Full Text
Standard Insurance Company Your Employee Benefits Guide Enroll Now To Help Secure Your Financial Future City of Blackfoot ---PAGE BREAK--- Benefits Guide Letter SI 16919-160407 (9/15) Welcome To Your Employee Benefits Guide Protect What Matters Most Building a financial safety net is important. It can also be easy if you take advantage of the benefits your employer offers. Take a few minutes now to explore your options and help protect your future and your loved ones. By enrolling in valuable insurance coverage from Standard Insurance Company – at affordable group rates – you can close key gaps in your financial safety net. You Can Count On The Standard The City of Blackfoot trusts The Standard, and you can too. Founded in 1906, The Standard has been keeping promises for more than 100 years. We specialize in employee benefits and offer plans designed to help give you peace of mind. Doing the right thing for our customers is in our DNA. Whether you have a question or need to file a claim, we’re easy to reach and ready to help – online or on the phone. Act Now To Protect Yourself And Those You Love As you explore your benefit options, think about what – and who – is important to you, now and in the future. You may also want to plan ahead to take care of financial responsibilities. Read on to learn more reasons to enroll. Then refer to the Benefits at a Glance and Coverage Highlights included in this guide for the details of each plan. Disability Insurance Protects A Key Asset – Your Income You insure assets like your car, home or other possessions. But your most valuable asset is your income. That’s why disability insurance is an important tool for securing your financial future. Disability insurance provides income replacement if you experience a covered illness, injury, pregnancy or mental disorder. The weekly or benefit payments can help with bills that continue even when you can’t work, like your mortgage or rent – expenses health insurance won’t cover. To help determine how much coverage you may need, use our easy online calculator at http://www.standard.com/calculators/dineeds.html. Short Term Disability Insurance After a short waiting period, Short Term Disability (STD) insurance helps replace a portion of your weekly income for a specified period of time if you cannot work because of a covered illness, injury, pregnancy or mental disorder. Whether you’re out for a planned absence like pregnancy or an unexpected illness or accident, STD insurance can help you pay bills and keep your finances on track. Refer to the Benefits at a Glance for more details. Your Employer-Paid Benefits Basic Life with Accidental Death & Dismemberment (AD&D) Basic Dependents Life Short Term Disability (STD) Valuable Benefits You Can Enroll In Now You may choose to enroll in any or all of the following plans at affordable group rates, with easy payroll deductions: Additional Life with optional Accidental Death & Dismemberment (AD&D) Additional Dependents Life with optional Accidental Death & Dismemberment (AD&D) Dental 1 ---PAGE BREAK--- Benefits Guide Letter SI 16919-160407 (9/15) Life Insurance – Plan Ahead For Peace Of Mind It’s not easy to think about, but what would happen to your loved ones if something happened to you? Or, how would you cope if a family member died? An unexpected death could leave your family with significant extra expenses, including final medical and funeral costs, on top of ongoing bills and possible loss of income. How much Life insurance is enough? Refer to the Benefits at a Glance and Coverage Highlights to learn more about the Life insurance coverage available through your employer. To help determine your needs, use our simple Life Insurance Calculator, available at http://www.standard.com/calculators/life.html. Accidental Death & Dismemberment Insurance Few people are prepared for the sudden financial loss brought on by an accidental death. Even fewer are financially prepared for the high cost of living after an accident results in a severe physical loss. Your employer offers additional financial support by including Accidental Death and Dismemberment (AD&D) insurance as part of a Group Life insurance policy or as a separate policy from The Standard. AD&D insurance is designed to pay a benefit if you or, if applicable, any other covered family member have an accident that results in a covered loss. Refer to the Benefits at a Glance and Coverage Highlights for more details on your Group Life and AD&D coverage. Dental Insurance With Group Dental insurance from The Standard, you can take advantage of the flexibility and service you would expect from a leading dental carrier with over two decades of dental benefits expertise. The Standard allows you to choose the dentist who is right for you or your family. In many areas, we offer access to an extensive network of Participating Provider Organization (PPO) member dentists whose services may help reduce your out-of-pocket expenses. To learn more, refer to the Highlights Summary. Ready To Enroll? You’ll Find The Form Right Here Now that you’ve reviewed your options and seen how important your benefits can be, the next step is to enroll using the form included at the end of this guide. If you have any questions, just ask your employee benefits manager. Remember, you have a limited time to enroll, so start securing your financial future today. 