Endorsement_Life_Plan_Design_-_Supplemental_B.pdf
PDF 56 KB Posted
- Attached to
- Group Life and Group Long Term Disability
- Solicitation number
- 240151
- Issued by
- Pima County, Tucson City, Arizona
About this file
This document is an Amendatory Rider from Hartford Life and Accident Insurance Company for a life insurance policy issued to the City of Tucson, with Policy Number 681052, effective July 1, 2017. The rider amends the 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 clarify the process for enrolling in supplemental employee and dependent life insurance coverage, including electronic enrollment options and specific conditions for coverage start dates.
The rider details the enrollment procedures, which include completing and signing a group insurance enrollment form and delivering it to the employer. It outlines the timing and conditions for enrolling in dependent coverage, such as during annual enrollment periods or within 31 days of a change in family status. The document also specifies the effective dates for coverage, distinguishing between contributory coverage that does not require evidence of insurability and coverage that does require evidence of insurability. The amendments provide clear guidelines for when dependent life insurance coverage begins, taking into account factors such as eligibility dates, annual enrollment periods, and marriage status.
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Other files
| File | Type | Posted |
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| Group_Life_and_Group_Long_Term_Disability_(Addendum_#3_Revision).pdf | ||
| Method_of_Approach_Questionnaire_updated_07022024.xlsx | XLSX spreadsheet | |
| Financial_Workbook_-_Life_and_LTD_RFP_final.xlsm | XLSM spreadsheet | |
| Q_E_Questionnaire.xlsx | XLSX spreadsheet | |
| DEVIATIONS_EXCEPTIONS.docx | DOCX document | |
| Life_Plan_Design_-_Basic_Life.pdf | ||
| Life_Plan_Design_-_Retirees.pdf | ||
| Employee_Leaves_Directive_2-01-07.pdf | ||
| Life_Plan_Design_-_Supplemental_Life.pdf | ||
| LTD_Plan_Design.pdf | ||
| Endorsement_Life_Plan_Design_-_Basic_A.pdf | ||
| NON-DISCLOSURE_STATEMENT.pdf | ||
| Offer_and_Acceptance.pdf | ||
| 5369-B.PDF | ||
| COT_ARPA_Terms_and_Conditions.pdf | ||
| FTA_TERMS_AND_CONDITIONS.pdf |
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Text version
Form PA-9394 (10/08) (AZ) (681052) (Life) B 11370 1 (681052) 2.03
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 Supplemental Life coverage?
To enroll for Supplemental Employee coverage You must:
1) complete and sign a group insurance enrollment form which is satisfactory to Us and
2) deliver it to Your Employer.
To enroll for Supplemental Dependent 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 Supplemental Dependent coverage. 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 31 days after a Change in Family Status if You are electing initial Dependents’ coverage.
Enrollment may be subject to the Evidence of Insurability Requirements provision.
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?
Contributory Coverage, for which Evidence of Insurability is not required, will start on the latest to occur of:
1) the date You become eligible for Supplemental 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) first day of the month following date of marriage, if You are electing initial Supplemental Dependent’s coverage within 31 days after a Change in Family Status.
Coverage for which Evidence of Insurability is required, will become effective on the later of:
1) the date You become eligible for Dependent coverage; or
2) the date We approve Your Dependents' Evidence of Insurability.
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 .