FORT WORTH ISD BENEFIT GUIDE EFFECTIVE: 09/01/2022 - 8/31/2023 WWW.MYBENEFITSHUB.COM/FORTWORTHISD
2 How to Enroll 4-5 Annual Benefit Enrollment 6-13 1. Benefit Updates 6 2. Section 125 Cafeteria Plan Guidelines 7 3. Annual Enrollment 8 4. Eligibility Requirements 9 5. Helpful Definitions 10 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) 11 TRS-ActiveCare Medical 12-19 EECU Health Savings Account (HSA) 20-21 Higginbotham Flexible Spending Account (FSA) 22-31 United Concordia Dental Indemnity 32-33 Humana Dental DHMO and Advantage 34-43 Humana Vision 44-47 The Hartford Long Term Disability 48-67 American Public Life Cancer 68-71 MetLife Optional Life and AD&D 72-77 Texas Life Permanent Life 78-81 CHUBB Accident 82-85 Texas Legal Services 86-91 January Savings Plan 92-93 MASA Medical Transportation 94-96 FLIP TO... HOW ENROLTOLPG. 4 SUMMARYPAGESPG. 6 BENEFITSYOURPG. 12
3 Benefit Contact Information FINANCIAL BENEFIT SERVICES FLEXIBLE SPENDING ACCOUNT HEALTH SAVINGS ACCOUNT Financial Benefit Services (800) 583 www.mybenefitshub.com/fortworthisd6908 flexservices.higginbotham.netF:P:Higginbotham(866)4193519(817)8829267 (817)EECU 882 www.eecu.org0800 FWISD BENEFITS OFFICE DENTAL DHMO DENTAL INDEMNITY (817) 814 Email:www.fwisd.org2240benefits@fwisd.org Group # www.humanadental.com(800)Humana5737019794760 Group # 821479 000/001/002/003 United Concordia (800) 332 www.ucci.com0366 TRS ACTIVECARE MEDICAL DENTAL ADVANTAGE COBRA (DENTAL, VISION) Blue Cross Blue Shield of Texas (866)355 5999 www.bcbstx.com/trsactivecare Group # 573701 Humana (800) 979 www.humanadental.com4760 National Benefit Services (800) 274 0503 www.nbsbenefits.com BAYLOR SCOTT AND WHITE LEGAL SERVICES COBRA (MEDICAL) Scott & White (800) 321 www.trs.swhp.org7947 Texas Legal (800) 252 www.texaslegal.org9346 (833)BSwift682 8972 BLUE ESSENTIALS MEDICAL PERMANENT LIFE HIGGINBOTHAM Blue Essentials HMO 888 378 www.bcbstx.com/trshmo1633 Texas Life (817) 545 3900 ext. 102 www.texaslife.com www.higginbotham.net(817)Higginbotham3477031 OPTIONAL LIFE AND AD&D DISABILITY 403(B) PLAN / 457 PLAN Group # 122673 1 G (800)MetLife638 6420 www.metlife.com Group # 395332 The (866)Hartford5479124 www.thehartford.com/mybenefits TCG www.tcgservices.com(800)Administrators9439179 VISION CANCER JANUARY SAVINGS PLAN Group # www.humanavisioncare.com(866)Humana5737015370229 Group # American18296Public Life (800) 256 www.ampublic.com8606 Fort Worth ISD Payroll Department (817) 814 www.fwisd.org2180 MEDICAL TRANSPORTATION ACCIDENT (800)MASA423 3226 www.masamts.com Group # BKRC671 (866)CHUBB445 www.combinedinsurance.com/us8874 en/ Corporate/Abou Chubb.aspx
Enrollment made simple through the new FBS Benefits App! OR SCAN Text “FBS FWISD” to (800) 583-6908 and get access to everything you need to complete your benefits enrollment: • Enrollment Resources • Online Support • Interactive Tools • And more! MOBILE APP DOWNLOAD Text “FBS FWISD” to (800) 583-6908 App Group #: FBSFWISD
How to Log In 1 www.mybenefitshub.com/fortworthisd 2 CLICK LOGIN 3 Benefits are available for spouses (including same sex). If you have any questions, please contact benefits@fwisd.org or (817) 814 2240. YourUsername:Username Is: Your email in THEbenefitsHUB. (Typically your work email) Your Password Is: Four (4) digits of your birth year followed by the last four (4) digits of your Social Security Number If you have previously logged in after July 1, 2022, you will use the password that you created, not the password format listed above. ENTER USERNAME & PASSWORDINTERACTIVEBENEFITINFOTOOLS ONLINE SUPPORT
Member ID numbers do not change unless you change medical plans, you may use your existing ID card until your new card arrives.
