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© Association County Commissioners of Georgia & Georgia Municipal Association 2024 First Responder Acknowledgments [To Be Provided with the Summary of Benefits & Maintained by First Responder and Entity] The Columbia County (“the County”) provides First Responder PTSD Benefits (“Coverage through the County”) to its employed First Responders* and its volunteer First Responders who are not employed First Responders with another Public Entity.* (*See definitions in the Summary of Benefits.) This document is not a contract or a description of coverage and does not create any rights. In the event of a conflict, the terms of the applicable Policy control. Coverage Status though the County for First Responder Named Below: Covered through the County if Employed as a First Responder for the County. Covered through the County if Serving as a Volunteer First Responder for the County and Not Employed as a First Responder by any other Public Entity NOT COVERED through the County (But Entitled to Similar Coverage) if Serving as a Volunteer First Responder for the County and Also Currently Employed as a First Responder by another Public Entity Acknowledgments: I have received a copy of the Summary of Benefits, which applies if I am Covered through the County now or will apply if I become Covered through the County at a later date. I am able to access which contains the full description of the Coverage and its requirements (the Certificate) as well as important Privacy Notices and claim forms. If I am a volunteer First Responder for the County, I must notify the County if I become employed as a First Responder with any other Public Entity or am no longer employed as a First Responder with any other Public Entity. If “Not Covered” according to the criteria above, I acknowledge and understand: • The other Public Entity for whom I am a paid First Responder must provide me similar coverage. • If I am unsure of whether my coverage is through the County or another Public Entity and I am diagnosed with occupational PTSD, I should submit a claim to MetLife, who will help determine the proper source of any coverage. I should file any claim for benefits directly with MetLife and I do not need to notify the County that I am making a claim. If “Covered” according to the criteria above, I acknowledge and understand: • The Summary of Benefits applies to me. It is available upon request from my employer, and I can review the full description of the Coverage and its requirements (the Certificate) as well as important Privacy Notices and claim forms on • I should file any claim for benefits directly with MetLife and I do not need to notify the County that I am making a claim. ---PAGE BREAK--- © Association County Commissioners of Georgia & Georgia Municipal Association 2024 • If I am diagnosed with PTSD after termination of my regularly scheduled First Responder services for the County and the PTSD is associated with a traumatic event that occurred while I was performing First Responder services for the County, I may be eligible for benefits according to the terms of the Certificate available at Name of First Responder