by the absence of all clinical, radiological, biological, and biochemical proof of the presence of the cancer.
EXCLUSIONS We will not pay for loss due to:
• Self-Inflicted Injuries – injuring or attempting to injure oneself intentionally or taking action that causes oneself to become injured;
− In Alaska: injuring or attempting to injure oneself intentionally • Suicide – committing or attempting to commit suicide, while sane or insane;
− In Missouri: committing or attempting to commit suicide, while sane − In Illinois and Minnesota: this exclusion does not apply
• Illegal Acts – participating or attempting to participate in an illegal activity, or working at an illegal job:
− In Arizona: participating in or attempting to commit a felony, or being engaged in
an illegal occupation; − In Florida: participating or attempting to participate in an illegal activity, or
working at an illegal occupation; − In Illinois and Pennsylvania: Illegal Occupation - committing or attempting to
commit a felony or being engaged in an illegal occupation; − In Michigan: Illegal Occupation – the commission of or attempt to commit a
felony, or being engaged in an illegal occupation; − In Nebraska: being engaged in an illegal occupation, or commission of or
attempting to commit a felony; − In Ohio: committing or attempting to commit a felony, or working at an illegal job
• Participation in Aggressive Conflict: − War (declared or undeclared) or military conflicts;
-In Florida: War does not include acts of terrorism -In Oklahoma: War, or act of war, declared or undeclared when serving in the military service or an auxiliary unit thereto
− Insurrection or riot − Civil commotion or civil state of belligerence
• Illegal Substance Abuse: − Abuse of legally-obtained prescription medication − Illegal use of non-prescription drugs
CHILDHOOD CONDITIONS RIDER
CYSTIC FIBROSIS 50%
CEREBRAL PALSY 50%
CLEFT LIP OR CLEFT PALATE 50%
DOWN SYNDROME 50%
PHENYLALANINE HYDROXYLASE DEFICIENCY DISEASE (PKU) 50%
SPINA BIFIDA 50%
TYPE 1 DIABETES 50%
One Time Benefit Amount
AUTISM SPECTRUM DISORDER (ASD) $3,000
Benefits are payable if a dependent child is diagnosed with one of the conditions listed.
− In Arizona: Being intoxicated or under the influence of any narcotic unless administered on the advice of a physician
− In Michigan, Nevada, and South Dakota: this exclusion does not apply
Diagnosis, treatment, testing, and confinement must be in the United States or its territories. All benefits under the plan, including benefits for diagnoses, treatment, confinement and covered tests, are payable only while coverage is in force.
TERMS YOU NEED TO KNOW
Bone Marrow Transplant (Stem Cell Transplant) means a procedure to replace damaged or destroyed bone marrow with healthy bone marrow stem cells. For a benefit to be payable, a Bone Marrow Transplant (Stem Cell Transplant) must be caused by at least one of the following diseases:
• Aplastic anemia • Congenital neutropenia • Severe immunodeficiency syndromes • Sickle cell anemia • Thalassemia
• Fanconi anemia • Leukemia • Lymphoma • Multiple myeloma
The Bone Marrow Transplant (Stem Cell Transplant) benefit is not payable if the transplant results from a covered critical illness for which a benefit has been paid under this plan.
Cancer (internal or invasive) is a disease that meets either of the following definitions:A malignant tumor characterized by:
• The uncontrolled growth and spread of malignant cells, and • The invasion of distant tissue.
A disease meeting the diagnostic criteria of malignancy, as established by the American Board of Pathology. A pathologist must have examined and provided a report on the histocytologic architecture or pattern of the tumor, tissue, or specimen.Cancer (internal or invasive) also includes:
• Melanoma that is Clark’s Level III or higher or Breslow depth equal to or greater than 0.77mm,
• Myelodysplastic syndrome – RCMD (refractory cytopenia with multilineage dysplasia),
• Myelodysplastic syndrome – RAEB
(refractory anemia with excess blasts), • Myelodysplastic syndrome – RAEB-T
(refractory anemia with excess blasts in transformation), or
• Myelodysplastic syndrome – CMML (chronic myelomonocytic leukemia).
The following are not considered internal or invasive cancers:
• Pre-malignant tumors or polyps • Carcinomas in Situ • Any superficial, non-invasive skin
cancers including basal cell and squamous cell carcinoma of the skin
• Melanoma in Situ
• Melanoma that is diagnosed as − Clark’s Level I or II, − Breslow depth less than 0.77mm, or − Stage 1A melanomas under TNM
Staging
Non-Invasive Cancer is a cancer that is in the natural or normal place, confined to the site of origin without having invaded neighboring tissue.
For the purposes of the plan, a Non-Invasive Cancer is: • Internal Carcinoma in Situ • Myelodysplastic Syndrome – RA
(refractory anemia)
• Myelodysplastic Syndrome – RARS (refractory anemia with ring sideroblasts)
Skin Cancer, as defined in this plan, is not payable under the Non-Invasive Cancer Benefit.
Skin Cancer is a cancer that forms in the tissues of the skin. The following are considered skin cancers:
• Basal cell carcinoma • Squamous cell carcinoma of the skin • Melanoma in Situ
• Melanoma that is diagnosed as
− Clark’s Level I or II, − Breslow depth less than 0.77mm,
or − Stage 1A melanomas under TNM
Staging
These conditions are not payable under the Cancer (internal or invasive) Benefit.
Cancer, non-invasive cancer, or skin cancer must be diagnosed in one of two ways:1. Pathological Diagnosis is a diagnosis based on a microscopic study of fixed tissue or
preparations from the hemic (blood) system. This diagnosis must be made by a certi-fied pathologist and conform to the American Board of Pathology standards.
2. Clinical Diagnosis is based only on the study of symptoms. A clinical diagnosis will be accepted only if:
− A doctor cannot make a pathological diagnosis because it is medically inappropriate or life-threatening,
− Medical evidence exists to support the diagnosis, and
− A doctor is treating you for cancer or carcinoma in situComplete Remission is defined as having no symptoms and no signs that can be identified to indicate the presence of cancer.
Civil Union: In Washington DC, Civil Union is defined as a relationship similar to marriage that is recognized by law. In Illinois, a Civil Union is defined as a legal relationship between two persons, of either the same or opposite sex, established pursuant to the Illinois Religious Freedom Protection and Civil Union Act.
Severe Burn or Severely Burned means a burn resulting from fire, heat, caustics, electricity, or radiation. The burn must:
• Be a full-thickness or third-degree burn, as determined by a doctor. A Full-Thickness Burn or Third-Degree Burn is the destruction of the skin through the entire thickness or depth of the dermis (or possibly into underlying tissues). This results in loss of fluid and sometimes shock.
• Cause cosmetic disfigurement to the body’s surface area of at least 35 square inches.
• Be caused solely by or be solely attributed to a covered accident.Coma means a state of continuous, profound unconsciousness, lasting at least seven consecutive days, and characterized by the absence of:
• Spontaneous eye movements, • Response to painful stimuli, and • Vocalization.
Coma does not include a medically-induced coma.
To be payable as an Accident benefit, the coma must be caused solely by or be solely attributed to a covered accident.
To be considered a critical illness, the coma must be caused solely by or be solely attributed to one of the following diseases:
• Brain Aneurysm • Diabetes • Encephalitis • Epilepsy • Hyperglycemia • Hypoglycemia • Meningitis Civil Union: In Washington
DC, Civil Union is defined as a relationship similar to marriage that is recognized by law. In Illinois, a Civil Union is defined as a legal relationship between two persons, of either the same or opposite sex, established pursuant to the Illinois Religious Freedom Protection and Civil Union Act.
Paralysis or Paralyzed means the permanent, total, and irreversible loss of muscle function to the whole of at least two limbs. To be payable as an Accident benefit, the paralysis must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, paralysis must be caused solely by or be solely attributed to one or more ofthe following diseases:
• Amyotrophic lateral sclerosis • Cerebral palsy
• Parkinson’s disease, • Poliomyelitis
The diagnosis of paralysis must be supported by neurological evidence.Loss of Sight means the total and irreversible loss of all sight in both eyes. To be payable as an Accident benefit, loss of sight must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, loss of sight must be caused solely by or be solely attributed to one of the following diseases:
• Retinal disease • Optic nerve disease • Hypoxia
Loss of Speech means the total and permanent loss of the ability to speak. To be payable as an Accident benefit, loss of speech must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, loss of speech must be caused solely by or be solely attributable to one of the following diseases:
• Alzheimer’s disease • Arteriovenous malformation
Loss of Hearing means the total and irreversible loss of hearing in both ears. Loss of hearing does not include hearing loss that can be corrected by the use of a hearing aid or device. To be payable as an Accident benefit, loss of hearing must be caused solely by or
be solely attributed to a covered accident.To be considered a critical illness, loss of hearing must be caused solely by or be solely attributed to one of the following diseases:
• Alport syndrome • Autoimmune inner ear disease • Chicken pox • Diabetes
• Goldenhar syndrome • Meniere’s disease • Meningitis • Mumps
Coronary Artery Bypass Surgery means open heart surgery to correct the narrowing or blockage of one or more coronary arteries with bypass grafts and where such narrowing or blockage is attributed to coronary artery disease or acute coronary syndrome. This excludes any non-surgical procedure, such as, but not limited to, balloon angioplasty, laser relief, or stents.
Critical Illness is a disease or a sickness as defined in the plan that first manifests while your coverage is in force. In Illinois, critical illness is a sickness or disease that began while the insured’s coverage is in force. In South Dakota, critical illness is a disease or a sickness that manifests while your coverage is in force.
Date of Diagnosis is defined as follows: • Bone Marrow Transplant (Stem Cell
Transplant): The date the surgery occurs.
• Cancer: The day tissue specimens, blood samples, or titer(s) are taken (diagnosis of cancer and/or carcinoma in situ is based on such specimens).
• Coma: The first day of the period for which a doctor confirms a coma that is due to one of the underlying diseases and that has lasted for at least seven consecutive days.
• Coronary Artery Bypass Surgery: The date the surgery occurs.
• Heart Attack (Myocardial Infarction): The date the infarction (death) of a portion of the heart muscle occurs. This is based on the criteria listed under the heart attack (myocardial Infarction) definition.
• Kidney Failure (End-Stage Renal Failure): The date a doctor recommends that an insured begin renal dialysis.
• Loss of Sight, Speech, or Hearing: The date the loss due to one of the underlying diseases is objectively determined by a doctor to be total and
irreversible. Major Organ Transplant: The date the surgery occurs.
• Non-Invasive Cancer: The day tissue specimens, blood samples, or titer(s) are taken (diagnosis of cancer and/or carcinoma in situ is based on such specimens).
• Paralysis: The date a doctor diagnoses an insured with paralysis due to one of the underlying diseases as specified in this plan, where such diagnosis is based on clinical and/or laboratory findings as supported by the insured’s medical records.
• Severe Burn: The date the burn takes place.
• Skin Cancer: The date the skin biopsy samples are taken for microscopic examination.
• Stroke: The date the stroke occurs (based on documented neurological deficits and neuroimaging studies).
• Sudden Cardiac Arrest: The date the pumping action of the heart fails (based on the sudden cardiac arrest definition)..
Dependent means your spouse or your dependent child. Spouse is your legal wife or husband, (In Delaware, Illinois, Nevada, Oregon, or Washington DC - or a person who is in a legally recognized domestic partnership, civil union, or similar relationship with you), who is listed on your application. Dependent children are your or your spouse’s natural children, step-children, legally adopted children, or children placed for adoption, who are younger than age 26 (in Indiana, this includes children subject to legal guardianship). Newborn children are automatically covered from the moment of birth.
There is an exception to the age-26 limit listed above. This limit will not apply to any dependent child who is incapable of self-sustaining employment due to mental or physical handicap and is dependent (in Arkansas, chiefly dependent) on a parent for support. The employee or the employee’s spouse must furnish proof of this incapacity and dependency to the company within 31 days (in Indiana, 120 days) following the dependent child’s 26th birthday.
• In South Dakota, this limit will not apply to any child who is incapable of self-sustaining employment and is chiefly dependent upon the insured for support and maintenance.
• In Texas, this limit will not apply to any dependent child who is incapable of self-sustaining employment due to mental or physical handicap and is dependent on a parent for support and maintenance. Dependent Children may also include grandchildren, who are unmarried, under age 26, and if they are your dependents for federal income tax purposes, or if you must provide medical support under an order issued under Chapter 154, Family Code, or enforceable by a court in this state.
• In New Mexico, coverage may be provided for the children of custodial and non-custodial parents.
• In Illinois, coverage of an unmarried dependent child who is under age 30 and who served in the military will not terminate if he/she is an Illinois resident, served as a member of the active or reserve components of any United States Armed
Forces branch, and has received a release or discharge (other than a dishonorable discharge). To be eligible for coverage, the eligible dependent must submit to us a form approved by the Illinois Department of Veterans’ Affairs stating the date on which the dependent was released from service.