2 ---PAGE BREAK--- Standard Insurance Company 1100 SW Sixth Avenue Portland OR 97204 SI 13279-160407 1 of 2 (12/15) Benefits at a Glance for the City of Blackfoot Group Policy # 160407 Effective Date October 1, 2015 Group Basic Life and Accidental Death and Dismemberment Insurance Basic Life insurance from Standard Insurance Company helps provide financial protection by promising to pay a benefit in the event of an eligible member’s, or his or her dependent’s, covered death. Basic Accidental Death and Dismemberment (AD&D) insurance may provide an additional amount in the event of a covered death or dismemberment as a result of an accident. The cost of this insurance is paid by the City of Blackfoot. Eligibility Definition of a Member You are a member if you are an active employee of the City of Blackfoot and regularly working at least 30 hours each week OR an active councilman of the City of Blackfoot. You are not a member if you are a temporary or seasonal employee, a full-time member of the armed forces, a leased employee or an independent contractor. Class Definition Class 1 Council Members Class 2 All other members Eligibility Waiting Period If you are already a member on the date the group policy is effective, you are eligible on that date. If you become a member after the group policy effective date, you are eligible on the first day of the month that follows or coincides with 60 days of membership. Benefits Basic Life Coverage Amount Your Basic Life coverage amount is $15,000. Basic AD&D Coverage Amount For a covered accidental loss of life, your Basic AD&D coverage amount is equal to your Basic Life coverage amount. For other covered losses, a percentage of this benefit will be payable. Age Reductions Basic Life and AD&D insurance coverage amounts reduce by 35 percent at age 65 and by 50 percent at age 70. Basic Dependents Life Coverage Amount The Basic Dependents Life coverage amount for your eligible spouse is $10,000. The Basic Dependents Life coverage amount for each of your eligible children is $10,000. 3 ---PAGE BREAK--- Standard Insurance Company 1100 SW Sixth Avenue Portland OR 97204 SI 13279-160407 2 of 2 (12/15) Other Basic Life Features and Services Accelerated Benefit (Class 1 only) Portability of Insurance Provision Repatriation Benefit Right to Convert Provision Standard Secure Access account payment option Travel Assistance Waiver of Premium (Class 1 only) Other Basic AD&D Features Air Bag Benefit Family Benefits Package Seat Belt Benefit This information is only a brief description of the group Basic Life/AD&D and Basic Dependents Life insurance policy sponsored by the City of Blackfoot. The controlling provisions will be in the group policy issued by The Standard. The group policy contains a detailed description of the limitations, reductions in benefits, exclusions and when The Standard and the City of Blackfoot may increase the cost of coverage, amend or cancel the policy. A group certificate of insurance that describes the terms and conditions of the group policy is available for those who become insured according to its terms. For more complete details of coverage, contact your human resources representative. 4 ---PAGE BREAK--- Standard Insurance Company Additional Life and AD&D Coverage Highlights City of Blackfoot SI 12506-ALAA-160407 1 of 4 (12/15) Additional Life and Accidental Death and Dismemberment (AD&D) Insurance Life insurance coverage can help your family meet daily expenses, maintain their standard of living, pay off debt, secure your children’s education, and more in the event of your passing. AD&D insurance can provide you and your family with extra protection in the event of death or dismemberment as a result of a covered accident. Standard Insurance Company (The Standard) has developed this document to provide you with information about the elective coverage you may select through City of Blackfoot. Eligibility Requirements Policy # 160407 The group policy effective date is October 1, 2015 Employee You must be insured for Basic Life through The Standard You must be an active employee of the City of Blackfoot, other than a councilman, working at least 30 hours each week Temporary and seasonal employees, full-time members of the armed forces, leased employees and independent contractors are not eligible You cannot be insured as both an employee and a dependent Dependent You must elect Additional Life insurance for yourself in order to elect Dependents Life insurance for