78-N1 - City of Burleson Life DI Questionnaire.xlsx

Front Cover Request for Proposal

* Life & AD&D

* Supplemental Life & AD&D

* LTD

*STD

City of Burleson

Prepared by: Lockton Companies

RFP Intro

https://www.burlesontx.com/https://www.burlesontx.com/Archive.aspx?AMID=186 Questionnaire

QUESTIONNAIRE

If requested or required, affirm that you are amenable to single case filing.

Life/AD&D: y/n STD: y/n LTD: y/n

Life Plan Design

All full-time Active Employees working a minimum of 30 hours each week who are citizens or legal residents of the United States, excluding temporary, leased or seasonal employees.

Eligibility Waiting Period (Months) If You are Actively at Work for the Employer prior to January 1, 2021: The first of the month following 30 days of continuous employment.

If You start working for the Employer on or after January 1, 2021: None

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a full-time Active Employee with the Employer under the Prior Policy.

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a part-time or seasonal employee with the Employer.

Rounded to the next higher $1,000

Child : birth to 26 years: $10,000

A minimum Accelerated Benefit Amount of $3,000

Occupational Death Benefit Benefit Amount: $300,000 Maximum Amount: $300,000

1 x's AE up to $300,000 for qualifying occupational illness or injury for Public Safety Officers

Public Safety Officer as “an Active Employee whose primary job duties include controlling or reducing crime or juvenile delinquency, criminal law enforcement, or fire suppression. Public Safety Officer means police officers, firefighters, corrections officers, judicial officers, and officially recognized or designated volunteer firefighters, if they otherwise meet the definition of Public Safety Officer”

In addition, You will be considered Disabled if You have been diagnosed with a life expectancy of 12 months or less.

Basic Spouse Life Insurance: No reduction

All full-time Active Employees working a minimum of 30 hours each week who are citizens or legal residents of the United States, excluding temporary, leased or seasonal employees.

Eligibility Waiting Period (Months) If You are Actively at Work for the Employer prior to January 1, 2021: The first of the month following 30 days of continuous employment.

If You start working for the Employer on or after January 1, 2021: None

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a full-time Active Employee with the Employer under the Prior Policy.

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a part-time or seasonal employee with the Employer.

Rounded to the next higher $1,000 Maximum Benefit Amount $500,000 $500,000, not to exceed 5 x Earnings

For newly enrolled:

Employees: up to 5 increments of $10,000.

For currently enrolled:

Employees: up to 5 increments of $10,000.

This open enrollment does not apply to employees previously declined for amounts of coverage, or for those who were required to submit Evidence of Insurability but failed to do so. This open enrollment also does not apply to employees who have not satisfied the service waiting period.

A minimum Accelerated Benefit Amount of $3,000

In addition, You will be considered Disabled if You have been diagnosed with a life expectancy of 12 months or less.

All full-time Active Employees working a minimum of 30 hours each week who are citizens or legal residents of the United States, excluding temporary, leased or seasonal employees.

Rounded to the next higher $1,000 Maximum Benefit Amount $250,000 Not to exceed 100% of Your Supplemental Life Benefit Amount

This document is intended to merely highlight or summarize certain aspects of the employer’s benefit program(s). It is not a summary plan description (SPD) or an official plan document. Your rights and obligations under the program(s) are set forth in the official plan documents. All statements in this summary are subject to the terms of the official plan documents, as interpreted by the appropriate plan fiduciary. In the case of an ambiguity or outright conflict between a provision in this summary and a provision in the plan documents, the terms of the plan documents control. The employer reserves the right to review, change, or terminate the plan, or any benefits under it, for any reason, at any time and without advance notice to any person.

ADD Plan Design (2)

All full-time Active Employees working a minimum of 30 hours each week who are citizens or legal residents of the United States, excluding temporary, leased or seasonal employees.

Eligibility Waiting Period (Months) If You are Actively at Work for the Employer prior to January 1, 2021: The first of the month following 30 days of continuous employment.

If You start working for the Employer on or after January 1, 2021: None

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a full-time Active Employee with the Employer under the Prior Policy.

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a part-time or seasonal employee with the Employer.

Benefit Type Multiple of Salary Rounded to the next higher $1,000,

Maximum Amount: $5,000

We will pay an additional Repatriation Benefit, if the death occurs outside the territorial limits of the state or country of the deceased person’s place of permanent residence.