• In Louisiana, dependent children must be unmarried and may also include grandchildren who are in the legal custody of and residing with a grandparent. Regarding the Age 26 limit exception - we will not require proof of incapacity and dependency more frequently than annually after the two-year period following the child’s attainment of the limiting age.
Diagnosis (Diagnosed) refers to the definitive and certain identification of an illness or disease that:
• Is made by a doctor and • Is based on clinical or laboratory investigations, as supported by your medical records.
Doctor is a person who is: • Legally qualified to practice medicine, • Licensed as a doctor by the state where
treatment is received, and • Licensed to treat the type of condition
for which a claim is made. • In Montana, for purposes of treatment,
you have full freedom of choice in the selection of any licensed physician,
physician assistant, dentist, osteopath, chiropractor, optometrist, podiatrist, licensed social worker, psychologist, licensed professional counselor, acupuncturist, naturopathic physician, physical therapist, or advanced practice registered nurse.
• In New Mexico, a doctor is also a practitioner of the healing arts.
A doctor does not include you or any of your family members. • In South Dakota, a doctor who is your family member may treat you if that doctor is
the only doctor in the area and acts within the scope of his or her practice.For the purposes of this definition, family member includes your spouse as well as the following members of your immediate family:
• Son • Daughter • Mother
• Father • Sister • Brother
This includes step-family members and family-members-in-law.
Domestic Partner: • In Washington DC, Domestic Partner is an unmarried same or opposite sex adult who
resides with you and has registered in a state or local domestic partner registry with you.
• In Nevada, Domestic Partner is defined as a person who is party to a valid domestic partnership, has not terminated that domestic partnership, and meets the requisites for a valid domestic partnership. In order to enter into a valid domestic partnership, it is necessary that the two persons register with the state of Nevada when it is established, by having previously furnished proof to the state of Nevada, that both persons have a common residence, neither person is married or a member of another domestic partnership, the two persons are not related by blood in a way that would prevent them from being married to each other in the state of Nevada, both persons are at least 18 years of age, and both persons are competent to consent to the domestic partnership.
Employee is a person who meets eligibility requirements and who is covered under the plan. The employee is the primary insured under the plan.Heart Attack (Myocardial Infarction) is the death of a portion of the heart muscle (myocardium) caused by a blockage of one or more coronary arteries due to coronary artery disease or acute coronary syndrome.
Heart Attack (Myocardial Infarction) does not include: • Any other disease or injury involving the
cardiovascular system. • Cardiac arrest not caused by a heart
attack (myocardial infarction).Diagnosis of a Heart Attack (Myocardial Infarction) must include the following:
• New and serial electrocardiographic (ECG) findings consistent with heart attack (myocardial infarction), and
• Elevation of cardiac enzymes above
generally accepted laboratory levels of normal. (In the case of creatine physphokinase (CPK) a CPK-MB measurement must be used.)
Confirmatory imaging studies, such as thallium scans, MUGA scans, or stress echocardiograms may also be used.
Kidney Failure (End-Stage Renal Failure) means end-stage renal failure caused by end-stage renal disease, which results in the chronic, irreversible failure of both kidneys to function.
Kidney Failure (End-Stage Renal Failure) is covered only under the following conditions: • A doctor advises that regular renal
dialysis, hemo-dialysis, or peritoneal dialysis (at least weekly) is necessary to
treat the kidney failure (end-stage renal failure); or
• The kidney failure (end-stage renal
failure) results in kidney transplantation.Maintenance Drug Therapy is a course of systemic medication given to a patient after a cancer goes into complete remission because of primary treatment. Maintenance Drug Therapy includes ongoing hormonal therapy, immunotherapy, or chemo-prevention therapy. Maintenance Drug Therapy is meant to decrease the risk of cancer recurrence; it is not meant to treat a cancer that is still present.
Major Organ Transplant means undergoing surgery as a recipient of a covered transplant of a human heart, lung, liver, kidney, or pancreas. A transplant must be caused by one or more of the following diseases:
• Bronchiectasis • Cardiomyopathy • Cirrhosis • Chronic obstructive pulmonary disease • Congenital Heart Disease • Coronary Artery Disease • Cystic fibrosis • Hepatitis
• Interstitial lung disease • Lymphangioleiomyomatosis. • Polycystic liver disease • Pulmonary fibrosis • Pulmonary hypertension • Sarcoidosis • Valvular heart disease
A Major Organ Transplant benefit is not payable if the major organ transplant results from a covered critical illness for which a benefit has been paid.
Party to a Civil Union: In Illinois, a person who has established a civil union pursuant to the Illinois Religious Freedom Protection and Civil Union Act.
Pathologist is a doctor who is licensed: • To practice medicine, and • By the American Board of Pathology to
practice pathologic anatomy.
A Pathologist also includes an Osteopathic Pathologist who is certified by the Osteopathic Board of Pathology.
Signs and/or symptoms are the evidence of disease or physical disturbance observed by a doctor or other medical professional. The doctor (or other medical professional) must observe these signs while acting within the scope of his license.
Stroke means apoplexy due to rupture or acute occlusion of a cerebral artery. The apoplexy must cause complete or partial loss of function involving the motion or sensation of a part of the body and must last more than 24 hours. Stroke must be either:
• Ischemic: Due to advanced arteriosclerosis or arteriosclerosis of the arteries of the neck or brain, or vascular embolism, or
• Hemorrhagic: Due to uncontrolled hypertension, malignant hypertension, brain aneurysm, or arteriovenous malformation.
The stroke must be positively diagnosed by a doctor based upon documented neurological deficits and confirmatory neuroimaging studies.
Stroke does not include: • Transient Ischemic Attacks (TIAs) • Head injury • Chronic cerebrovascular insufficiency
• Reversible ischemic neurological deficits unless brain tissue damage is confirmed by neurological imaging
Stroke will be covered only if the Insured submits evidence of the neurological damage by providing:
• Computed Axial Tomography (CAT scan) images, or
• Magnetic Resonance Imaging (MRI).
Sudden Cardiac Arrest is the sudden, unexpected loss of heart function in which the heart, abruptly and without warning, stops working as a result of an internal electrical system heart malfunction due to coronary artery disease, cardiomyopathy, or hypertension.
Sudden Cardiac Arrest is not a heart attack (myocardial infarction). A sudden cardiac arrest benefit is not payable if the sudden cardiac arrest is caused by or contributed to by a heart attack (myocardial infarction).
Total Disability or Totally Disabled means you are: • Not working at any job for pay or benefits, • Under the care of a doctor for the treatment of a covered critical illness, and • Unable to Work, which means either:
− During the first 365 days of total disability, you are unable to work at the occupation you were performing when your total disability began; or
− After the first 365 days of total disability, you are unable to work at any gainful occupation for which you are suited by education, training, or experience.
− In Ohio, Unable to Work is defined as the inability to perform duties of any gainful occupation for which you are reasonably fitted by training, experience, and accomplishment.
Treatment or Medical Treatment is the consultation, care, or services provided by a doctor. This includes receiving any diagnostic measures and taking prescribed drugs and medicines.
Treatment-Free From Cancer refers to the period of time without the consultation, care, or services provided by a doctor. This includes receiving diagnostic measures and taking prescribed drugs and medicines. Treatment does not include maintenance drug therapy or routine follow-up visits to verify whether cancer or carcinoma in situ has returned.
In Montana, Consultation is not considered treatment or medical treatment.
OPTIONAL BENEFITS RIDERDate of Diagnosis is defined as follows:
• Advanced Alzheimer’s Disease: The date a doctor diagnoses the insured as incapacitated due to Alzheimer’s disease.
• Advanced Parkinson’s Disease: The date a doctor diagnoses the insured as incapacitated due to Parkinson’s disease.
• Benign Brain Tumor: The date a doctor determines a benign brain tumor is present based on examination of tissue (biopsy or surgical excision) or specific neuroradiological examination.
Optional Benefit is one of the illnesses defined below and shown in the rider schedule: Advanced Alzheimer’s Disease means Alzheimer’s Disease that causes the insured to be incapacitated. Alzheimer’s Disease is a progressive degenerative disease of the brain that is diagnosed by a psychiatrist or neurologist as Alzheimer’s Disease. To be incapacitated due to Alzheimer’s Disease, the insured must:
• Exhibit the loss of intellectual capacity involving impairment of memory and judgment, resulting in a significant reduction in mental and social functioning, and
• Require substantial physical assistance from another adult to perform at least three ADLs.
Advanced Parkinson’s Disease means Parkinson’s Disease that causes the insured to be incapacitated. Parkinson’s Disease is a brain disorder that is diagnosed by a psychiatrist or neurologist as Parkinson’s Disease. To be incapacitated due to Parkinson’s Disease, the insured must:
• Exhibit at least two of the following clinical manifestations: - Muscle rigidity - Tremor - Bradykinesis (abnormal slowness of movement, sluggishness of physical and mental responses), and
• Require substantial physical assistance from another adult to perform at least three ADLs.
Benign Brain Tumor is a mass or growth of abnormal, noncancerous cells in the brain. The tumor is composed of similar cells that do not follow normal cell division and growth patterns and develop into a mass of cells that microscopically do not have the characteristic appearance of a Cancer. Benign Brain Tumor must be caused by Multiple Endocrine Neoplasia, Neurofibromatosis, or Von Hippel-Lindau Syndrome.
• Multiple Endocrine Neoplasia is a genetic disease in which one or more of the endocrine glands are overactive or form a tumor.
• Neurofibromatosis is a genetic disease in which the nerve tissue grows tumors that may be benign and may cause serious damage by compressing nerves and other tissue.
• Von Hippel-Lindau Syndrome is a genetic disease that predisposes a person to have benign or malignant tumors.
Activities of Daily Living (ADLs) are activities used in measuring levels of personal functioning capacity. These activities are normally performed without assistance, allowing personal independence in everyday living. For the purposes of this plan, ADLs include the following:
• Bathing – the ability to wash oneself in a tub, shower, or by sponge bath. This includes the ability to get into and out of the tub or shower with or without the assistance of equipment;
• Dressing – the ability to put on, take off, and secure all necessary and appropriate items of clothing and any necessary braces or artificial limbs;
• Toileting – the ability to get to and from the toilet, get on and off the toilet, and perform associated personal hygiene with or without the assistance of equipment;
• Transferring – the ability to move in and out of a bed, chair, or wheelchair with or without the assistance of equipment;
• Mobility – the ability to walk or wheel on a level surface from one room to another with or without the assistance of equipment;
• Eating – the ability to get nourishment into the body by any means once it has been prepared and made available with or without the assistance of equipment; and
• Continence – the ability to voluntarily maintain control of bowel and/or bladder function. In the event of incontinence, the ability to maintain a reasonable level of personal hygiene.
PROGRESSIVE DISEASE RIDERDate of Diagnosis is defined for each specified critical illness as follows:
• Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease): The date a Doctor Diagnoses an Insured as having ALS and where such Diagnosis is supported by medical records.
• Sustained Multiple Sclerosis: The date a Doctor Diagnoses an Insured as having Multiple Sclerosis and where such Diagnosis is supported by medical records.
• Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease) means a chronic, progressive motor neuron disease occurring when nerve cells in the brain and spinal cord that control voluntary movement degenerate, causing muscle weakness and atrophy, eventually leading to paralysis.
• Sustained Multiple Sclerosis means a chronic degenerative disease of the central nervous system in which gradual destruction of myelin occurs in the brain or spinal cord or both, interfering with the nerve pathways. Sustained Multiple Sclerosis results in one of the following symptoms for at least 90 consecutive days:
• Muscular weakness,
• Loss of coordination,
• Speech disturbances, or
• Visual disturbances.
CHILDHOOD CONDITIONS RIDERDate of Diagnosis is defined as follows:
• Autism Spectrum Disorder: The date a Doctor Diagnoses a Dependent Child as having Autism Spectrum Disorder and where such Diagnosis is supported by medical records.
• Cystic Fibrosis: The date a Doctor Diagnoses a Dependent Child as having Cystic Fibrosis and where such Diagnosis is supported by medical records.
• Cerebral Palsy: The date a Doctor Diagnoses a Dependent Child as having Cerebral Palsy and where such Diagnosis is supported by medical records.
• Cleft Lip or Cleft Palate: The date a Doctor Diagnoses a Dependent Child as having Cleft Lip or Cleft Palate and where such Diagnosis is supported by medical records.
• Down Syndrome: The date a Doctor Diagnoses a Dependent Child as having Down Syndrome and where such Diagnosis is supported by medical records.
• Phenylalanine Hydroxylase Deficiency Disease (PKU): The date a Doctor Diagnoses a Dependent Child as having PKU and where such Diagnosis is supported by medical records.
• Spina Bifida: The date a Doctor Diagnoses a Dependent Child as having Spina Bifida and where such Diagnosis is supported by medical records.
• Type I Diabetes: The date a Doctor Diagnoses a Dependent Child as having Type I Diabetes and where such Diagnosis is supported by medical records.