your spouse and eligible child(ren) You must elect Additional AD&D insurance for yourself in order to elect AD&D insurance for your dependents Spouse means a person to whom you are legally married Child means your child from live birth through age 20 (through age 24 if a registered student in full-time attendance at an accredited educational institution) Your spouse or children must not be full-time member(s) of the armed forces Premium You pay 100 percent of the premium for this coverage through easy payroll deduction Coverage Amount Guidelines Within the coverage amount guidelines shown below, you select the amount of Additional Life with or without AD&D and Dependents Life with or without AD&D insurance for which you are interested in applying. Minimum Incremental Unit Guarantee Issue Amount Maximum Employee $10,000 $10,000 $100,000 $500,000 Spouse $5,000 $5,000 $25,000 $250,000 Child $10,000 Note: Amounts of coverage elected above the Guarantee Issue amount are subject to medical underwriting approval. To submit a medical history statement online, visit: www.standard.com/mhs All late applications (applying 31 days after becoming eligible), requests for coverage increases and reinstatements are subject to medical underwriting approval. Employees eligible but not insured under the prior life insurance plan are also subject to medical underwriting approval. Your combined Basic Life and Additional Life amounts may not exceed a maximum of 6 times your Annual Earnings. The coverage amount for your spouse cannot exceed 100 percent of your Additional Life coverage. 5 ---PAGE BREAK--- Standard Insurance Company Additional Life and AD&D Coverage Highlights City of Blackfoot SI 12506-ALAA-160407 2 of 4 (12/15) Coverage Amount Needed Your family has a unique set of circumstances and financial demands. To help you figure out the amount of Additional Life insurance you may need to protect your loved ones, The Standard has created a Life Insurance Needs Calculator found at: http://www.standard.com/lifeneeds. Employee Coverage Effective Date To become insured, you must satisfy the eligibility requirements listed above, serve an eligibility waiting period*, receive medical underwriting approval (if applicable), agree to pay premium, and be actively at work (able to perform all normal duties of your job) on the day before the scheduled effective date of insurance. If you are not actively at work on the day before the scheduled effective date of insurance, including Dependents Life insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee. Please contact your human resources representative for more information regarding these requirements that must be satisfied for your insurance to become effective. *If you are already a member on the date the group policy is effective, you are eligible on that date. If you become a member after the group policy effective date, you are eligible on the first day of the month that follows or coincides with 60 days of membership. Life and AD&D Age Reductions Under this plan, your coverage amount reduces by your age as follows: by 35 percent at age 65 and by 50 percent at age 70, and by 65 percent at age 75. Your spouse’s coverage amount reduces by your age as follows: by 35 percent at age 65 and by 50 percent at age 70, and by 65 percent at age 75. If you are age 65 or over, ask your human resources representative for the amount of coverage available. Life Insurance Exclusions This plan contains an exclusion for death resulting from suicide or other intentionally self-inflicted injury. The amount payable will exclude amounts that have not been continuously in effect for at least two years on the date of death. This is subject to state variations. Life Insurance Features and Benefits Please see your human resources representative for additional information about the features and benefits below. Waiver of Premium If you become totally disabled while insured under this plan and under age 60, and complete a waiting period of 180 days, your Basic and Additional Life insurance may continue without premium payment until age 65 provided you give us satisfactory proof that you remain totally disabled. Waiver of Premium does not apply to AD&D insurance. Accelerated Benefit If you become terminally ill, you may be eligible to receive up to 75 percent of your combined Basic and Additional Life benefit to a maximum of $500,000. Portability If your insurance ends because your employment terminates, you may be eligible to buy portable group insurance coverage. Conversion If your insurance ends or reduces, you may be eligible to convert your life insurance to an individual life insurance policy without submitting proof of good health. 