Seat Belt Maximum Amount: $25,000

Seat Belt Minimum Amount: $1,000

If it cannot be determined that the injured person was wearing a Seat Belt at the time of Accident, a Minimum Benefit will be payable under the Seat Belt Benefit Air Bag Use Benefit Air Bag Benefit Amount: 10% of Basic and Supplemental AD&D Principal Sum

Air Bag Maximum Amount: $25,000

If a Seat Belt Benefit is payable, We will also pay an Air Bag Benefit if the injured person was:

1) positioned in a seat equipped with a factory-installed Air Bag; and

2) properly strapped in the Seat Belt when the Air Bag inflated.

1) it results from the forced landing, stranding, sinking or wrecking of a conveyance in which You or Your Dependent were an occupant at the time of the accident; and

2) The Policy would have covered an Injury resulting from the accident.

Disappearance: 100% Child Care Benefit Benefit Amount: 5% of Basic and Supplemental AD&D Principal Sum

Maximum Amount: $5,000

Minimum Amount: $2,500

We will make one Day Care Benefit payment each year, for a maximum of four Day Care Benefit payments, for each Child.

We will pay the Minimum Amount for this Benefit in accordance with the Claims to be Paid provision for payment of benefits for Loss of life if:

1) a Principal Sum is payable because of the deceased person’s death; and

2) no person qualifies as a Child eligible for the Day Care Benefit.

Child Education Benefit Benefit Amount: 5% of Basic and Supplemental AD&D Principal Sum

Maximum Amount: $5,000

Minimum Amount: $2,500

We will pay the Child Education Benefit to a qualifying Student until the first to occur of:

1) Our payment of the fourth Child Education Benefit to or on behalf of that person; or

2) the end of the 12th consecutive month during which We have not received proof satisfactory to Us that he or she is a Student.

We will not pay more than one Child Education Benefit to any one Student during any one school year

We will pay the Minimum Amount for this Benefit in accordance with the Claims to be Paid provision of The Policy if:

1) a Principal Sum is payable because of Your death or Your Spouse’s death; and

2) no person qualifies as a Student.

Spouse Education Benefit Benefit Amount: 3% of Basic and Supplemental AD&D Principal Sum

Maximum Amount: $3,000

Minimum Amount: $1,250

The Spouse Education Benefit is the least of:

1) the Expense Incurred for Occupational Training;

2) the amount resulting from multiplying Your amount of Principal Sum by the Spouse Education Benefit Percentage; or

3) the Maximum Amount for this Benefit.

If a Principal Sum is payable because of Your death and there is no surviving Spouse, We will pay the Minimum Amount for this Benefit in accordance with the Claims to be Paid provision.

All full-time Active Employees working a minimum of 30 hours each week who are citizens or legal residents of the United States, excluding temporary, leased or seasonal employees.

Eligibility Waiting Period (Months) If You are Actively at Work for the Employer prior to January 1, 2021: The first of the month following 30 days of continuous employment.

If You start working for the Employer on or after January 1, 2021: None

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a full-time Active Employee with the Employer under the Prior Policy.

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a part-time or seasonal employee with the Employer.

Rounded to the next higher $1,000

Not to exceed 5 x Earnings

Maximum Amount: $5,000 We will pay an additional Repatriation Benefit, if the death occurs outside the territorial limits of the state or country of the deceased person’s place of permanent residence.

Seat Belt Maximum Amount: $25,000

Seat Belt Minimum Amount: $1,000

If it cannot be determined that the injured person was wearing a Seat Belt at the time of Accident, a Minimum Benefit will be payable under the Seat Belt Benefit Air Bag Use Benefit Air Bag Benefit Amount: 10% of Basic and Supplemental AD&D Principal Sum

Air Bag Maximum Amount: $25,000

If a Seat Belt Benefit is payable, We will also pay an Air Bag Benefit if the injured person was:

1) positioned in a seat equipped with a factory-installed Air Bag; and

2) properly strapped in the Seat Belt when the Air Bag inflated.

1) it results from the forced landing, stranding, sinking or wrecking of a conveyance in which You or Your Dependent were an occupant at the time of the accident; and

2) The Policy would have covered an Injury resulting from the accident.

Disappearance: 100% Child Care Benefit Benefit Amount: 5% of Basic and Supplemental AD&D Principal Sum

Maximum Amount: $5,000

Minimum Amount: $2,500

We will make one Day Care Benefit payment each year, for a maximum of four Day Care Benefit payments, for each Child.