Autism Spectrum Disorder is a biological based neurodevelopment disorder characterized by impairment in two major domains:
• Deficits in social communication and interaction; and
• Restricted repetitive patterns of behavior, interests, and activities.
A Doctor must Diagnose Autism Spectrum Disorder based on DSM-V diagnostic criteria. The Diagnosis must include the DSM-V severity level specifier for both major domains listed above.
Cystic Fibrosis is a hereditary chronic disease of the exocrine glands. This disease is characterized by the production of viscid mucus that obstructs the pancreatic ducts and bronchi, leading to infection and fibrosis.
Cerebral Palsy is a disorder of movement, muscle tone, or posture that is caused by injury or abnormal development in the immature brain. Cerebral Palsy can be characterized by stiffness and movement difficulties, involuntary and uncontrolled movements, or disturbed sensation.
• Spastic Cerebral Palsy is characterized by stiffness and movement difficulties.
• Athetoid Cerebral Palsy is characterized by involuntary and uncontrolled movements.
• Ataxic Cerebral Palsy is characterized by a disturbed sense of balance and depth perception.
Cleft Lip occurs when there is an opening (one or two vertical fissures) in the lip. A Cleft Palate occurs when the two sides of a palate do not join, resulting in an opening in the roof of the mouth or soft tissue in the back of the mouth. Sometimes, an opening in the bones of the upper jaw or upper gum accompanies a Cleft Palate.
A Cleft Lip or Palate can occur on one or both sides of the face. If a Dependent Child has both a Cleft Lip and Cleft Palate or has one on each side of the face, we will pay this benefit only once.
Down Syndrome is a chromosomal condition characterized by the presence of an extra
copy of genetic material on the 21st chromosome, either in whole or part.
Phenylalanine Hydroxylase Deficiency Disease (PKU) is an autosomal recessive metabolic genetic disorder characterized by homozygous or compound heterozygous mutations in the gene for the hepatic enzyme phenylalanine hydroxylase (PAH), rendering it nonfunctional. A Doctor must Diagnose this disease based on a PKU test.
Spina Bifida refers to any birth defect involving incomplete closure of the spinal canal or spine. This includes:
• Spina Bifida Cystica, which is a condition where a cyst protrudes through the defect in the vertebral arch.
• Spina Bifida Occulta, which is a condition where the bones of the spine do not close, but the spinal cord and meninges remain in place. Skin usually covers the defect.
• Meningoceles, which is a condition where the tissue covering the spinal cord sticks out of the spinal defect, but the spinal cord remains in place.
• Myelomeningocele, which is a condition where the un-fused portion of the spinal column allows the spinal cord to protrude through an opening. The meningeal membranes that cover the spinal cord form a sac enclosing the spinal elements.
Type I Diabetes means a form of diabetes mellitus causing total insulin deficiency of a Dependent Child along with continuous dependence on exogenous insulin in order to maintain life. A Doctor must Diagnose Type I Diabetes based on one of the following diagnostic tests:
• Glycated hemoglobin (A1C) test
• Random blood sugar test
• Fasting blood sugar test
SPECIFIED DISEASE RIDERDate of Diagnosis is defined for each Specified Disease as follows:
• Adrenal Hypofunction (Addison’s Disease): The date a Doctor Diagnoses an Insured as having Adrenal Hypofunction and where such Diagnosis is supported by medical records.
• Cerebrospinal Meningitis: The date a Doctor Diagnoses an Insured as having Cerebrospinal Meningitis and where such Diagnosis is supported by medical records.
• Diphtheria: The date a Doctor Diagnoses an Insured as having Diphtheria based on clinical and/or laboratory findings as supported by medical records.
• Huntington’s Chorea: The date a Doctor Diagnoses an Insured as having Huntington’s Chorea based on clinical findings as supported by medical records.
• Legionnaire’s Disease: The date a Doctor Diagnoses an Insured as having Legionnaire’s Disease by finding Legionella bacteria in a clinical specimen taken from the Insured.
• Malaria: The date a Doctor Diagnoses an Insured as having Malaria and where such Diagnosis is supported by medical records.
• Muscular Dystrophy: The date a Doctor Diagnoses an Insured as having Muscular Dystrophy and where such Diagnosis is supported by medical records.
• Myasthenia Gravis: The date a Doctor Diagnoses an Insured as having Myasthenia Gravis and where such Diagnosis is supported by medical records.
• Necrotizing Fasciitis: The date a Doctor Diagnoses an Insured as having Necrotizing Fasciitis and where such Diagnosis is supported by medical records.
• Osteomyelitis: The date a Doctor Diagnoses an Insured as having Osteomyelitis and where such Diagnosis is supported by medical records.
• Poliomyelitis: The date a Doctor Diagnoses an Insured as having Poliomyelitis and where such Diagnosis is supported by medical records.
• Rabies: The date a Doctor Diagnoses an Insured as having Rabies and where such Diagnosis is supported by medical records.
• Sickle Cell Anemia: The date a Doctor Diagnoses an Insured as having Sickle Cell Anemia and where such Diagnosis is supported by medical records.
• Systemic Lupus: The date a Doctor Diagnoses an Insured as having Systemic Lupus and where such Diagnosis is supported by medical records.
• Systemic Sclerosis (Scleroderma): The date a Doctor Diagnoses an Insured as having Systemic Sclerosis and where such Diagnosis is supported by medical records.
• Tetanus: The date a Doctor Diagnoses an Insured as having Tetanus by finding Clostridium tetani bacteria in a clinical specimen taken from the Insured.
• Tuberculosis: The date a Doctor Diagnoses an Insured as having Tuberculosis by finding Mycobacterium tuberculosis bacteria in a clinical specimen taken from the Insured.
Adrenal Hypofunction (Addison’s Disease) means a disease occurring when the body’s adrenal glands do not produce sufficient steroid hormones.
Adrenal Hypofunction does not include secondary and tertiary adrenal insufficiency.
Cerebrospinal Meningitis means a disease resulting in the inflammation of the meninges of both the brain and spinal cord caused by infection from viruses, bacteria, or other microorganisms or from Cancer.
Diphtheria means an infectious disease caused by the bacterium Corynebacterium diphtheriae and characterized by the production of a systemic toxin and the formation of a false membrane lining of the mucous membrane of the throat and other respiratory passages, causing difficulty in breathing, high fever, and/or weakness.
Diphtheria can be Diagnosed either through laboratory tests that confirm Diphtheria through a culture obtained from the infected area or through clinical observation of visible symptoms.
Huntington’s Chorea means a hereditary disease characterized by gradual loss of brain function and voluntary movement due to degenerative changes in the cerebral cortex and basal ganglia.
Legionnaire’s Disease means an infectious lung disease caused by species of the aerobic bacteria belonging to the genus Legionella.
Malaria means an infectious disease characterized by cycles of chills, fever, and sweating, caused by the bite of an anopheles mosquito infected with a protozoan of the genus Plasmodium.
Muscular Dystrophy means a genetic disease that causes progressive weakness and degeneration in the musculoskeletal system and where such muscles are replaced by scar tissue and fat. Muscular Dystrophy is characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissues.
Myasthenia Gravis means a disease characterized by progressive weakness and exhaustibility of voluntary muscles without atrophy or sensory disturbance and caused by an autoimmune attack on acetylcholine receptors at the neuromuscular junction.
Necrotizing Fasciitis means a severe soft tissue infection by bacteria that is marked by edema and necrosis of subcutaneous tissues with involvement of adjacent fascia and by
painful red swollen skin over the affected areas.
Osteomyelitis means an infectious inflammatory disease of the bone that typically results from a bacterial infection and may result in the death of bone tissue.
Poliomyelitis (Polio) means an acute infectious disease caused by the poliovirus and characterized by fever, motor paralysis, and atrophy of skeletal muscles. It often results in permanent disability and deformity, and marked by inflammation of nerve cells in the anterior gray matter in each lateral half of the spinal cord.
Rabies means an acute viral disease of the nervous system caused by a rhabdovirus, which is usually transmitted through the bite of a rabid animal. It is typically characterized by increased salivation, abnormal behavior, and eventual paralysis.
Sickle Cell Anemia means a hereditary disease caused by a genetic blood disorder. It is characterized by red blood cells that assume an abnormal, rigid, sickle shape due to a mutation on the hemoglobin gene.
Systemic Lupus means an autoimmune disease where the body’s immune system attacks healthy tissue, leading to long-term inflammation. This disease is primarily characterized by joint pain and swelling.
Systemic Sclerosis (Scleroderma) means a progressive autoimmune disease characterized by the hardening and tightening of the skin and connective tissues.
Tetanus means a disease marked by rigidity and spasms of the voluntary muscles, caused by the bacterium Clostridium tetani.
Tuberculosis means an infectious disease caused by Mycobacterium tuberculosis bacteria. It is characterized by the growth of nodules in the bodily tissues, as well as by fever, cough, difficulty breathing, caseation, pleural effusions, and fibrosis.
YOU MAY CONTINUE YOUR COVERAGEYour coverage may be continued with certain stipulations. See certificate for details.
TERMINATION OF COVERAGEYour insurance may terminate when the plan is terminated; the 31st day after the premium due date if the premium has not been paid; or the date you no longer belong to an eligible class. If your coverage terminates, we will provide benefits for valid claims that arose while your coverage was in force.
NOTICES
If this coverage will replace any existing individual policy, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy.
Notice to Consumer: The coverages provided by Continental American Insurance Company (CAIC) represent supplemental benefits only. They do not constitute comprehensive health insurance coverage and do not satisfy the requirement of minimum essential coverage under the Affordable Care Act. CAIC coverage is not intended to replace or be issued in lieu of major medical coverage. It is designed to supplement a major medical program.
Group Benefits PLAN-59888
RATES TABLE FOR: ELGIN ISD - GP-10984 / GROUP CRITICAL ILLNESS - PLAN-59888
DEDUCTION FREQUENCY : Semimonthly (24pp / yr)
Employee - Non-Tobacco
$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000
18-29 $2.62 $3.77 $4.93 $6.08 $7.24 $8.39 $9.55 $10.70 $11.86 $13.01
30-39 $3.25 $5.05 $6.84 $8.64 $10.43 $12.23 $14.02 $15.81 $17.61 $19.40
40-49 $4.83 $8.19 $11.56 $14.92 $18.29 $21.65 $25.02 $28.38 $31.75 $35.11
50-59 $7.89 $14.32 $20.75 $27.18 $33.61 $40.04 $46.47 $52.90 $59.33 $65.76
60+ $13.65 $25.84 $38.04 $50.23 $62.42 $74.61 $86.80 $99.00 $111.19 $123.38
Employee - Tobacco
$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000
18-29 $3.03 $4.60 $6.16 $7.73 $9.30 $10.87 $12.43 $14.00 $15.57 $17.14
30-39 $4.18 $6.90 $9.62 $12.34 $15.06 $17.78 $20.50 $23.22 $25.95 $28.67
40-49 $6.67 $11.88 $17.10 $22.31 $27.52 $32.73 $37.94 $43.16 $48.37 $53.58
50-59 $11.75 $22.05 $32.34 $42.64 $52.93 $63.23 $73.52 $83.82 $94.11 $104.40
60+ $20.41 $39.35 $58.30 $77.25 $96.19 $115.14 $134.09 $153.03 $171.98 $190.93
Spouse - Non-Tobacco
$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000
18-29 $2.48 $3.49 $4.51 $5.53 $6.54 $7.56 $8.58 $9.59 $10.61 $11.63
30-39 $3.12 $4.77 $6.43 $8.08 $9.74 $11.39 $13.05 $14.70 $16.36 $18.01
40-49 $4.69 $7.91 $11.14 $14.37 $17.59 $20.82 $24.05 $27.27 $30.50 $33.72
50-59 $7.75 $14.04 $20.33 $26.63 $32.92 $39.21 $45.50 $51.79 $58.08 $64.37
60+ $13.51 $25.57 $37.62 $49.67 $61.73 $73.78 $85.83 $97.89 $109.94 $121.99
Spouse - Tobacco
$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000
18-29 $2.89 $4.32 $5.75 $7.17 $8.60 $10.03 $11.46 $12.89 $14.32 $15.75
30-39 $4.04 $6.62 $9.20 $11.79 $14.37 $16.95 $19.53 $22.11 $24.69 $27.28
40-49 $6.53 $11.61 $16.68 $21.75 $26.83 $31.90 $36.97 $42.04 $47.12 $52.19
50-59 $11.62 $21.77 $31.93 $42.08 $52.24 $62.39 $72.55 $82.70 $92.86 $103.02
60+ $20.27 $39.08 $57.88 $76.69 $95.50 $114.31 $133.11 $151.92 $170.73 $189.54
IV (4/19)AGC1901055
Aflac Group Hospital Indemnity INSURANCE
Even a small trip to the hospital can have a major impact on your finances.
Here’s a way to help make your visit a little more affordable.
The plan that can help with expenses and protect your savings.
Does your major medical insurance cover all of your bills?
Even a minor trip to the hospital can present you with unexpected expenses and medical bills. And even with major medical insurance, your plan may only pay a portion of your entire stay.