6 ---PAGE BREAK--- Standard Insurance Company Additional Life and AD&D Coverage Highlights City of Blackfoot SI 12506-ALAA-160407 3 of 4 (12/15) Additional AD&D Insurance Benefit Schedule The amount of the Additional AD&D benefit for loss of your, or your dependents, life is equal to the amount payable for your Additional Life or your Dependents Life benefit on the date of the accident. The amount of the Additional AD&D benefit for other covered losses is a percentage of the amount payable for the Additional AD&D benefit on the date of the accident as shown below. Loss: Percentage Payable: Loss of Life 100% One hand or one foot 50% Sight in one eye 50% Two or more of the losses listed above 100% The loss must be caused solely and directly by an accident and occurs independently of all other causes, within 365 days after the accident. Loss of life must be evidenced by a certified copy of the death certificate. All other losses must be certified by a physician in the appropriate specialty as determined by The Standard. No more than 100 percent of the AD&D benefit will be paid for all losses resulting from one accident. Additional AD&D Insurance Exclusions Subject to state variations, AD&D benefits are not payable for death or dismemberment caused or contributed to by: War or act of war, declared or undeclared, whether civil or international, and any substantial armed conflict between organized forces of a military nature Suicide or other intentionally self-inflicted injury Committing or attempting to commit an assault or felony, or actively participating in a violent disorder or riot Voluntary use or consumption of any poison, chemical compound, alcohol or drug, unless used or consumed according to the directions of a physician Sickness or pregnancy existing at the time of the accident Heart attack or stroke Medical or surgical treatment for any of the above When Insurance Ends Coverage ends automatically on the earliest of the following: The last date the last period ends for which a premium was paid The date your employment terminates The date you cease to meet the eligibility requirements (coverage may continue for limited periods under certain circumstances) The date the group policy, or your employer’s coverage under the group policy, terminates For each elective insurance coverage, the date that coverage terminates under the group policy For Additional AD&D insurance for you, the date your Additional life insurance ends In addition to the above requirements, your Dependents Life with or without AD&D coverage ends automatically on the date your dependent ceases to meet the eligibility requirements for a dependent. For more details on when insurance ends, contact your human resources representative. Group Insurance Certificate If coverage becomes effective, and you become insured, you will receive a group insurance certificate containing a detailed description of the insurance coverage including the definitions, exclusions, limitations, reductions and terminating events. The controlling provisions will be in the group policy. Neither the information presented in this summary nor the certificate modifies the group policy or the insurance coverage in any way. 7 ---PAGE BREAK--- Standard Insurance Company Additional Life and AD&D Coverage Highlights City of Blackfoot SI 12506-ALAA-160407 4 of 4 (12/15) Employee Rates If you elect Additional Life insurance, your rate for this plan is indicated in the table below. Premiums for this coverage will be deducted directly from your paycheck. Employee’s Age (as of First of Month following or coinciding with date of birth) Rate (Per $1,000 of Total Coverage) To calculate your premium: <30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ $0.081 $0.084 $0.096 $0.144 $0.206 $0.352 $0.577 $0.784 $1.395 $3.043 $11.536 1. Amount Elected: Write this amount on the Additional Life or Additional Life with AD&D requested amount line on your Enrollment and Change Form. Line 1: 2. Line 1 divided by $1,000 = Line 2. Line 2: 3. Select your rate from the rate table and enter on Line 3. Line 3: 4. Line 2 multiplied by Line 3 = Your cost. Line 4: NOTE: If you elect to add AD&D insurance to your Additional Life insurance, your rate is $0.04 per $1,000 of AD&D benefit added to the above rates. Premiums for this coverage will be deducted directly from your paycheck. Spouse Rates If you elect Dependents Life insurance for your spouse, your rate for this coverage is indicated in the table below. Premiums for this coverage will be deducted directly from your paycheck. Employee’s Age (as of First of Month following or coinciding with date of birth) Rate (Per $1,000 of Total Coverage) To calculate the premium for your spouse: <30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ $0.058 $0.058 $0.065 $0.100 $0.142 $0.248 $0.420 $0.654 $1.164 $2.538 $9.621 1. Amount Elected: Write this amount on the Spouse Life or Spouse Life with AD&D requested amount line on your Enrollment and Change Form. Line 1: 2. Line 1 divided by $1,000 = Line 2. Line 2: 3. Select your rate from the rate table and enter on Line 3. Line 3: 4. Line 2 multiplied by Line 3 = Your cost. Line 4: NOTE: If you elect to add AD&D insurance to Dependents Life insurance for your spouse, your rate is $0.04 per $1,000 of AD&D benefit added to the above rates. Premiums for this coverage will be deducted directly from your paycheck. Child Rates If you elect Dependents Life insurance for your eligible child(ren), your rate for this coverage is $2.00 for $10,000 regardless of the number of eligible children covered. Premiums for this coverage will be deducted directly from your paycheck. NOTE: If you elect to add AD&D insurance to Dependents Life insurance for your eligible child(ren), your rate is $0.40 for $10,000 of AD&D benefit added to the above rate. Premiums for this coverage will be deducted directly from your paycheck. GP190-LIFE/S399, GP399-LIFE/TRUST, GP899-LIFE, GP190-LIFE/A997/S399 8 ---PAGE BREAK--- Standard Insurance Company 1100 SW Sixth Avenue Portland OR 97204 SI 13275-160407 1 of 2 (12/15) Benefits at a Glance for the City of Blackfoot Group Policy # 160407 Effective Date October 1, 2015 Group Short Term Disability Insurance Group Short Term Disability (STD) insurance from Standard Insurance Company helps provide financial protection for insured members by promising to pay a weekly benefit in the event of a covered disability. The cost of this insurance is paid by the City of Blackfoot. Eligibility Definition of a Member You are a member if you are a regular fire chief, fire marshal or employee of the City of Blackfoot, other than an attorney, a council member, the mayor or any other fire department employee, actively working at least 30 hours each week, and a citizen or resident of the United States or Canada. You are not a member if you are a temporary or seasonal employee, a full-time member of the armed forces, a leased employee or an independent contractor. Eligibility Waiting Period If you are already a member on the date the group policy is effective, you are eligible on that date. If you become a member after the group policy effective date, you are eligible on the first day of the month that follows or coincides with 60 days of membership. Benefits Weekly Benefit 66 2/3 percent of the first $1,800 of weekly predisability earnings as of the date of disability, reduced by deductible income work earnings, workers’ compensation, state disability, etc.) Maximum Weekly Benefit $1,200 Minimum Weekly Benefit $15 Benefit Waiting Period Your weekly benefit becomes payable after you have been continuously disabled for seven days for disability caused by accidental injury, physical disease, pregnancy or mental disorder. 9 ---PAGE BREAK--- Standard Insurance Company 1100 SW Sixth Avenue Portland OR 97204 SI 13275-160407 2 of 2 (12/15) Definition of Disability For the benefit waiting period and while the STD benefits are payable, you are considered disabled if you: Are unable – as a result of physical disease, injury, pregnancy or mental disorder – to perform with reasonable continuity the material duties of your own occupation; and Suffer a loss of at least 20 percent of your predisability earnings when working in your own occupation. You will no longer be considered disabled when your earnings from any occupation meet or exceed 80 percent of your predisability earnings. Maximum Benefit Period 90 days Other Features and Services Reasonable Accommodation Expense Benefit Return to Work Incentive Return to Work Responsibility Temporary Recovery Provision This information is only a brief description of the group STD insurance policy sponsored by the City of Blackfoot. The controlling provisions will be in the group policy issued by The Standard. The group policy contains a detailed description of the limitations, reductions in benefits, exclusions and when The Standard and the City of Blackfoot may increase the cost of coverage, amend or cancel the policy. A group certificate of insurance that describes the terms and conditions of the group policy is available for those who become insured according to its terms. For more complete details of coverage, contact your human resources representative. 10 ---PAGE BREAK--- City of Blackfoot Dental Highlight Sheet Standard Insurance Company Benefit and Cost Summary Highlight Sheet Plan 1: Dental Plan Summary Effective Date: 10/1/2015 Plan Benefit In Network Out of Network Type 1 100% 80% Type 2 80% 70% Type 3 50% 40% Deductible $50/Calendar Year Type 2 & 3 $50/Calendar Year Type 2 & 3 Waived Type 1 Waived Type 1 $150/family $150/family Maximum (per person) $1,500 per calendar year $1,500 per calendar year Allowance PPO Max 90th U&C Waiting Period None None Annual Eye Exam None None LASIK AssistSM None None Annual Open Enrollment None None Orthodontia Summary - Child Only Coverage In Network Out of Network Allowance Discounted Fee U&C Plan Benefit 50% 50% Lifetime Maximum (per person) $1,000 $1,000 Waiting Period 12 months New Enrollees Only 12 months New Enrollees Only Sample Procedure Listing (Current Dental