76-M4 - Voluntary Short Term Disability.pdf

Voluntary Short-Term Disability (“VSTD”) 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 in active employment. Temporary and seasonal workers are not eligible for coverage.

Benefit Amount Minimum Weekly Benefit Who’s Paying for Coverage?

• Benefit: 60% of weekly Pre-disability Earnings

• Maximum: $1,500 per week, reduced by Other

Income Amounts

• $25 • You pay for the cost of coverage.

Maximum Payment Duration Elimination Period Definition of Disability

• 11 weeks • If Disability is due to Injury: 14 days

• If Disability is due to Sickness: 14 days

(number of days you must be Disabled before VSTD benefits become payable)

Regular Occupation and a Reasonable Employment Option offered to you by the Employer, with Residual Disability

Enrolling for VSTD Coverage You may enroll in the VSTD plan coverage within the first 31 days after the date you become eligible. If you enroll after this period, you will be considered a late enrollee and will have to submit satisfactory Evidence of Insurability in order to become covered.

Contact your employer for details on the enrollment process and refer to the Eligibility for Coverage section in your Certificate of coverage.

Active Employment Requirement If you are not in Active Employment on the date that you become eligible for coverage, your coverage will be delayed until you return to Active Employment. This applies to both initial coverage and increases or additions to coverage. “Active Employment” means working at the Employer’s regular work site, performing the material and substantial duties of your regular occupation, and includes normal non-workdays such as vacation, weekends and holidays.

Standard Provisions

• Maternity is covered the same as any other condition.

• Temporary Recovery during the Elimination Period and Maximum Benefit Duration: Please refer to your Certificate for the periods allowed for temporary recovery.

• Other Income Amounts: Your gross VSTD benefit will be reduced by any Other Income Amounts you receive or are eligible to receive, including, but not limited to, any disability or retirement benefits you or your spouse and dependent children receive from Social Security. Refer to your Certificate for a complete list of offsets.

• Cost-of-living freeze: Except for increases in income earned or received from any form of employment, once Other Income Amounts have been subtracted from the gross VSTD benefit, your payment will not be further reduced due to a cost-of-living increase in that Other Income Amount.

• A Return-to-Work Incentive is included to encourage disabled individuals to return to work. This means that if you are working while disabled and earning more than 20% of Pre-disability earnings but less than the earnings test, no offset will be taken for Other Income Amounts (which includes income from employment), until the sum of the gross VSTD benefit and Other Income Amounts exceeds 100% of your Pre-disability Earnings.

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

Summary of Benefits

Exclusions and Limitations Coverage is subject to exclusions and limitations, including but not limited to an exclusion for an injury arising out of, or in the course of, any work for wage or profit, and a sickness for which you are entitled to benefits under any Workers’ Compensation Act, Occupational disease law, Compulsory Benefit Act or law or similar law, unless you are a partner or sole proprietor not covered by any of these acts or laws.

Value-Added Services Your STD coverage includes the following Value-Added Services:

• Employee Assistance Program (EAP): The EAP finds the resources you and your household family members need to help with a variety of issues, such as finding child or elder care, managing a serious illness or dealing with work/life issues, and provides access to confidential counseling, financial information and resources, and legal support. It also includes online access to important estate planning tools such as a last will and testament, living will, healthcare power of attorney, financial power of attorney, and final arrangements.

• Well-Being Coaching: Empowers clients to discover and reflect on aspects of their well-being that are most important to them.

Services offer holistic one-on-one support for a variety of issues.

• Computerized Cognitive Behavioral Therapy (CCBT): Provides a digital program available by mobile app, tablet or desktop offering guided programs to help reduce personal roadblocks, whenever and wherever needed.

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.

VSTD Rate Calculating Your Cost for VSTD Coverage

Monthly rate per $10 of weekly benefit:

$0.242

$0.242 /10 = $ (rate) x (your weekly salary x .60 to a maximum of $1,500) Monthly Voluntary

Short Term Disability cost

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 Voluntary Short-Term Disability Insurance coverage insured by Symetra Life Insurance Company under the GDC 4000 12/05 policy series. For a complete description of coverage, including all definitions, exclusions, limitations, and reductions in coverage, as well as information on termination of benefits, 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