That’s how the Aflac Group Hospital Indemnity plan can help.
It provides financial assistance to enhance your current coverage. So you may be able to avoid dipping into savings or having to borrow to address out-of-pocket-expenses major medical insurance was never intended to cover. Like transportation and meals for family members, help with child care, or time away from work, for instance.
The Aflac Group Hospital Indemnity plan benefits include the following:
• Hospital Confinement Benefit
• Hospital Admission Benefit
• Hospital Intensive Care Benefit
• Successor Insured Benefit
AFLAC GROUP HOSPITAL INDEMNITY HIG
Policy Series C80000
How it works
The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions.
The Aflac Group
Hospital Indemnity High plan is
selected.
The insured has a high fever and
goes to the emergency
room.
The physician admits the insured into the hospital.
The insured is released after two
days.
The Aflac Group Hospital Indemnity High plan pays
$2,400 Amount payable was generated based on benefit amounts for: Hospital Admission ($2,000), and Hospital Confinement ($200 per day).
Benefits OverviewHIGH MID
HOSPITAL ADMISSION BENEFIT per confinement (once per covered sickness or accident per calendar year for each insured)Payable when an insured is admitted to a hospital and confined as an in-patient because of a covered accidental injury or covered sickness. We will not pay benefits for confinement to an observation unit, or for emergency room treatment or outpatient treatment.
$2,000 $1,000
HOSPITAL CONFINEMENT per day (maximum of 31 days per confinement for each covered sickness or accident for each insured)Payable for each day that an insured is confined to a hospital as an in-patient as the result of a covered accidental injury or covered sickness. If we pay benefits for confinement and the insured becomes confined again within six months because of the same or related condition, we will treat this confinement as the same period of confinement. This benefit is payable for only one hospital confinement at a time even if caused by more than one covered accidental injury, more than one covered sickness, or a covered accidental injury and a covered sickness.
$200 $150
HOSPITAL INTENSIVE CARE BENEFIT per day (maximum of 10 days per confinement for each covered sickness or accident for each insured) Payable for each day when an insured is confined in a Hospital Intensive Care Unit because of a covered accidental injury or covered sickness. We will pay benefits for only one confinement in a Hospital's Intensive Care Unit at a time. Once benefits are paid, if an insured becomes confined to a Hospital's Intensive Care Unit again within six months because of the same or related condition, we will treat this confinement as the same period of confinement.
This benefit is payable in addition to the Hospital Confinement Benefit.
$400 $300
LIMITATIONS AND EXCLUSIONSEXCLUSIONS (in Montana: LIMITATIONS)We will not pay for loss due to:
• War – voluntarily participating in war, any act of war, or military conflicts, declared or undeclared, or voluntarily participating or serving in the military, armed forces, or an auxiliary unit thereto, or contracting with any country or international authority. (We will return the prorated premium for any period not covered by the certificate when the insured is in such service.) War also includes voluntary participation in an insurrection, riot, civil commotion or civil state of belligerence. War does not include acts of terrorism (except in Illinois).
− In Connecticut: a riot is not excluded. − In Oklahoma: War, or any act of war, declared or undeclared, when serving in the
military, armed forces, or an auxiliary unit thereto. (We will return the prorated premium for any period not covered by the certificate when the insured is in such service.) War does not include acts of terrorism.
• Suicide – committing or attempting to commit suicide, while sane or insane. − In Missouri, Montana, and Vermont: committing or attempting to commit suicide,
while sane. − In Minnesota: this exclusion does not apply.
• Self-Inflicted Injuries – injuring or attempting to injure oneself intentionally. − In Missouri: injuring or attempting to injure oneself intentionally which is
obviously not an attempted suicide. − In Vermont: injuring or attempting to injure oneself intentionally, while sane.
• Racing – riding in or driving any motor-driven vehicle in a race, stunt show or speed test in a professional or semi-professional capacity.
• Illegal Occupation – voluntarily participating in, committing, or attempting to commit
a felony or illegal act or activity, or voluntarily working at, or being engaged in, an illegal occupation or job.
− In Connecticut: voluntarily participating in, committing, or attempting to commit a felony.
− In Illinois: committing or attempting to commit a felony or being engaged in an illegal occupation.
− In Nebraska and Tennessee: voluntarily participating in, committing, or attempting to commit a felony or voluntarily working at, or being engaged in, an illegal occupation or job.
− In Pennsylvania: committing or attempting to commit a felony, or being engaged in an illegal occupation.
− In South Dakota: voluntarily committing a felony. • Sports – participating in any organized sport in a professional or semi-professional
capacity. • Custodial Care – this is non-medical care that helps individuals with the basic tasks
of everyday life, the preparation of special diets, and the self-administration of medication which does not require the constant attention of medical personnel.
• Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including any resulting complications.
• Services performed by a family member. − In South Dakota: this exclusion does not apply.
• Services related to sex or gender change, sterilization, in vitro fertilization, vasectomy or reversal of a vasectomy, or tubal ligation.
− In Washington D.C. and Washington: Services related to sterilization, in vitro fertilization, vasectomy or reversal of a vasectomy, or tubal ligation.
SUCCESSOR INSURED BENEFITIf spouse coverage is in force at the time of the employee’s death, the surviving spouse may elect to continue coverage. Coverage would continue according to the existing plan and would also include any dependent child coverage in force at the time.
HIG
In order to receive benefits for accidental injuries due to a covered accident, an insured must be admitted within six months of the date of the covered accident (in Washington, twelve months).
Continental American Insurance Company (CAIC ), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands.
Continental American Insurance Company • Columbia, South Carolina
The certificate to which this sales material pertains may be written only in English; the certificate prevails if interpretation of this material varies. This brochure is a brief description of coverage and is not a contract. Benefits, terms, and conditions may vary by state.
This brochure is subject to the terms, conditions, and limitations of Policy Series C80000. In Texas, C80100TX.
• Elective Abortion – an abortion for any reason other than to preserve the life of the person upon whom the abortion is performed.
− In Tennessee, or if the pregnancy was the result of rape or incest, or if the fetus is non-viable.
• Dental Services or Treatment.
• Cosmetic Surgery, except when due to: − Reconstructive surgery, when the service is related to or follows surgery
resulting from a Covered Accidental Injury or a Covered Sickness, or is related to or results from a congenital disease or anomaly of a covered dependent child.
− Congenital defects in newborns.
TERMS YOU NEED TO KNOWA Covered Accident is an accident that occurs on or after an insured’s effective date while coverage is in force, and that is not specifically excluded by the plan.Dependent means your spouse or dependent children, as defined in the applicable rider, who have been accepted for coverage. Spouse is your legal wife, husband, or partner in a legally recognized union. Refer to your certificate for details. Dependent Children are your or your spouse’s natural children, step-children, grandchildren who are in your legal custody and residing with you, foster children, children subject to legal guardianship, legally adopted children, or children placed for adoption. Newborn children are automatically covered from the moment of birth for 60 days. Newly adopted children are automatically covered for 60 days also. See certificate for details. Dependent children must be younger than age 26 (and in Louisiana, unmarried), however this limit will not apply to any insured dependent child who is incapable of self-sustaining employment due to mental or physical handicap and is chiefly dependent on a parent for support and maintenance. Doctor is a person who is duly qualified as a practitioner of the healing arts acting within the scope of his license, and: is licensed to practice medicine; prescribe and administer drugs; or to perform surgery, or is a duly qualified medical practitioner according to the laws and regulations in the state in which treatment is made.In Montana: For purposes of treatment, the insured has full freedom of choice in the selection of any licensed physician, physician assistant, dentist, osteopath, chiropractor, optometrist, podiatrist, licensed social worker, psychologist, licensed professional counselor, acupuncturist, naturopathic physician, physical therapist, or advanced practice registered nurse.A Doctor does not include you or any of your Family Members. For the purposes of this definition, Family Member includes your spouse as well as the following members of your immediate family: son, daughter, mother, father, sister, or brother. In South Dakota, however, a doctor who is your family member may treat you if that doctor is the only
doctor in the area and acts within the scope of his or her practice.A Hospital is not a nursing home; an extended care facility; a skilled nursing facility; a rest home or home for the aged; a rehabilitation facility; a facility for the treatment of alcoholism or drug addiction (except in Vermont); an assisted living facility; or any facility not meeting the definition of a Hospital as defined in the certificate.A Hospital Intensive Care Unit is not any of the following step-down units: a progressive care unit; a sub-acute intensive care unit; an intermediate care unit; a private monitored room; a surgical recovery room; an observation unit; or any facility not meeting the definition of a Hospital Intensive Care Unit as defined in the certificateSickness means an illness, infection, disease, or any other abnormal physical condition or pregnancy that is not caused solely by, or the result of, any injury (In Maine, illness or disease of an insured). A Covered Sickness is one that is not excluded by name, specific description, or any other provision in this plan. For a benefit to be payable, loss arising from the covered sickness must occur while the applicable insured’s coverage is in force (except in Montana).Treatment is the consultation, care, or services provided by a doctor. This includes receiving any diagnostic measures and taking prescribed drugs and medicines. Treatment does not include telemedicine services (except in Kansas).You May Continue Your CoverageYour coverage may be continued with certain stipulations. See certificate for details.Termination of CoverageYour insurance may terminate when the plan is terminated; the 31st day after the premium due date if the premium has not been paid; or the date you no longer belong to an eligible class. If your coverage terminates, we will provide benefits for valid claims that arose while your coverage was in force.
NOTICESIf this coverage will replace any existing individual policy, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy.
Notice to Consumer: The coverages provided by Continental American Insurance Company (CAIC) represent supplemental benefits only. They do not constitute comprehensive health insurance coverage and do not satisfy the requirement of minimum essential coverage under the Affordable Care Act. CAIC coverage is not intended to replace or be issued in lieu of major medical coverage. It is designed to supplement a major medical program.
For more information, ask your insurance agent/producer, call 1.800.433.3036, or visit aflacgroupinsurance.com.
Group Benefits PLAN-71032
RATES TABLE FOR: ELGIN ISD - GP-10984 / GROUP HOSPITAL INDEMNITY - PLAN-71032
DEDUCTION FREQUENCY : Semimonthly (24pp / yr)
Deduction Frequency Semimonthly (24pp / yr)
Employee Periodic Cost $9.64
Employee And Spouse Periodic Cost $19.52
Employee And Child Periodic Cost $15.50
Family Periodic Cost $25.38
Group Benefits PLAN-71030
RATES TABLE FOR: ELGIN ISD - GP-10984 / GROUP HOSPITAL INDEMNITY - PLAN-71030
DEDUCTION FREQUENCY : Semimonthly (24pp / yr)
Deduction Frequency Semimonthly (24pp / yr)
Employee Periodic Cost $16.46
Employee And Spouse Periodic Cost $33.50
Employee And Child Periodic Cost $26.14
Family Periodic Cost $43.18
Elgin ISD Dental Highlight Sheet
Low Plan: Dental Plan Summary Effective Date: 9/1/2019
Plan Benefit Type 1 100% Type 2 50%
Deductible $50/Calendar Year Type 2 Waived Type 1
Maximum (per person) $1,000 per calendar year Allowance Network Allowance Waiting Period None
Sample Procedure Listing (Current Dental Terminology © American Dental Association.)
Type 1 Type 2
⚫ Routine Exam
⚫ Bitewing X-rays
⚫ Full Mouth/Panoramic X-rays
⚫ Cleaning
⚫ Fluoride for Children 14 and under
⚫ Sealants (age 14 and under)
⚫ Restorative Amalgams
⚫ Restorative Composites
(anterior and posterior teeth)
⚫ Simple Extractions
Semi-Monthly Rates
Employee Only (EE) $6.04 EE + Spouse $13.48 EE + Children $19.94 EE + Spouse & Children $27.94
Ameritas Information
We're Here to Help This plan was designed specifically for the associates of Elgin ISD. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritas.com.
Dental Health Scorecard
How would you rate your dental health?
In 2016, you can receive your Dental Health Report Card by signing into your secure member account online. Your assessment is based on claims submitted. The report card also offers suggestions if you strive to improve your dental health. Ameritas members can access the personalized report card by going to ameritas.com, click Account Access in the top right corner and choose the Dental/Vision/Hearing drop down. Select the Secure Member Account link and sign in to see your report.
Rx Savings
Our valued plan members and their covered dependents can save on prescription medications at over 60,000 pharmacies across the nation including CVS, Walgreens, Rite Aid and Walmart. This Rx discount is offered at no additional cost, and it is not insurance.
To receive this Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card.
Eyewear Savings
Ameritas plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium.
To receive the eyewear savings identification card, Ameritas plan members can visit ameritas.com and sign-in (or create) a secure member account. Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount.
Dental Network Information
To find a provider, visit ameritas.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose the Ameritas Network found on your ID Card or contact Customer Connections at 800-487-5553.
Elgin ISD Dental Highlight Sheet
Pretreatment
While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed.
Open Enrollment
If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on September 1.
