49-I12 - Supplemental Life and ADD.pdf

Supplemental Life/Accidental Death & Dismemberment (AD&D) Insurance

Eligibility for Coverage All full-time employees working at least 30 hours per week. An employee must be a citizen or permanent resident of the United States who is Actively at Work. Temporary, leased, and seasonal workers are not eligible for coverage.

Who’s Paying?

You pay for the cost of this coverage.

Benefit Amount Guaranteed Issue Benefit Reductions Employee Increments of $10,000, up to the lesser of $500,000 or 5 times earnings

Employee $150,000

Employee Original benefits are reduced to 65% at age 65, to 50% at age 70, and to 35% at age 75

Spouse Increments of $5,000, up to $250,000 not to exceed 100% of the Employee's Supplemental Life amount

Spouse $50,000

Spouse Original benefits are reduced to 65% at age 65, to 50% at age 70, and to 35% at age 75 (Reductions are based on age of the employee)

Child(ren) $20,000 Live Birth to 26 Years

Child $20,000

Child Not applicable

Enrolling for Coverage If you do not enroll within the first 31 days after the date you become eligible, you may only enroll during an Annual Enrollment Period, if designated by the Policyholder, or within 31 days of the date you have Change in Family Status, and you may have to submit satisfactory Evidence of Insurability in order to become covered.

*Contact your HR department or your company intranet for the most current enrollment information*

Evidence of Insurability Evidence of Insurability is required for any Life insurance elected after the initial 31 day eligibility period and for any amount exceeding the Guaranteed Issue amount. Evidence of Insurability is not required for Child Life Insurance. Contact your employer for details on the enrollment process and refer to the Eligibility and Enrollment section in your Certificate of coverage.

Actively at Work Requirement

If you are not Actively at Work on the date that you become eligible for coverage, your coverage will be delayed until you return to being Actively at Work. This applies to both initial coverage and any increases or additions to coverage. “Actively at Work” means working for your Employer on a scheduled workday, performing all the job duties in the usual way for the usual number of hours, and includes regularly scheduled vacation days or holidays.

Dependent Non-Confinement Requirement

If a Dependent is confined, initial coverage, new coverage, and increases in coverage will be delayed until the Dependent is no longer confined and has the ability to engage in all the normal and customary activities of a person of like age and gender, in good health, for at least 15 consecutive days. This does not apply to newborns or to disabled children who qualify under the definition of Dependent Children.

Please refer to your Certificate for additional information.

City of Burleson Policy# 01-017859-00 Class #1 – All Active Full-Time Employees

Summary of Benefits

Additional Provisions Accelerated Death Benefit If an employee has been diagnosed as terminally ill, Symetra Life Insurance Company may pay a portion of the death benefit in advance to the employee.

Conversion A conversion benefit is available that allows you to convert your group coverage to a permanent, individual policy if certain conditions apply.

Portability This coverage may be continued at group portability rates upon termination of employment for a limited period of time. Certain restrictions apply.

Waiver of Premium With proof of disability, Symetra Life Insurance Company will waive Life Insurance premiums for a period of time for an active employee that becomes totally disabled prior to a certain qualifying age.

Certain restrictions, such as an elimination period, apply.

AD&D Benefit Riders Includes Seat Belt, Airbag, Repatriation and more.

Continuity of Coverage Continuity of coverage is included for employees covered under the Employer’s prior plan on the day prior to the Policy effective date.

Exclusions AD&D coverage is subject to exclusions and limitations, including a suicide exclusion.

Duplicate Coverage A person may not be covered as a Dependent if they are covered as an employee under the Policy, and no person can be insured as a Dependent of more than one employee.

Please refer to your employee certificate for additional information.

Value Add Services Beneficiary Assistance Support services and compassionate guidance for beneficiaries who have experienced a loss.

Travel Assistance Pre-trip planning information, medical assistance and transport services, and emergency travel services and other assistance due to covered medical issues and emergencies that may occur when the insured or eligible dependent is on a trip 100 miles or more from home lasting 90 days or less.

Identity Theft Assistance Identity theft assistance offers insureds and eligible dependents peace of mind by providing step-by-step coaching, fraud assistance, and document replacement to help resolve identity theft.

Estate Planning Provides a simple, secure, and affordable online tool that allows insureds to decide what documents they need, from a last will and testament, living will, healthcare power of attorney, financial power of attorney, and/or final arrangements, for, at most, a minor additional fee.

Value Add Services are provided by third-party vendors. Benefits may not be available in all states and are not available in any U.S.

Territory.

Rates for Supplemental Life & AD&D Coverage Calculating Your Cost Supplemental Employee and Spouse Life Rates per $1,000 of coverage

Employee Age

Employee Rate

Spouse Age

Spouse Rate

Under 25 $0.070 Under 25 $0.070 25 - 29 $0.070 25 - 29 $0.070 30 - 34 $0.080 30 - 34 $0.080 35 - 39 $0.100 35 - 39 $0.100 40 - 44 $0.140 40 - 44 $0.140 45 - 49 $0.220 45 - 49 $0.220 50 - 54 $0.330 50 - 54 $0.330 55 - 59 $0.540 55 - 59 $0.540 60 - 64 $0.720 60 - 64 $0.720 65 – 69 $1.220 65 – 69 $1.220 70 – 74 $2.160 70 – 74 $2.160 75 + $8.180 75 + $8.180

*Spouse rates are based on Employee age

Supplemental Child Life Rate per $1,000 of coverage is $2

Supplemental AD&D Rates per $1,000 of coverage:

• Employee: $0.030

• Spouse: $0.030

• Child: $0.040

Supplemental Employee Life:

/1,000 = $

(volume) x (rate) Monthly Cost

Supplemental Spouse Life:

/1,000 = $

Supplemental Child Life:

2 /1,000 = $

Supplemental Employee AD&D: 0.030 /1,000 = $

Supplemental Spouse AD&D:

0.030 /1,000 = $

Supplemental Child AD&D:

0.040 /1,000 = $

Claims Contact Information:

Phone: 1-877-377-6773 Fax: 1-877-737-3650 Mail: Symetra Life Insurance Company, Life and Absence Management Center, P.O. Box 1230, Enfield, CT 06083-1230

This summary provides only a brief description of the Supplemental Life Insurance coverage insured by Symetra Life Insurance Company under the LGC-13000 8/06 series Group Life Insurance Policy. For a complete description, including all definitions, exclusions, limitations, and reductions in coverage, please contact your benefit administrator or refer to the Group Insurance Certificate you will receive when you become insured. Coverage will be offered under Group Policy number 01-017859-00. We will administer claims according to the terms and conditions of the Group Policy which may be subject to state-required variations and restrictions. If there is a difference between the information in this summary and the information contained in the Group Policy, the terms of the Group Policy will prevail. The terms of coverage may change over time; always refer to your current Group Insurance Certificate for information regarding your insurance benefits.

Insured by Symetra Life Insurance Company