Terminology © American Dental Association.) In Network Type 1 Type 2 Type 3 Routine Exam (1 in 6 months) Bitewing X-rays (1 in 12 months) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (1 in 6 months) Fluoride for Children 18 and under (1 in 12 months) Sealants (age 18 and under) Space Maintainers Restorative Amalgams Restorative Composites Crown Repair Endodontics (nonsurgical) Endodontics (surgical) Periodontics (nonsurgical) Periodontics (surgical) Denture Repair Simple Extractions Complex Extractions Onlays Crowns (1 in 7 years per tooth) Implants Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 7 years) Anesthesia Out of Network Type 1 Type 2 Type 3 Routine Exam (1 in 6 months) Bitewing X-rays (1 in 12 months) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (1 in 6 months) Fluoride for Children 18 and under (1 in 12 months) Sealants (age 18 and under) Space Maintainers Restorative Amalgams Restorative Composites Crown Repair Endodontics (nonsurgical) Endodontics (surgical) Periodontics (nonsurgical) Periodontics (surgical) Denture Repair Simple Extractions Complex Extractions Onlays Crowns (1 in 7 years per tooth) Implants Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 7 years) Anesthesia 11 ---PAGE BREAK--- City of Blackfoot Dental Highlight Sheet Standard Insurance Company Benefit and Cost Summary Highlight Sheet Rates Employee Only (EE) $27.43 EE + Spouse $56.16 EE + Children $75.85 EE + Spouse & Children $104.58 About The Standard As a leading provider of employee benefits products and services, Standard Insurance Company is dedicated to meeting the unique insurance needs of each customer. More than 27,100 groups trust The Standard for group insurance products and services, and the company covers nearly 7 million employees. Founded in Portland, Oregon, in 1906, The Standard has built a national reputation for delivering quality insurance products, personalized service and strong financial performance. The Standard wrote its first group insurance policy in 1951, and it remains in force today as a testament to the company's commitment to building successful long-term relationships. Customer Service Your local Standard Insurance Company Employee Benefits Sales and Service Office will provide most of the ongoing service for your plan and can be reached at [PHONE REDACTED] during normal business hours. We will assign your company a service representative who will provide regular contact and address questions and concerns related to the plan or the services we provide. We also make it easy for covered employees and dentists to contact us to confirm eligibility or request claims information by calling 1-[PHONE REDACTED]. Our customer service representatives are available Monday through Thursday from 5:00 a.m. until 10:00 p.m. Pacific Time and until 4:30 p.m. Pacific Time on Friday. For plan information any time, access our automated voice response system or go online to standard.com. Orthodontia Waiting Period - new enrollees only The group of initial employees who enroll in this plan have no waiting period for orthodontia benefits. Anyone hired after the initial plan enrollment will have a 12-month waiting period, after they enroll in this dental plan, before they are eligible to receive orthodontia benefits. Dental Network Information Employees and dependents have access to an extensive nationwide network of member dentists. The cost-saving benefits of visiting a network member dentist are automatically available to all employees and dependents who are covered by any of The Standard's dental plans and who live in areas where the nationwide network is available. To find member dentists in your area, visit: http://www.standard.com/dental and click on "Find a Dentist." California Residents: When prompted to select your network, choose the network found on your ID Card. 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. 12 ---PAGE BREAK--- City of Blackfoot Dental Highlight Sheet Standard Insurance Company Benefit and Cost Summary Highlight Sheet Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered. This form is a benefit highlight, not a certificate of insurance. 13 ---PAGE BREAK--- Return completed form to your Human Resources Department. SI 7533D-160407 (9/15) 1 of 2 (2/11) Standard Insurance Company Enrollment and Change To Be Completed By Human Resources Group Number 160407 Division Billing Category Date of Employment To Be Completed By Applicant Apply for Coverage Beneficiary Change Complete Beneficiary Section below. Name Change Add or Delete Dependent Date of add/delete Your Name (Last, First, Middle) Your Social Security Number Birth Date Male Female Your Address City State ZIP Former Name (Last, First, Middle) Complete only if name change Phone Number Employer Name City of Blackfoot Job Title/Occupation Hours Worked Per Week Earnings Per: Hour Week Month Year Coverage Check with your Human Resources Department about coverage