Section 125
This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period.
Dental Cost Estimator
Ever wonder what a dental procedure usually costs? The answer can be found using the Ameritas group division’s Dental Cost Estimator tool located in our Secure Member Account portal.
Members can search by ZIP Code for a specific dental procedure and see fee range estimates for out-of-network general dentists in that area. Of course, we always suggest that members partner with their dentists, so they know what’s involved in any recommended treatment plan.
The estimator tool is powered by Go2Dental and uses FAIR Health data that is updated annually. Please note, cost estimates do not reflect discounted rates available through provider networks, and the estimator does not include orthodontic estimates at this time.
In addition, when members are in their Secure Member Account, they can: ⚫ Go paperless with electronic Explanation of Benefits statements and reduce the clutter in their mailboxes⚫ View their certificate of insurance and specific plan benefits information⚫ Access value-added extras like the Rx discount ID card
Worldwide Support
When our members travel abroad, they’ll have peace of mind knowing that should a dental or vision need arise, help is just a phone call away. Through AXA Assistance, Ameritas offers its dental and vision plan members 24-hour access to dental or vision provider referrals when traveling outside the U.S.
Immediately after a call is made to AXA, an assistance coordinator assesses the situation, provides credible provider referrals and can even assist with making the appointment. Within 48 hours following the appointment, the coordinator calls the member to find out if additional assistance is needed. If all is well, the case is closed. Then, the plan member may submit a claim to Ameritas for reimbursement consideration based on applicable plan benefits. Contact AXA Assistance USA toll free by calling 866-662-2731, or call collect from anywhere in the world by dialing 1-312-935-3727.
Language Services
We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance.
This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.
Elgin ISD Dental Highlight Sheet
High Plan 1: Dental Plan Summary Effective Date: 9/1/2019
Plan Benefit Type 1 100% Type 2 80% Type 3 50%
Deductible $50/Calendar Year Type 2 & 3 Waived Type 1
Maximum (per person) $1,500 per calendar year Allowance Network Allowance Waiting Period None
Orthodontia Summary - Adult and Child Coverage
Allowance U&C Plan Benefit 50% Lifetime Maximum (per person) $1,000 Waiting Period None
Sample Procedure Listing (Current Dental Terminology © American Dental Association.)
Type 1 Type 2 Type 3
⚫ Routine Exam
⚫ Bitewing X-rays
⚫ Full Mouth/Panoramic X-rays
⚫ Cleaning
⚫ Fluoride for Children 14 and under
⚫ Sealants (age 14 and under)
⚫ Space Maintainers
⚫ Restorative Amalgams
⚫ Restorative Composites
(anterior and posterior teeth)
⚫ Simple Extractions
⚫ Onlays
⚫ Crowns
⚫ Crown Repair
⚫ Endodontics (nonsurgical)
⚫ Endodontics (surgical)
⚫ Periodontics (nonsurgical)
⚫ Periodontics (surgical)
⚫ Denture Repair
⚫ Implants
⚫ Prosthodontics (fixed bridge; removable
complete/partial dentures)
⚫ Complex Extractions
⚫ Anesthesia
Semi-Monthly Rates
Employee Only (EE) $13.72 EE + Spouse $29.92 EE + Children $39.48 EE + Spouse & Children $54.48
Ameritas Information
We're Here to Help This plan was designed specifically for the associates of Elgin ISD. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritas.com.
Dental Health Scorecard
How would you rate your dental health?
In 2016, you can receive your Dental Health Report Card by signing into your secure member account online. Your assessment is based on claims submitted. The report card also offers suggestions if you strive to improve your dental health. Ameritas members can access the personalized report card by going to ameritas.com, click Account Access in the top right corner and choose the Dental/Vision/Hearing drop down. Select the Secure Member Account link and sign in to see your report.
Rx Savings
Our valued plan members and their covered dependents can save on prescription medications at over 60,000 pharmacies across the nation including CVS, Walgreens, Rite Aid and Walmart. This Rx discount is offered at no additional cost, and it is not insurance.
To receive this Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card.
Elgin ISD Dental Highlight Sheet
Eyewear Savings
Ameritas plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, Ameritas plan members can visit ameritas.com and sign-in (or create) a secure member account. Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount.
Dental Network Information
To find a provider, visit ameritas.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose the Ameritas Network found on your ID Card or contact Customer Connections at 800-487-5553.
Pretreatment
While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed.
Open Enrollment
If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on September 1.
Section 125
This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period.
Dental Cost Estimator
Ever wonder what a dental procedure usually costs? The answer can be found using the Ameritas group division’s Dental Cost Estimator tool located in our Secure Member Account portal. Members can search by ZIP Code for a specific dental procedure and see fee range estimates for out-of-network general dentists in that area. Of course, we always suggest that members partner with their dentists, so they know what’s involved in any recommended treatment plan. The estimator tool is powered by Go2Dental and uses FAIR Health data that is updated annually. Please note, cost estimates do not reflect discounted rates available through provider networks, and the estimator does not include orthodontic estimates at this time. In addition, when members are in their Secure Member Account, they can: ⚫ Go paperless with electronic Explanation of Benefits statements and reduce the clutter in their mailboxes ⚫ View their certificate of insurance and specific plan benefits information ⚫ Access value-added extras like the Rx discount ID card
Worldwide Support
When our members travel abroad, they’ll have peace of mind knowing that should a dental or vision need arise, help is just a phone call away. Through AXA Assistance, Ameritas offers its dental and vision plan members 24-hour access to dental or vision provider referrals when traveling outside the U.S. Immediately after a call is made to AXA, an assistance coordinator assesses the situation, provides credible provider referrals and can even assist with making the appointment. Within 48 hours following the appointment, the coordinator calls the member to find out if additional assistance is needed. If all is well, the case is closed. Then, the plan member may submit a claim to Ameritas for reimbursement consideration based on applicable plan benefits. Contact AXA Assistance USA toll free by calling 866-662-2731, or call collect from anywhere in the world by dialing 1-312-935-3727.
Language Services
We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance.
This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.
DHMO Semi-monthly premiums
Employee Only $6.60
Employee + Spouse $12.53
Employee + Children $13.19
Employee + Family $20.45
IN-NETWORK BENEFITS
Eye Examination Every 12 months, Covered in fullafter $10 copayment
Eyeglasses
Spectacle LensesEvery 12 months, Covered in fullFor standard single-vision, lined bifocal, or trifocal lenses after $10 copayment
Frames
Every 12 months, Covered in fullAny Fashion or Designer frame from Davis Vision’s Collection/1 (value up to $175)
OR$130 retail allowance toward any frame from provider, plus 20% off balance/2
Contact Lenses
Contact Lens Evaluation, Fitting & Follow Up Care
Every 12 months,Collection Contacts: Covered in full after $10 copay
ORNon Collection Contacts:Standard Contacts: Covered in full after $10 copaySpecialty Contacts/3: $60 allowance with 15% off balance/2 less $10 copay
Contact Lenses (in lieu of eyeglasses)
Every 12 months, Covered in fullAny contact lenses from Davis Vision’s Contact Lens Collection/1
OR$130 retail allowance toward provider supplied contact lenses, plus 15% off balance/2
ADDITIONAL DISCOUNTED LENS OPTIONS & COATINGS
MOST POPULAR OPTIONSSavings based on in-network usage and average retail values.
Without Davis Vision
With Davis Vision
Scratch-Resistant Coating $40 $0Polycarbonate Lenses $64 $0Standard Anti-Reflective (AR) Coating $62 $35Standard Progressives (no-line bifocal) $154 $50Plastic Photosensitive (Transitions®/4) $123 $65
1/ The Davis Vision Collection is available at most participating independent provider locations. Collection is subject to change. Collection is inclusive of select toric and multifocal contacts.
2/ Additional discounts not applicable at Walmart or Sam’s Club locations.3/ Including, but not limited to toric, multifocal and gas permeable contact lenses.4/ Transitions® is a registered trademark of Transitions Optical Inc.Davis Vision has made every effort to correctly summarize your vision plan features. In the event of a conflict between this information and your organization’s contract with Davis Vision, the terms of the contract or insurance policy will prevail.
For more details about the plan, just log on to the Open Enrollment section of our Member site at davisvision.com or call 1.877.923.2847 and enter Client Code 3591.
Contact your Human Resources department today to enroll.
Elgin Independent School District
Designer Vision Plan
Service Without Davis Vision
With Davis Vision
Eye Examination $100 $10Lenses
Bifocals $80 $10Scratch-Resistant Coating $40 $0Transitions®/4 $123 $65
Frame $150 $0
Total $493 $85
Lower costs and more benefits!
OE00732 4/28/14
Employee Contributions Semi-MonthlyEmployee $4.50Employee plus Family $10.36
How to locate a Network Provider...Just log on to the Open Enrollment section of our Member site at davisvision.com and click “Find a Provider” to locate a provider near you including:
One-year eyeglass breakage warranty included on plan eyewear at no additional cost!
Healthy eyes and clear vision are an important part of your overall health and quality of life. Your vision plan helps you care for your eyes while saving you money by offering:
Paid-in-full eye examinations, eyeglasses and contacts!
Frame Collection: Your plan includes a selection of designer, name brand frames that are completely covered in full./1
Contact Lens Collection: Select from the most popular contact lenses on the market today with Davis Vision’s Contact Lens Collection./1
life insuranceyou can keep!
purelife-plus
Life insurance can be an ideal way to provide money for your family when they need it most. purelife-plus offers permanent insurance with a high death benefit and long guarantees1 that can provide financial peace of mind for you and your loved ones. purelife-plus is an ideal complement to any group term and optional term life insurance your employer might provide and has the following features:
1. Aftertheguaranteeperiod,premiumsmaygodown,staythesameorgoup.2. CoveragenotavailableonchildreninWAorongrandchildreninWAorMD.
InMD,childrenmustresidewiththeapplicanttobeeligibleforcoverage.3. Conditionsapply.4. ChronicIllnessRideravailableforanadditionalcostforemployeesonly.
Conditionsapply.RidernotavailableinCA.FormICC15-ULABR-CI-15orFormSeriesULABR-CI-15
DURING THE LAST SIX MONTHS, HAS THE PROPOSED INSURED:
Been actively at work on a full time basis, performing usual duties?
Been absent from work due to illness or medical treatment for a period of more than 5 consecutive working days?
Been disabled or received tests, treatment or care of any kind in a hospital or nursing home or received chemotherapy, hormonal therapy for cancer, radiation, dialysis treatment, or treatment for alcohol or drug abuse?
QUICKQUESTIONS3 You can qualify by answering just
3 questions – no exams or needles.
1
2
3
FlexiblePremiumAdjustableLifeInsurancetoage121.PolicyFormICC18-PRFNG-NI-18orFormSeriesPRFNG-NI-18.Somelimitationsapply.SeethePureLife-plusbrochurefordetails.TexasLifeislicensedtodobusinessintheDistrictofColumbiaandeverystatebutNewYork.
19M016-CFFGA1092(exp0321)
It’s Affordable You own it
You can take it with you when you change jobs or retire
You pay for it through convenient payroll deductions
You can cover your spouse, children and grandchildren, too2
You can get a living benefit if you become terminally ill3
You can get cash to cover living expenses if you become chronically ill4
Here’s how it works:
• If you’re no longer able to perform any two of the six activities of daily living (eating, bathing, dressing, toileting, transferring, maintaining continence) or if you suffer serious cognitive impairment, you can receive a living benefit. 1
– Example: You own a $100,000 Texas Life insurance policy with the Chronic Illness rider. A medical professional certifies that you can no longer perform 2 of the 6 activities or have suffered serious cognitive impairment, you can receive $92,000 minus a $150 processing fee. 2
• The money is yours to do with as you choose: you do not have to go to a nursing home, convalescent center or receive home health care to receive the cash.
• The cost to add this valuable living benefit to your life insurance policy is minimal – just 10% of the policy’s base premium.
19M018-C 1094 (exp0321)
1 Six Activities of Daily Living include: bathing, continence, dressing, eating, toileting, and transferring. Severe Cognitive Impairment means a deterioration or loss in intellectual capacity that: (1) places the Insured in jeopardy of harming him/herself or others and, therefore, the Insured requires Substantial Supervision by another individual; and (2) is measured by clinical evidence and standardized tests which reliably measure impairment in: (a) short or long-term memory; (b) orientation to people, places or time; and (c) deductive or abstract reasoning.
2 The Accelerated Death Benefit Rider for Chronic Illness pays 92% of the insurance proceeds less a $150 administration fee ($100 in FL) in lieu of the benefit payable at death. Conditions apply. Any outstanding loans will reduce the cash value and death benefit. This rider is not available in CA. Policy form series ULABR-CI-15 or ICC15-ULABR-CI-15.