We will pay the Minimum Amount for this Benefit in accordance with the Claims to be Paid provision for payment of benefits for Loss of life if:

1) a Principal Sum is payable because of the deceased person’s death; and

2) no person qualifies as a Child eligible for the Day Care Benefit.

Child Education Benefit Benefit Amount: 5% of Basic and Supplemental AD&D Principal Sum

Maximum Amount: $5,000

Minimum Amount: $2,500

We will pay the Child Education Benefit to a qualifying Student until the first to occur of:

1) Our payment of the fourth Child Education Benefit to or on behalf of that person; or

2) the end of the 12th consecutive month during which We have not received proof satisfactory to Us that he or she is a Student.

We will not pay more than one Child Education Benefit to any one Student during any one school year

We will pay the Minimum Amount for this Benefit in accordance with the Claims to be Paid provision of The Policy if:

1) a Principal Sum is payable because of Your death or Your Spouse’s death; and

2) no person qualifies as a Student.

Spouse Education Benefit Benefit Amount: 3% of Basic and Supplemental AD&D Principal Sum

Maximum Amount: $3,000

Minimum Amount: $1,250

The Spouse Education Benefit is the least of:

1) the Expense Incurred for Occupational Training;

2) the amount resulting from multiplying Your amount of Principal Sum by the Spouse Education Benefit Percentage; or

3) the Maximum Amount for this Benefit.

If a Principal Sum is payable because of Your death and there is no surviving Spouse, We will pay the Minimum Amount for this Benefit in accordance with the Claims to be Paid provision.

All full-time Active Employees working a minimum of 30 hours each week who are citizens or legal residents of the United States, excluding temporary, leased or seasonal employees.

Eligibility Waiting Period (Months) If You are Actively at Work for the Employer prior to January 1, 2021: The first of the month following 30 days of continuous mployment.

If You start working for the Employer on or after January 1, 2021: None

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a full-time Active Employee with the Employer under the Prior Policy.

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a part-time or seasonal employee with the Employer.

Rounded to the next higher $1,000

Not to exceed 100% of Your Supplemental AD&D Principal Sum

70% at age 50 65% at age 65

All full-time Active Employees working a minimum of 30 hours each week who are citizens or legal residents of the United States, excluding temporary, leased or seasonal employees.

Disability Plan Design

You must be working at least 30 hours per week.

If your employment ends and you are rehired by the same employer within one year, we will apply your previous employment in an eligible class toward completing the waiting period. All other provisions of this plan apply.

(11 week maximum payable benefit)

You must be working at least 30 hours per week.

If you are entering an eligible class on or after January 1, 2021: None.

If your employment ends and you are rehired by the same employer within 1 year, we will apply your previous employment in an eligible class toward completing the waiting period. All other provisions of this plan apply.

Combined with Substance Abuse Limitation and Self-Reported Limitation Substance Abuse Limitation 24 months Combined with Mental/Nervous Limitation and Self-Reported Limitation Self-Reported Limitation 24 months Combined with Mental/Nervous Limitation and Substance Abuse Limitation

Work Incentive: 24 months

Indexed pre-disability earnings: Your basic monthly earnings in effect just prior to the date your disability began adjusted on the first anniversary of benefit payments and each following anniversary. Each adjustment will be based on the lesser of 10% or the current annual percentage increase in the Consumer Price Index. The Consumer Price Index means the CPI-W as published by the U.S. Department of Labor. We reserve the right to use some other similar measurement if the U.S. Department of Labor changes or stops publishing the CPI-W.

Vocational Rehabilitation: These services may include vocational testing and training, job modifications, job placement, or other services we find reasonably needed to assist you in returning to active employment either full-time or part-timeWe will determine the extent to which these services may be provided. We will pay for these services with the service provider(s), unless we agree to other arrangements.

Continuity of Coverage This document is intended to merely highlight or summarize certain aspects of the employer’s benefit program(s). It is not a summary plan description (SPD) or an official plan document. Your rights and obligations under the program(s) are set forth in the official plan documents. All statements in this summary are subject to the terms of the official plan documents, as interpreted by the appropriate plan fiduciary. In the case of an ambiguity or outright conflict between a provision in this summary and a provision in the plan documents, the terms of the plan documents control. The employer reserves the right to review, change, or terminate the plan, or any benefits under it, for any reason, at any time and without advance notice to any person.

Basic Life_AD&D Rates

Notes:

Commissions

Supp Life_AD&D Rates

Disability Rates