Endorsement_Life_Plan_Design_-_Basic_A.pdf
PDF 55 KB Posted
- Attached to
- Group Life and Group Long Term Disability
- Solicitation number
- 240151
- Issued by
- Pima County, Tucson City, Arizona
About this file
The document is an Amendatory Rider from Hartford Life and Accident Insurance Company for a life insurance policy (Policy Number 681052) issued to the City of Tucson, effective July 1, 2017. The rider modifies the existing certificate's enrollment and dependent coverage provisions for active employees, including permanent, appointed, elected, and non-permanent employees who meet the policyholder's eligibility requirements.
The amendments primarily address how employees can enroll in Basic Employee and Dependent Life coverage, specifying enrollment periods and timelines for adding coverage after life events such as marriage or birth of a child. The rider outlines that basic employee life coverage will be automatically enrolled, but employees must complete a beneficiary designation form. For dependent coverage, employees must complete and submit a group insurance enrollment form, with options to enroll electronically during annual enrollment periods or within specific timeframes following changes in family status.
View the file
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| DEVIATIONS_EXCEPTIONS.docx | DOCX document | |
| Endorsement_Life_Plan_Design_-_Supplemental_B.pdf | ||
| Life_Plan_Design_-_Basic_Life.pdf | ||
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Text version
Form PA-9394 (10/08) (AZ) (681052) (Life) A 11370 1 (681052) 1.05
Amendatory Rider
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
One Hartford Plaza
Hartford, Connecticut 06155 (A stock insurance company)
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries.
This rider forms a part of a certificate given in connection with Policy Number 681052, issued to City of Tucson where 681052 is the Policy Number and City of Tucson is the Policyholder.
This rider becomes effective on July 1, 2017.
With respect to All Active Employees who are permanent or appointed employees, elected officials or non-permanent employees who have met the policyholder’s eligibility requirements, Your certificate is amended as follows:
1. The Enrollment provision shown in the Eligibility and Enrollment section of the Life Insurance portion of Your Certificate is amended to read as follows:
Enrollment: How do I enroll for coverage?
For Basic Employee Life Coverage, Your Employer will automatically enroll You for the Amount of Life Insurance.
However, You will be required to complete a beneficiary designation form.
To enroll for Basic Dependent Life coverage You must:
1) complete and sign a group insurance enrollment form which is satisfactory to Us and
2) deliver it to Your Employer.
You have the option to enroll electronically. Your Employer will provide instructions.
You must enroll for Basic Dependent Life coverage for Your Dependents’. If You do not enroll for Your Dependents’ coverage before becoming eligible under The Policy, or if You were eligible to enroll under the Prior Policy and did not do so, and later choose to enroll You may enroll for Your Dependents’ coverage only:
1) during an Annual Enrollment Period designated by the Policyholder; or
2) within 60 days after a Change in Family Status if You are electing initial Dependent Child(ren) coverage; or
3) within 31 days after a Change in Family Status if You are electing initial Dependent Spouse coverage.
2. The Dependent Effective Date provision shown in the Period of Coverage section of the Life Insurance portion of Your certificate is amended to read as follows:
Dependent Effective Date: When does Dependent coverage start?
Non-Contributory Coverage will start on the latest to occur of:
1) the date You become eligible for Dependent Life Insurance, if You enroll on or before that date; or
2) the July 1st on or next following the last day of the Annual Enrollment Period, if You enroll during an Annual
Enrollment Period; or
3) effective on Your Dependent Child’s date of birth, if You are electing initial Dependent Child(ren) coverage within 60 days after a Change in Family Status; or
4) first day of the month following date of marriage, if You are electing initial Dependent Spouse coverage within
31 days after a Change in Family Status.
In all other respects the certificate remains the same.
Signed for Hartford Life and Accident Insurance Company
File details come from the government source that posted it. Updated .