Accelerated Death Benefit Due to Chronic Illness Rider
PureLife-plus is a Flexible Premium Adjustable Life Insurance to Age 121. Some limitations apply. See the Purelife-plus brochure for details. Policy Form ICC18-PRFNG-NI-18 or Form Series PRFNG-NI-18 Texas Life is licensed to do business in the District of Columbia and every state but NY.
purelife-pluslife insurance highlightsAdditional Policy Benefits
For pennies a day, you can get both a living benefit,
should you need it, and a death benefit if you don’t.
Non
-Tob
acco
Employee semi-monthly p r e m i u m s
PureLife-plus — Standard Risk Table Premiums — Non-Tobacco — Express IssueGUARANTEED
Semi-Monthly Premiums for Life Insurance Face Amounts Shown PERIOD
Includes Added Cost for Age to Which
Issue Accidental Death Benefit (Ages 17-59) Coverage is
Age and Accelerated Death Benefit for Chronic Illness (All Ages) Guaranteed at
(ALB) $10,000 $25,000 $50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 Table Premium
15D-1 83
2-3 83
4-10 79
11-16 75
17-20 5.70 10.28 14.85 19.43 28.58 37.73 46.88 56.03 73
21-22 5.84 10.55 15.27 19.98 29.40 38.83 48.25 57.68 73
23-25 5.98 10.83 15.68 20.53 30.23 39.93 49.63 59.33 71
26 6.12 11.10 16.09 21.08 31.05 41.03 51.00 60.98 72
27 6.25 11.38 16.50 21.63 31.88 42.13 52.38 62.63 72
28 6.25 11.38 16.50 21.63 31.88 42.13 52.38 62.63 71
29 6.39 11.65 16.92 22.18 32.70 43.23 53.75 64.28 71
30-31 6.53 11.93 17.33 22.73 33.53 44.33 55.13 65.93 70
32 6.80 12.48 18.15 23.83 35.18 46.53 57.88 69.23 70
33 7.08 13.03 18.98 24.93 36.83 48.73 60.63 72.53 71
34 7.35 13.58 19.80 26.03 38.48 50.93 63.38 75.83 72
35 7.77 14.40 21.04 27.68 40.95 54.23 67.50 80.78 73
36 8.04 14.95 21.87 28.78 42.60 56.43 70.25 84.08 73
37 8.32 15.50 22.69 29.88 44.25 58.63 73.00 87.38 73
38 8.73 16.33 23.93 31.53 46.73 61.93 77.13 92.33 74
39 9.28 17.43 25.58 33.73 50.03 66.33 82.63 98.93 75
40 4.61 9.83 18.53 27.23 35.93 53.33 70.73 88.13 105.53 76
41 4.88 10.52 19.90 29.29 38.68 57.45 76.23 95.00 113.78 77
42 5.27 11.48 21.83 32.18 42.53 63.23 83.93 104.63 125.33 78
43 5.65 12.44 23.75 35.07 46.38 69.00 91.63 114.25 136.88 80
44 6.04 13.40 25.68 37.95 50.23 74.78 99.33 123.88 148.43 81
45 6.48 14.50 27.88 41.25 54.63 81.38 108.13 134.88 161.63 82
46 6.92 15.60 30.08 44.55 59.03 87.98 116.93 145.88 174.83 83
47 7.30 16.57 32.00 47.44 62.88 93.75 124.63 155.50 186.38 83
48 7.74 17.67 34.20 50.74 67.28 100.35 133.43 166.50 199.58 84
49 8.24 18.90 36.68 54.45 72.23 107.78 143.33 178.88 214.43 85
50 8.84 20.42 39.70 58.99 78.28 86
51 9.56 22.20 43.28 64.35 85.43 87
52 10.44 24.40 47.68 70.95 94.23 88
53 11.32 26.60 52.08 77.55 103.03 90
54 11.92 28.12 55.10 82.09 109.08 90
55 12.47 29.49 57.85 86.22 114.58 91
56 13.02 30.87 60.60 90.34 120.08 91
57 13.63 32.38 63.63 94.88 126.13 91
58 14.29 34.03 66.93 99.83 132.73 91
59 14.89 35.54 69.95 104.37 138.78 91
60 15.32 36.60 72.08 107.55 143.03 91
61 16.14 38.67 76.20 113.74 151.28 91
62 17.02 40.87 80.60 120.34 160.08 92
63 17.96 43.20 85.28 127.35 169.43 92
64 18.95 45.68 90.23 134.78 179.33 92
65 19.99 48.29 95.45 142.62 189.78 92
66 21.15 92
67 22.41 92
68 23.79 92
69 25.22 93
70 26.65 93
PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the
Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.
Form: 18M049-ICC EXP-K-S-3AD
Tob
acco
Employee semi-monthly p r e m i u m s
PureLife-plus — Standard Risk Table Premiums — Tobacco — Express IssueGUARANTEED
Semi-Monthly Premiums for Life Insurance Face Amounts Shown PERIOD
Includes Added Cost for Age to Which
Issue Accidental Death Benefit (Ages 17-59) Coverage is
Age and Accelerated Death Benefit for Chronic Illness (All Ages) Guaranteed at
(ALB) $10,000 $25,000 $50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 Table Premium
15D-1 83
2-3 83
4-10 79
11-16 75
17-20 8.04 14.95 21.87 28.78 42.60 56.43 70.25 84.08 70
21-22 8.32 15.50 22.69 29.88 44.25 58.63 73.00 87.38 70
23-25 8.73 16.33 23.93 31.53 46.73 61.93 77.13 92.33 69
26 8.87 16.60 24.34 32.08 47.55 63.03 78.50 93.98 69
27 9.00 16.88 24.75 32.63 48.38 64.13 79.88 95.63 68
28 9.14 17.15 25.17 33.18 49.20 65.23 81.25 97.28 68
29 9.28 17.43 25.58 33.73 50.03 66.33 82.63 98.93 68
30-31 10.38 19.63 28.88 38.13 56.63 75.13 93.63 112.13 69
32 10.65 20.18 29.70 39.23 58.28 77.33 96.38 115.43 69
33 10.79 20.45 30.12 39.78 59.10 78.43 97.75 117.08 69
34 10.93 20.73 30.53 40.33 59.93 79.53 99.13 118.73 68
35 11.62 22.10 32.59 43.08 64.05 85.03 106.00 126.98 69
36 12.03 22.93 33.83 44.73 66.53 88.33 110.13 131.93 69
37 12.72 24.30 35.89 47.48 70.65 93.83 117.00 140.18 70
38 13.13 25.13 37.13 49.13 73.13 97.13 121.13 145.13 70
39 13.95 26.78 39.60 52.43 78.08 103.73 129.38 155.03 70
40 6.75 15.19 29.25 43.32 57.38 85.50 113.63 141.75 169.88 72
41 7.14 16.15 31.18 46.20 61.23 91.28 121.33 151.38 181.43 73
42 7.63 17.39 33.65 49.92 66.18 98.70 131.23 163.75 196.28 74
43 8.40 19.32 37.50 55.69 73.88 110.25 146.63 183.00 219.38 76
44 8.84 20.42 39.70 58.99 78.28 116.85 155.43 194.00 232.58 77
45 9.45 21.93 42.73 63.53 84.33 125.93 167.53 209.13 250.73 78
46 10.00 23.30 45.48 67.65 89.83 134.18 178.53 222.88 267.23 79
47 10.55 24.68 48.23 71.78 95.33 142.43 189.53 236.63 283.73 79
48 11.10 26.05 50.98 75.90 100.83 150.68 200.53 250.38 300.23 80
49 11.98 28.25 55.38 82.50 109.63 163.88 218.13 272.38 326.63 82
50 12.58 29.77 58.40 87.04 115.68 82
51 13.52 32.10 63.08 94.05 125.03 83
52 14.67 34.99 68.85 102.72 136.58 85
53 15.61 37.33 73.53 109.73 145.93 87
54 16.38 39.25 77.38 115.50 153.63 87
55 17.15 41.18 81.23 121.28 161.33 87
56 18.03 43.38 85.63 127.88 170.13 87
57 18.85 45.44 89.75 134.07 178.38 87
58 19.84 47.92 94.70 141.49 188.28 87
59 20.67 49.98 98.83 147.68 196.53 87
60 21.26 51.45 101.78 152.10 202.43 87
61 22.69 55.03 108.93 162.83 216.73 88
62 24.01 58.33 115.53 172.73 229.93 88
63 25.27 61.49 121.85 182.22 242.58 88
64 26.54 64.65 128.18 191.70 255.23 89
65 27.86 67.95 134.78 201.60 268.43 89
66 29.29 89
67 30.83 89
68 32.42 89
69 34.13 89
70 35.94 90
PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the
Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.
Form: 18M049-ICC EXP-K-S-3AD
Non
-Tob
acco
Employee/Spouse/Child semi-monthly p r e m i u m s
PureLife-plus — Standard Risk Table Premiums — Non-Tobacco — Express IssueGUARANTEED
Semi-Monthly Premiums for Life Insurance Face Amounts Shown PERIOD
Includes Added Cost for Age to Which
Issue Accidental Death Benefit (Ages 17-59) Coverage is
Age Guaranteed at
(ALB) $10,000 $25,000 $50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 Table Premium
15D-1 4.00 6.88 83
2-3 4.13 7.13 83
4-10 4.25 7.38 79
11-16 4.38 7.63 75
17-20 5.38 9.63 13.88 18.13 26.63 35.13 43.63 52.13 73
21-22 5.50 9.88 14.25 18.63 27.38 36.13 44.88 53.63 73
23-25 5.63 10.13 14.63 19.13 28.13 37.13 46.13 55.13 71
26 5.75 10.38 15.00 19.63 28.88 38.13 47.38 56.63 72
27 5.88 10.63 15.38 20.13 29.63 39.13 48.63 58.13 72
28 5.88 10.63 15.38 20.13 29.63 39.13 48.63 58.13 71
29 6.00 10.88 15.75 20.63 30.38 40.13 49.88 59.63 71
30-31 6.13 11.13 16.13 21.13 31.13 41.13 51.13 61.13 70
32 6.38 11.63 16.88 22.13 32.63 43.13 53.63 64.13 70
33 6.63 12.13 17.63 23.13 34.13 45.13 56.13 67.13 71
34 6.88 12.63 18.38 24.13 35.63 47.13 58.63 70.13 72
35 7.25 13.38 19.50 25.63 37.88 50.13 62.38 74.63 73
36 7.50 13.88 20.25 26.63 39.38 52.13 64.88 77.63 73
37 7.75 14.38 21.00 27.63 40.88 54.13 67.38 80.63 73
38 8.13 15.13 22.13 29.13 43.13 57.13 71.13 85.13 74
39 8.63 16.13 23.63 31.13 46.13 61.13 76.13 91.13 75
40 4.33 9.13 17.13 25.13 33.13 49.13 65.13 81.13 97.13 76
41 4.58 9.75 18.38 27.00 35.63 52.88 70.13 87.38 104.63 77
42 4.93 10.63 20.13 29.63 39.13 58.13 77.13 96.13 115.13 78
43 5.28 11.50 21.88 32.25 42.63 63.38 84.13 104.88 125.63 80
44 5.63 12.38 23.63 34.88 46.13 68.63 91.13 113.63 136.13 81
45 6.03 13.38 25.63 37.88 50.13 74.63 99.13 123.63 148.13 82
46 6.43 14.38 27.63 40.88 54.13 80.63 107.13 133.63 160.13 83
47 6.78 15.25 29.38 43.50 57.63 85.88 114.13 142.38 170.63 83
48 7.18 16.25 31.38 46.50 61.63 91.88 122.13 152.38 182.63 84
49 7.63 17.38 33.63 49.88 66.13 98.63 131.13 163.63 196.13 85
50 8.18 18.75 36.38 54.00 71.63 86
51 8.83 20.38 39.63 58.88 78.13 87
52 9.63 22.38 43.63 64.88 86.13 88
53 10.43 24.38 47.63 70.88 94.13 90
54 10.98 25.75 50.38 75.00 99.63 90
55 11.48 27.00 52.88 78.75 104.63 91
56 11.98 28.25 55.38 82.50 109.63 91
57 12.53 29.63 58.13 86.63 115.13 91
58 13.13 31.13 61.13 91.13 121.13 91
59 13.68 32.50 63.88 95.25 126.63 91
60 14.03 33.38 65.63 97.88 130.13 91
61 14.78 35.25 69.38 103.50 137.63 91
62 15.58 37.25 73.38 109.50 145.63 92
63 16.43 39.38 77.63 115.88 154.13 92
64 17.33 41.63 82.13 122.63 163.13 92
65 18.28 44.00 86.88 129.75 172.63 92
66 19.33 92
67 20.48 92
68 21.73 92
69 23.03 93
70 24.33 93
PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the
Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.