Higginbotham
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• All benefits eligible employees may have a Flexible Spending Account. FSA elections must be re elected annually and are USE IT or LOSE IT with a 60 day grace period. 2022 FSA Max is $2,850. Limited FSA If employees elect both an FSA and HSA, the FSA becomes LIMITED and may only be used for Dental and Vision expenses. calling at (817) 814 2240. 5. is available 8/4 8/18, M F, 8 5 by calling the Call Center at 817 710 8135.
ONLINE BENEFIT Thewww.mybenefitshub.com/fortworthisdPORTALemployeebenefitportalprovidesaccess to benefit information 24/7. You can review and print the consolidated enrollment form, benefit guide, access claim forms, plan summaries and links to carrier provider searches. • Login and complete your benefit enrollment from 07/18/2022 08/18/2022 • Login assistance is available by
• Health Savings Accounts require enrollment in a High Deducible medical plan. HSA elections must be re elected annually. 2022 HSA max is $3,650 individual, $7,300 family, +55 may add $1,000.
Rates for TRS ActiveCare plans are now regionalized by Education Service Center. FWISD is located in Region 11. Rates for 2022 23 have decreased for Primary + and remained the same for the Primary, HD and AC2.
TRS ACTIVECARE Plan changes effective 9/1/2022
the FWISD Benefits Department
• Enrollment assistance
Baylor Scott and White received a slight increase. All plans had changes, review TRS plan documents on benefit website for details, highlights include: New specialty drug program through PrudentRx. New musculoskeletal health program provided by Airrosti and Hinge Health All ActiveCare plans will now have a Consultation fee for TRS Virtual Health Teladoc®. Primary, Primary + and AC2 plans now have a capped maximum out of pocket cost for insulin. Preventative Care remains at $0 for enrolled members.
• REQUIRED: Provide correct dependent social security numbers. SUMMARY PAGES Annual EnrollmentBenefit
Benefit Office hours are M F, 8
REVIEW HSA AND FSA ELECTIONS
7 CHANGES IN (CIS):STATUS QUALIFYING EVENTS
A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.
Eligibility for Government Programs
SUMMARY PAGES
Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 31 days of the event and meet with your Benefit Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.
Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.
If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.
Judgment/Decree/Order
Change in Status of Employment Affecting Coverage Eligibility
Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.
An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements under an employer's plan may include change in age, student, marital, employment or tax dependent status.
A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).
Marital Status
Gain/Loss of EligibilityDependents'Status
A Cafeteria plan enables you to save money by using pre tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit.
Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.
Change in Number of Tax Dependents
New Hire Enrollment
Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent eligibility.
SUMMARY PAGES
Employee Eligibility Requirements
All new hire enrollment elections must be completed in the online enrollment system within 31 calendar days from your date of hire. Failure to complete elections during this time frame will result in forfeiture of coverage.
During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs.
• Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.
FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse's FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance.
Benefits eligible
• Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.
• Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.
Medical and Supplemental Benefits: Employees who are active contributing TRS members are eligible for all benefits.
Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse eligibility.
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Employees who are not active contributing TRS members are eligible to participate in TRS ActiveCare. Eligibility criteria may be found at https://www.fwisd.org/Page/2561.
employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if your 2022 benefits become effective on September 1, 2022, you must be actively at work on September 1, 2022 to be eligible for your new benefits.
Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee's enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.
9 PLAN CARRIER MAXIMUM AGE CONTINUATION Medical BCBS 26 COBRA bswift Dental United Concordia 26 COBRA NBS Dental Humana 26 COBRA NBS Vision Humana 26 COBRA NBS Disability The Hartford N/A N/A Basic Life MetLife N/A Conversion* Optional Life and AD&D MetLife 26 Conversion* Individual Life Texas Life 26 Contact TX Life for direct pay* Medical Flex (FSA) Higginbotham IRS Dependent COBRA NBS Dependent Care Higginbotham 12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes N/A Accident CHUBB 26 Contact CHUBB for direct pay Health Savings Account EECU IRS Dependent covered on your HDHP Contact EECU for direct pay Cancer APL 26 Conversion* Medical Transportation MASA 26, Including disabled children Complete application on benefits website to continue Platinum plan Requirements You can cover eligible dependent children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the Fort Worth ISD or as both employees and dependents.Ifyourdependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your Benefit Administrator to request a continuation of coverage. * Contact Carrier within 30 days of loss. SUMMARY PAGES
Pre Existing Conditions
Annual Enrollment
Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).