options available to you and Evidence Of Insurability requirements. Life Insurance Basic Life with AD&D (Employer Paid) You may choose one of the following options for yourself: Additional Life requested amount OR Additional Life with AD&D requested amount Dependents Life Insurance Spouse Life $10,000 / Child(ren) Life $10,000 (Employer Paid) You may choose one of the following options for your spouse: Spouse Life requested amount OR Spouse Life with AD&D requested amount You may choose one of the following options for your child(ren): Child(ren) Life $10,000 OR Child(ren) Life with AD&D $10,000 Short Term Disability Employer Paid STD Dental Voluntary Dental Coverage requested for You, your Spouse & Children You & your Spouse You only You & your Children (no Spouse) Are you covered for dental insurance under another plan? Yes No Are one or more dependents? Yes No List dependents to enroll or delete for Dental, if applicable (Attach sheet for additional dependents, if needed). Spouse Full Name Male Female Birth Date Child 1 Full Name Male Female Birth Date Child 2 Full Name Male Female Birth Date Child 3 Full Name Male Female Birth Date Dental Insurance Waiver: Contributory Dental Insurance The insurance coverage available to me and my dependents has been explained to me and I do not want to enroll at this time. I understand that if I elect to enroll in the future, the insurance coverage may be subject to a Late Enrollment Penalty. I decline Dental insurance for myself. I decline Dental insurance for one or more dependents. Beneficiary This designation applies to Life/Life with AD&D Insurance available through your Employer, if any. Designations are not valid unless signed, dated, and delivered to the Employer during your lifetime. See page 2 for further information. Primary - Full Name Address Soc. Sec. No. Relationship % of Benefit Contingent - Full Name Address Soc. Sec. No. Relationship % of Benefit Signature I wish to make the choices indicated on this form. If electing coverage, I authorize deductions from my wages to cover my contribution, if required, toward the cost of insurance. I understand that my deduction amount will change if my coverage or costs change. Member/Employee Signature Required Date (Mo/Day/Yr) 15 Reset ---PAGE BREAK--- SI 7533D 2 of 2 (2/11) Beneficiary Information Your designation revokes all prior designations. Benefits are only payable to a contingent Beneficiary if you are not survived by one or more primary Beneficiary(ies). If you name two or more Beneficiaries in a class: 1. Two or more surviving Beneficiaries will share equally, unless you provide for unequal shares. 2. If you provide for unequal shares in a class, and two or more Beneficiaries in that class survive, we will pay each surviving Beneficiary his or her designated share. Unless you provide otherwise, we will then pay the share(s) otherwise due to any deceased Beneficiary(ies) to the surviving Beneficiaries pro rata based on the relationship that the designated percentage or fractional share of each surviving Beneficiary bears to the total shares of all surviving Beneficiaries. 3. If only one Beneficiary in a class survives, we will pay the total death benefits to that Beneficiary. If a minor (a person not of legal age), or your estate, is the Beneficiary, it may be necessary to have a guardian or a legal representative appointed by the court before any death benefit can be paid. If the Beneficiary is a trust or trustee, the written trust must be identified in the Beneficiary designation. For example, “Dorothy Q. Smith, Trustee under the trust agreement dated A power of attorney must grant specific authority, by the terms of the document or applicable law, to make or change a Beneficiary designation. If you have any questions, consult your legal advisor. Dependents Insurance, if any, is payable to you, if living, or as provided under your Employer’s coverage under the Group Policy. 16 Print Enrollment Form ---PAGE BREAK--- Enrollment Booklet SI 16891-160407 (12/15) Standard Insurance Company For more than 100 years we have been dedicated to our core purpose: to help people achieve financial well- being and peace of mind. We have earned a national reputation for quality products and superior service by always striving to do what is right for our customers. Headquartered in Portland, Oregon, The Standard is a nationally recognized provider of group Disability, Life, Dental and Vision insurance and Individual Disability insurance. We provide insurance to more than 24,800 groups, covering over 8 million employees nationwide.* Our first group policy, written in 1951 and still in force today, stands as a testament to our commitment to building long-term relationships. To learn more about products from The Standard, contact your human resources department or visit us at www.standard.com. * As of June 30, 2013, based on internal data developed by Standard Insurance Company.