Form: 18M049-ICC EXP-K-S-3AD
Tob
acco
Employee/Spouse/Child semi-monthly p r e m i u m s
PureLife-plus — Standard Risk Table Premiums — Tobacco — Express IssueGUARANTEED
Semi-Monthly Premiums for Life Insurance Face Amounts Shown PERIOD
Includes Added Cost for Age to Which
Issue Accidental Death Benefit (Ages 17-59) Coverage is
Age Guaranteed at
(ALB) $10,000 $25,000 $50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 Table Premium
15D-1 83
2-3 83
4-10 79
11-16 75
17-20 7.50 13.88 20.25 26.63 39.38 52.13 64.88 77.63 70
21-22 7.75 14.38 21.00 27.63 40.88 54.13 67.38 80.63 70
23-25 8.13 15.13 22.13 29.13 43.13 57.13 71.13 85.13 69
26 8.25 15.38 22.50 29.63 43.88 58.13 72.38 86.63 69
27 8.38 15.63 22.88 30.13 44.63 59.13 73.63 88.13 68
28 8.50 15.88 23.25 30.63 45.38 60.13 74.88 89.63 68
29 8.63 16.13 23.63 31.13 46.13 61.13 76.13 91.13 68
30-31 9.63 18.13 26.63 35.13 52.13 69.13 86.13 103.13 69
32 9.88 18.63 27.38 36.13 53.63 71.13 88.63 106.13 69
33 10.00 18.88 27.75 36.63 54.38 72.13 89.88 107.63 69
34 10.13 19.13 28.13 37.13 55.13 73.13 91.13 109.13 68
35 10.75 20.38 30.00 39.63 58.88 78.13 97.38 116.63 69
36 11.13 21.13 31.13 41.13 61.13 81.13 101.13 121.13 69
37 11.75 22.38 33.00 43.63 64.88 86.13 107.38 128.63 70
38 12.13 23.13 34.13 45.13 67.13 89.13 111.13 133.13 70
39 12.88 24.63 36.38 48.13 71.63 95.13 118.63 142.13 70
40 6.28 14.00 26.88 39.75 52.63 78.38 104.13 129.88 155.63 72
41 6.63 14.88 28.63 42.38 56.13 83.63 111.13 138.63 166.13 73
42 7.08 16.00 30.88 45.75 60.63 90.38 120.13 149.88 179.63 74
43 7.78 17.75 34.38 51.00 67.63 100.88 134.13 167.38 200.63 76
44 8.18 18.75 36.38 54.00 71.63 106.88 142.13 177.38 212.63 77
45 8.73 20.13 39.13 58.13 77.13 115.13 153.13 191.13 229.13 78
46 9.23 21.38 41.63 61.88 82.13 122.63 163.13 203.63 244.13 79
47 9.73 22.63 44.13 65.63 87.13 130.13 173.13 216.13 259.13 79
48 10.23 23.88 46.63 69.38 92.13 137.63 183.13 228.63 274.13 80
49 11.03 25.88 50.63 75.38 100.13 149.63 199.13 248.63 298.13 82
50 11.58 27.25 53.38 79.50 105.63 82
51 12.43 29.38 57.63 85.88 114.13 83
52 13.48 32.00 62.88 93.75 124.63 85
53 14.33 34.13 67.13 100.13 133.13 87
54 15.03 35.88 70.63 105.38 140.13 87
55 15.73 37.63 74.13 110.63 147.13 87
56 16.53 39.63 78.13 116.63 155.13 87
57 17.28 41.50 81.88 122.25 162.63 87
58 18.18 43.75 86.38 129.00 171.63 87
59 18.93 45.63 90.13 134.63 179.13 87
60 19.43 46.88 92.63 138.38 184.13 87
61 20.73 50.13 99.13 148.13 197.13 88
62 21.93 53.13 105.13 157.13 209.13 88
63 23.08 56.00 110.88 165.75 220.63 88
64 24.23 58.88 116.63 174.38 232.13 89
65 25.43 61.88 122.63 183.38 244.13 89
66 26.73 89
67 28.13 89
68 29.58 89
69 31.13 89
70 32.78 90
PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the
Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.
Form: 18M049-ICC EXP-K-S-3AD
.
GROUP BENEFIT PROGRAM SUMMARY
For ELGIN ISD / TEEBC TRUST F021842 - 328
The death of a family provider can mean that a family will not only find itself facing the loss of a loved one, but also the loss of financial security. With our Group Term Life plan, an employee can achieve peace of mind by giving their family the security they can depend on.
EMPLOYER PAID BASIC GROUP TERM LIFE/AD&D
This information is only a product highlight. Life benefits may be subject to medical underwriting. Coverage for a medically underwritten benefit is not effective until the date the insurer has approved the employee’s application. The policy has exclusions, limitations, and reduction of benefits and/or terms under which the policy may be continued or discontinued. The policy may be cancelled by the insurer at any time. The insurer reserves the right to change premium rates, but not more than once in a 12-month period.
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® Life Insurance Company, (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico. Product features and availability vary by state and company, and are solely the responsibility of each affiliate. Refer to your certificate for complete details and limitations of coverage. (For internal use only: Policy number FDL1-504-707)
For employee distribution
Eligibility All Active Full Time Employees regularly working 20 hours per week are eligible for insurance on their date of hire.
Group Term Life/AD&D Benefit:
$25,000
Guarantee Issue Amount – Employee $25,000
Age Reduction Schedule Life and AD&D benefits reduce by 35% of the original amount at age 70 then 50% of the original amount at age 75. Benefits terminate at retirement.
Waiver of Premium If an employee is unable to engage in any occupation as a result of injury or sickness for a minimum of 9 months, prior to age 60, premium will be waived for the employee’s life insurance benefit until the employee is no longer disabled or reaches age 65, whichever occurs first.
Definition of Disability Diagnosed by a doctor to be completely unable, because of sickness or injury to engage in any occupation for wage or profit or any occupation for which they become qualified by education, training or experience.
Accelerated Death Benefit (ADB) Upon the employee’s request, this benefit pays a lump sum up to 75% of the employee’s Life insurance, if diagnosed with a terminal illness and has a life expectancy of 12 months or less. Minimum: $7,500. Maximum: $250,000. The amount of group term life insurance otherwise payable upon the employee’s death will be reduced by the ADB.
Conversion Privilege Included.
Beneficiary Resource Services Includes grief, legal and financial counseling for beneficiaries, funeral planning; and online legal library, including templates to create a legal will and other legal documents.
Travel Resource Services Helps travelers deal with the unexpected that may take place while traveling. Services include emergency medical assistance, financial, legal and communication assistance, and access to other critical services and resources available via the internet.
GROUP ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) PROGRAM SUMMARY
Group AD&D is an additional death benefit that pays in the event a covered employee dies or is dismembered in a covered accident. AD&D benefit is 24-hour coverage.
AD&D Schedule of Loss* Principal Sum
Loss of Life 100%
Loss of Both Hands or Both Feet 100%
Loss of One Hand and One Foot 100%
Loss of Speech and Hearing 100%
Loss of Sight of Both Eyes 100%
Loss of One Hand and the Sight of One Eye 100%
Loss of One Foot and the Sight of One Eye 100% Quadriplegia 100%
Paraplegia 75%
Hemiplegia 50%
Loss of Sight of One Eye 50%
Loss of One Hand or One Foot 50% Loss of Speech or Hearing 50%
Loss of Thumb and Index Finger of Same Hand 25%
Uniplegia 25% * Loss must occur within 365 days of the accident.
AD&D Product Features Included:
Seatbelt and Airbag Benefits Repatriation Benefit Education Benefit
Exclusions – Unless specifically covered in the policy, or required by state law, we will not pay any AD&D benefit for any loss that, directly or indirectly, results in any way from or is contributed to by: 1. disease of the mind or body, or any treatment thereof; 2. infections, except those from an accidental cut or wound; 3. suicide or attempted suicide; 4. intentionally self-inflicted injury; 5. war or act of war; 6. travel or flight in any aircraft while a member of the crew; 7. commission of, or participation in a felony; 8. under the influence of certain drugs, narcotics, or hallucinogen unless properly used as prescribed by a physician; or 9. intoxication as defined in the jurisdiction where the accident occurred; 10. participation in a riot.
This information is only a product highlight. Life benefits may be subject to medical underwriting. Coverage for a medically underwritten benefit is not effective until the date the insurer has approved the employee’s application. The policy has exclusions, limitations, and reduction of benefits and/or terms under which the policy may be continued or discontinued. The policy may be cancelled by the insurer at any time. The insurer reserves the right to change premium rates, but not more than once in a 12-month period. Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® Life Insurance Company, (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico. Product features and availability vary by state and company, and are solely the responsibility of each affiliate. Refer to your certificate for complete details and limitations of coverage. (For internal use only: Policy number FDL1-504-707)
For employee distribution
BENEFIT PROGRAM SUMMARY
For ELGIN ISD / TEEBC TRUST F021842 - 328
SUPPLEMENTAL GROUP TERM LIFE
Eligibility All Active Full Time Employees regularly working 20 hours per week are eligible for insurance on their date of hire.
Group Term Life Benefit: Employee
$10,000 - $300,000, in increments of $10,000, not to exceed 5 times your annual earnings.
Guarantee Issue Amount – Employee $150,000 Group Term Life Benefit: Spouse (Includes Domestic Partners)
$1,000 - $100,000, in increments of $1,000, not to exceed 100% of the employee benefit amount.
Guarantee Issue Amount – Spouse $50,000
Group Term Life Benefit: Child(ren) 14 Days – to 6 months - $500; 6 months to Age 26 - $5,000 or $10,000
Age Reduction Schedule Life and AD&D benefits reduce by 35% of the original amount at age 70 then 50% of the original amount at age 75. Benefits terminate at retirement.
Spouse Supplemental Group Term Life benefits terminate upon the Spouse attainment of age 70.
Employee Contribution 100%
Waiver of Premium If an employee is unable to engage in any occupation as a result of injury or sickness for a minimum of 9 months, prior to age 60, premium will be waived for the employee’s life insurance benefit until the employee is no longer disabled or reaches age 65, whichever occurs first.
Accelerated Death Benefit (ADB) Upon the employee’s request, this benefit pays a lump sum up to 75% of the employee’s Life insurance, if diagnosed with a terminal illness and has a life expectancy of 12 months or less. Minimum: $7,500. Maximum: $250,000. The amount of group term life insurance otherwise payable upon the employee’s death will be reduced by the ADB.
Portability Feature (Life coverage) Included. (Employee)
Conversion Privilege (Life coverage) Included.
Exclusions One-year suicide exclusion applies to Supplemental Group Term Life coverage. AD&D exclusions are the same as Basic AD&D exclusions.
This information is only a product highlight. Life benefits may be subject to medical underwriting. Coverage for a medically underwritten benefit is not effective until the date the insurer has approved the employee’s application. The policy has exclusions, limitations, and reduction of benefits and/or terms under which the policy may be continued or discontinued. The policy may be cancelled by the insurer at any time. The insurer reserves the right to change premium rates, but not more than once in a 12-month period. Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® Life Insurance Company, (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico. Product features and availability vary by state and company, and are solely the responsibility of each affiliate. Refer to your certificate for complete details and limitations of coverage. (For internal use only: Policy number FDL1-504-707)
For employee distribution
SUPPLEMENTAL GROUP LIFE PREMIUM RATE GRID
EligibilityAll Active Full Time Employees regularly working 20 hours per week are eligiblefor insurance on their date of hire.
Supplemental Life InsuranceEmployee Benefit: $10,000 - $300,000 in $10,000 increments, not to exceed 5 times Rates
annual earnings. $0.046Spouse Benefit: $1,000 - $100,000 in $1,000 increments, but not to exceed $0.055
100% of the employee benefit. $0.074Note: Spouse may not have coverage unless the employee has coverage. $0.083
$0.092Child Coverage $0.13814 Days to 6 months: $500 $0.2126 months to Age 26: $0.396
$0.607Employee: Life benefits reduce by 35% of the original amount at age 70, then 50% at $1.167
age 75. All benefits terminate at retirement. $1.894Spouse: Benefits terminate at Spouse's attained age 70.
