Policy_Document_-_LTD_A_Amendment_5_OE.pdf
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- Solicitation number
- 2026-RFP-065-PR
- Issued by
- Dane County, Wisconsin
About this file
This is a group policy amendment document issued by Standard Insurance Company to the County of Dane, Wisconsin, regarding Long Term Disability (LTD) insurance coverage under Group Policy No. 163054-A. Amendment No. 5, effective May 1, 2022, modifies the Evidence of Insurability requirements for employees enrolling in contributory LTD insurance during the specified open enrollment period from February 21, 2022 through March 18, 2022. The amendment establishes that Evidence of Insurability will be waived for eligible members applying during this open enrollment window, subject to active work provisions. However, the waiver does not apply to individuals whose previous evidence of good health was denied by the insurer or any preceding plan administrators.
The Evidence of Insurability requirement, when applicable, mandates that employees complete and sign a medical history statement, authorize the insurer to obtain health information, submit to a physical examination including blood testing if required, and provide any additional information reasonably requested regarding insurability. This amendment specifically addresses the enrollment procedures and underwriting criteria for the County of Dane's long-term disability insurance program, establishing clear guidelines for when medical evidence requirements may be satisfied or waived during the designated enrollment period.
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Text version
Group Policy No. 163054-A Page 1 of 1 of Amendment No. 5
GROUP POLICY AMENDMENT NO. 5
Attached to and made a part of Group Policy 163054-A issued to
County of Dane as Policyholder.
Effective May 1, 2022, and subject to the Active Work Provisions, item C. of the When Your Insurance
Becomes Effective section is amended to read as follows:
C. Evidence Of Insurability Requirement
Evidence Of Insurability satisfactory to us is required:
a. For late application for Contributory insurance.
b. For Members eligible but not insured under the Prior Plan.
c. For reinstatements if required.
Evidence Of Insurability will not be required to become insured for Contributory insurance on May
1, 2022 if you apply during the open enrollment period beginning February 21, 2022 and ending March 18, 2022. However, Evidence Of Insurability will not be waived if you are not insured for
Contributory coverage because you previously submitted evidence of good health that was not approved by us or by the insurer(s) of the Prior Plan or any preceding plans.
Providing Evidence Of Insurability means you must:
1. Complete and sign our medical history statement;
2. Sign our form authorizing us to obtain information about your health;
3. Undergo a physical examination, if required by us, which may include blood testing; and
4. Provide any additional information about your insurability that we may reasonably require.
STANDARD INSURANCE COMPANY
By
File details come from the government source that posted it. Updated .