Guarantee Issue: Employee $150,000Spouse $50,000
$5,000 $0.50 Supplemental Life Insurance $10,000 $1.00Monthly Premium Cost (Based on 12 payroll deductions per year) EMPLOYEE
Benefit Amount <25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+
$10,000 $0.46 $0.55 $0.74 $0.83 $0.92 $1.38 $2.12 $3.96 $6.07 $11.67 $18.94$20,000 $0.92 $1.10 $1.48 $1.66 $1.84 $2.76 $4.24 $7.92 $12.14 $23.34 $37.88$30,000 $1.38 $1.65 $2.22 $2.49 $2.76 $4.14 $6.36 $11.88 $18.21 $35.01 $56.82$40,000 $1.84 $2.20 $2.96 $3.32 $3.68 $5.52 $8.48 $15.84 $24.28 $46.68 $75.76$50,000 $2.30 $2.75 $3.70 $4.15 $4.60 $6.90 $10.60 $19.80 $30.35 $58.35 $94.70$60,000 $2.76 $3.30 $4.44 $4.98 $5.52 $8.28 $12.72 $23.76 $36.42 $70.02 $113.64$70,000 $3.22 $3.85 $5.18 $5.81 $6.44 $9.66 $14.84 $27.72 $42.49 $81.69 $132.58$80,000 $3.68 $4.40 $5.92 $6.64 $7.36 $11.04 $16.96 $31.68 $48.56 $93.36 $151.52$90,000 $4.14 $4.95 $6.66 $7.47 $8.28 $12.42 $19.08 $35.64 $54.63 $105.03 $170.46
$100,000 $4.60 $5.50 $7.40 $8.30 $9.20 $13.80 $21.20 $39.60 $60.70 $116.70 $189.40$110,000 $5.06 $6.05 $8.14 $9.13 $10.12 $15.18 $23.32 $43.56 $66.77 $128.37 $208.34$120,000 $5.52 $6.60 $8.88 $9.96 $11.04 $16.56 $25.44 $47.52 $72.84 $140.04 $227.28$130,000 $5.98 $7.15 $9.62 $10.79 $11.96 $17.94 $27.56 $51.48 $78.91 $151.71 $246.22$140,000 $6.44 $7.70 $10.36 $11.62 $12.88 $19.32 $29.68 $55.44 $84.98 $163.38 $265.16$150,000 $6.90 $8.25 $11.10 $12.45 $13.80 $20.70 $31.80 $59.40 $91.05 $175.05 $284.10
SPOUSE (Spouse's attained Age)$5,000 $0.23 $0.28 $0.37 $0.42 $0.46 $0.69 $1.06 $1.98 $3.04 $5.84 $9.47
$10,000 $0.46 $0.55 $0.74 $0.83 $0.92 $1.38 $2.12 $3.96 $6.07 $11.67 $18.94$15,000 $0.69 $0.83 $1.11 $1.25 $1.38 $2.07 $3.18 $5.94 $9.11 $17.51 $28.41$20,000 $0.92 $1.10 $1.48 $1.66 $1.84 $2.76 $4.24 $7.92 $12.14 $23.34 $37.88$25,000 $1.15 $1.38 $1.85 $2.08 $2.30 $3.45 $5.30 $9.90 $15.18 $47.35 $47.35$30,000 $1.38 $1.65 $2.22 $2.49 $2.76 $4.14 $6.36 $11.88 $18.21 $35.01 $56.82$35,000 $1.61 $1.93 $2.59 $2.91 $3.22 $4.83 $7.42 $13.86 $21.25 $40.85 $66.29$40,000 $1.84 $2.20 $2.96 $3.32 $3.68 $5.52 $8.48 $15.84 $24.28 $46.68 $75.76$45,000 $2.07 $2.48 $3.33 $3.74 $4.14 $6.21 $9.54 $17.82 $27.32 $52.52 $85.23$50,000 $2.30 $2.75 $3.70 $4.15 $4.60 $6.90 $10.60 $19.80 $30.35 $58.35 $94.70
Policy Provisions may vary by state. Refer to a certificate or enrollment brochure for details about coveragefeatures and limitations. For internal use only: Policy number FDL1-504-707
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® LifeInsurance Company® (Downers Grove, IL) (formerly known as Fort Dearborn Life Insurance Company®) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
ELGIN ISD / TEEBC TRUST F021842 - 328
Monthly rates per $1,000Supplemental Life
50-54
30-34
Age
35-39
ATTAINED AGE
40-4445-49
65-6960-64
70+
55-59$5,000 or $10,000
Monthly Premium per Family
25-29
EMPLOYEE & SPOUSE
Under 25
Dependent Life (Children)
Group Voluntary AD&D Insurance Plan Design Summary for ELGIN ISD / TEEBC TRUST F021842 - 328
Voluntary AD&D Employee Only Plan Spouse Plan
Eligibility All Active Full Time Employees regularly working 20 hours per week are eligible for insurance on their date of hire.
Spouse of Covered Employee
Employee Voluntary AD&D Benefit An amount between $15,000 -$300,000 in $1,000 increments to a maximum of 6 times your Annual Earnings.
Family Plan Benefits (Pct of Covered Employee Benefit)
An amount between $1,000 - $50,000 in $1,000 increments, not to exceed 100% of the employee amount.
Age Reduction Schedule
Benefits are reduced by the percentage indicated and are calculated from the original amount at the attainment of the age shown.
35% at age 70 50% at age 75 Benefits terminate at retirement.
Benefits terminate at retirement.
Additional AD&D Features Seat Belt Benefit 10% - $10,000 10% - $10,000 Air Bag Benefit 5% - $5,000 5% - $5,000 Education Benefit N/A 3% - $3,000 per year
Up to four years Repatriation Benefit $5,000 $5,000 Felonious Assault Benefit 10% - $25,000 10% - $25,000 Coma Benefit 1% - 11 months 1% - 11 months Waiver of Premium Included Included
COSTS
Policyholder Contribution 0% 0% Minimum Participation Requirement (Combined Individual and Family Plan)
25% of eligible employees 25% of eligible employees
Employee Only Monthly Rate per $1,000
Spouse Plan Monthly Rate per $1,000
$.02 $.02
Exclusions and Limitations for Voluntary AD&D* Dearborn National will not pay any benefit for a loss resulting from or caused by:
• Disease of the mind or body, and any medical or surgical treatment thereof
• Infection
• Suicide or attempted suicide
• Intentionally self-inflicted injury
• War
• Travel or flight in any aircraft while a member of the crew
• Under the influence of any narcotic
• Intoxication
• Participation in a riot *Refer to the policy and certificate for other exclusions and limitations that may apply.
•
The Accidental Death and Dismemberment (AD&D) plan pays an additional benefit when a covered insured loses their life, or a limb due to an accident. The loss must occur within 365 days of the accident. Benefits are paid based on the following schedule.
AD&D SCHEDULE OF LOSSES BENEFIT AMOUNT Loss of Life 100% Loss of Both Hands or Both Feet 100% Loss of One Hand and One Foot 100% Loss of Sight of Both Eyes 100% Loss of One Hand and the Sight of One Eye 100% Loss of One Foot and the Sight of One Eye 100% Loss of Sight of One Eye 50% Loss of One Hand or One Foot 50% Loss of Thumb and Index Finger of Same Hand 25%
The following additional benefits are included with our Accidental Death & Dismemberment plan. For amount and availability of benefits, please refer to the Plan Design Summary.
Seat Belt Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while wearing a properly worn seat belt.
Air Bag Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while seated in a seat containing a factory installed air bag.
Repatriation If a covered insured dies as a result of an accident more than 75 miles from their principal place of residence, the benefit pays the actual costs, up to the maximum amount indicated in the Plan Design Summary, for the preparation and transportation of the insured employee's body back to their home.
Education Benefit For employees who have elected the Family Plan , pays an additional benefit, up to the percentage and annual maximum indicated in the Plan Design Summary, if a covered insured dies in an accident and has qualified dependent children attending a school of higher learning. The benefit is payable for each insured child and up to four annual payments.
Coma Benefit Pays a monthly benefit, up to the percentage and number of months indicated in the Plan Design Summary, if the covered insured becomes comatose within 31 days of an accident and remains in a coma for 31 days. If the insured person dies before receiving the full coma benefits, the balance of their principal sum will become payable.
RETIREMENT OPTIONS TCG Administrators offers a variety of options to help supplement your future income and help achieve your financial goals
Which One Is Right for Me?
403(b) A 403(b) is a retirement savings plan generally offered by public schools and other tax-exempt organizations that allows employees to make contributions on a pretax basis. Most plans allow you to start, stop, increase or decrease contributions at any time. The employer determines the investment providers and employees must open an account with one of those providers to contribute. TCG Administrators (formerly JEM Resource Partners) is the plan administrator; you can elect salary deductions at www.region10rams.org. Your initial password to enroll online is: elgin403 (case sensitive). All investing involves risk. Past performance is not a guarantee of future returns.
457(b) Section 457(b) Deferred Compensation Plan refers to Section 457(b) of the Internal Revenue Code of 1986. This is a district-sponsored voluntary retirement savings plan that allows an employee to save money for retirement on a tax-deferred basis. This plan allows you to start, stop, increase or decrease contributions at any time. The plan contains most of the same features of the 403(b) plan, but is particularly different in one unique way: distributions from the 457(b) Deferred Compensation Plan are not subject to the 10% excise tax for early withdrawal.
In 2019, you can contribute 100% of your includible compensation up to $19,000, whichever is less. If you are age 50 or older, you can contribute up to an additional $6,000. TCG Administrators (formerly JEM Resource Partners) is the plan administrator; you can elect salary deductions at www.region10rams.org. Your initial password to enroll online is: elgin457 (case sensitive). All investing involves risk. Past performance is not a guarantee of future returns.
Welcome to LifeWorks!
LifeWorks is an exciting and innovative well-being solution that:
• Supports you with a confidential EmployeeAssistance Program (EAP) and well-being
resource, available 24/7 by phone, online,
and by mobile app.
• Connects you to information, tips, and
updates to support your well-being and
success at work.
• Rewards you with a range of special offers
and Perks, helping you save money on daily
essentials and luxury brands.
Watch for your one-time sign-up instructions
to create your personal account on the
LifeWorks platform.
Online:
Download the free app for iOS or Android -
simply search for ‘LifeWorks’.
For EAP services, we are here for you any time 24/7:
Call us: 1-800
En español:
Share LifeWorks with your friends and family
You can invite family members and significant others to access
confidential help and advice on hundreds of topics available on the
LifeWorks platform. Simply access the LifeWorks website, then under
“Profile” select “Family” and “Invite Family Members”.
Feel supported, connected and rewarded.
login.lifeworks.com
Copyright © 2018
LifeWorks - The Total Well-being Experience™ All rights reserved.
Apple and the Apple logo are trademarks of Apple Inc., registered in the US and other countries. App Store is a service mark of Apple Inc., registered in the US, and other countries. Google Play and the Google Play logo are trademarks of Google Inc.
800-456-0018
888-732-9020
Your Guide for Online Enrollment
Visit the enrollment website and enter your login and password
Enrollment site: h ps://ffga.benselect.com/enroll Login ID: Your SSN or Employee ID (#########)
Personal Iden fica on Number (PIN) is the last 4 digits of your SSN and the last 2 digits of the year your were born (this should be a 6 digit number).
*Your PIN may be required on some applica ons for electronic signature.
Once you get signed in you will arrive at the Welcome screen. Important informa on regarding benefits may be listed on this page.
Click Next located at the top right or bo om right to con nue.
You may be asked to review your Personal Informa on. Click Next to con nue to the Dependents page.
Due to the Affordable Care Act, please enter all your eligible dependents, even if you do not intend to cover them on your medical insurance.
Click on the + sign to enter a new dependent or to correct informa on previously entered click on the .
Once you have entered all your eligible dependents click Next.
Your Guide for Online Enrollment
You will arrive at the Benefit Summary page. All available benefits will be listed. Some benefits may require ac on on your part, and some you may not be able to enroll in un l a pre‐requisite has been met.
You can scroll through this screen and waive the benefits you do not want to enroll in by clicking Keep Exis ng Elec on.
Once you have waived the benefits you do not want to enroll in, click Next to begin the enrolling, or just click Next and you will be taken through each benefit and given the opportunity to enroll or waive each available plan.
Once you have enrolled or waived all available and eligible benefits, you will then review/sign your confirma on form. Either click the Sign Form Bu on or enter your PIN, whichever op on presented.
A er you signed your confirma on form you will be taken to the Congratula ons screen and should see the blue scrolling banner. You have completed your enrollment.
You can scroll down to the bo om of the page, to download/print your signed confirma on form, and if your email address is in the system, you should receive an email of your confirmed elec ons.
IMPORTANT CONTACTS
Benefit Vendor Phone Website Medical TRS ActiveCare Aetna 800-222-9205 www.trsactivecareaetna.com
Dental PPO Ameritas 800-487-5553 www.ameritas.com
Dental DHMO Metlife 800-438-6388 www.metlife.com
Vision Davis 800-999-5431 www.davisvision.com
Disability American Fidelity 800-654-8489 www.americanfidelity.com
Cancer American Fidelity 800-654-8489 www.americanfidelity.com
Accident AFLAC 800-992-3522 www.AFLAC.com
Critical Illness AFLAC 800-992-3522 www.AFLAC.com
Hospital Indemnity AFLAC 800-992-3522 www.AFLAC.com
Permanent Life Texas Life 800-283-9233 www.texaslife.com
Group Life Dearborn 800-348-4512 www.dearbornnational.com
ID Theft Protection iLOCK360 855-287-8888 www.iLOCK360.com
Medical FSA and Dependent Care First Financial 800-523-8422 www.ffga.com
Health Savings Account (HSA) First Financial 800-523-8422 www.ffga.com
457(b) Retirement Plan
Region 10 RAMS 800-943-9179 www.region10rams.org
403(b) Retirement Plan Region 10 RAMS 800-943-9179 www.region10rams.org
Edith bergman, ACCOUNT MANAGER 2009 RR 620 N STE 123, AUSTIN TX 78734
OFFICE: 800-672-9666 | CELL: 619-278-9497 | EMAIL: [email protected]