Helpful Definitions
The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period.
Out of Pocket Maximum
For benefit summaries and claim forms, go to your school district’s benefit portal: www.mybenefitshub.com/fortworthisd
For supplemental benefit questions, you can contact your Benefits department or you can call 817 814 2240 for assistance. Where can I find forms?
If the insurance carrier provides ID cards, you can expect to receive those 3 4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.
If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.
Actively at work and/or pre existing condition exclusion provisions do apply, as applicable by carrier.
Annual Deductible
The most an eligible or insured person can pay in co insurance for covered expenses.
The period during which existing employees are given the opportunity to enroll in or change their current elections.
Calendar Year January 1st through December 31st Co insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
SUMMARY PAGES
Please go to: www.mybenefitshub.com/fortworthisd. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.
10 on a full time basis, either at one of the employer’s usual places of business or at some location to which the employer’s business requires you to travel If you will not be actively at work beginning 9/1/2022 please notify your benefits administrator.
Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section.
In Network Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.
Q&A Who do I contact with Questions?
When will I receive ID cards?
How can I find a Network Provider?
The amount you pay each plan year before the plan begins to pay covered expenses.
Guaranteed Issue (GI)
11 Health Savings Account (HSA) (IRC Sec. 223) Flexible Spending Account (FSA) (IRC Sec. 125) Description Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax free. Allows employees to pay out of pocket expenses for copays, deductibles and certain services not covered by medical plan, tax free. This also allows employees to pay for qualifying dependent care tax free. Employer Eligibility TRS ActiveCare HD All employers Contribution Source Employee Employee Account Owner Individual Employer Underlying RequirementInsurance High deductible health plan None Maximum Contribution $3,650 single (2022) $7,300 family (2022) $2,850 Permissible Use Of Funds Employees may use funds any way they wish. If used for non qualified medical expenses, subject to current tax rate plus 20% penalty. Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC). Cash-Outs of Unused Amounts (if no medical expenses) Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65). Not permitted Year to year rollover of account balance? Yes No. Remaining balances are available through October 31, 2023. Does the account earn interest? Yes No Portable? Yes, portable year to year and between jobs. No SUMMARY PAGESHSA vs. FSA FLIP TO FOR HSA INFORMATION PG. 20 FLIP TO FOR FSA INFORMATION PG. 22
12 Fort Worth Independent School District ActiveCare Plan Rates (Effective 9 1 2022 through 8 31 2023 ) TRS ACTIVECARE EmployeePRIMARYCost TRS ACTIVECARE EmployeeHD Cost TRS ACTIVECARE EmployeePRIMARY+Cost TRS ACTIVECARE Employee2 Cost BAYLOR SCOTT AND WHITE EmployeeWHITECost 12 Checks Employee Only $130.00 $142.00 $238.00 $726.00 $282.24 Employee Spouse $889.00 $922.00 $997.00 $2,115.00 $1,144.08 Employee Child(ren) $464.00 $485.00 $558.00 $1,220.00 $628.65 Employee Family $1,118.00 $1,158.00 $1,327.00 $2,554.00 $1,360.24 Spousal Both Employees of FWISD* $831.00 $871.00 $1,040.00 $2,267.00 $1,073.24 Spousal One Employee of FWISD and one Other District** $415.50 $435.50 $520.00 $1,133.50 $536.62 18 Checks Employee Only $86.67 $94.67 $158.67 $484.00 $188.16 Employee Spouse $592.67 $614.67 $664.67 $1,410.00 $762.72 Employee Child(ren) $309.33 $323.33 $372.00 $813.33 $419.10 Employee Family $745.33 $772.00 $884.67 $1,702.67 $906.83 Spousal Both Employees of FWISD* $554.00 $580.67 $693.33 $1,511.33 $715.49 Spousal One Employee of FWISD and one Other District** $277.00 $290.33 $346.67 $755.67 $357.75 24 Checks Employee Only $65.00 $71.00 $119.00 $363.00 $141.12 Employee Spouse $444.50 $461.00 $498.50 $1,057.50 $572.04 Employee Child(ren) $232.00 $242.50 $279.00 $610.00 $314.33 Employee Family $559.00 $579.00 $663.50 $1,277.00 $680.12 Spousal Both Employees of FWISD* $415.50 $435.50 $520.00 $1,133.50 $536.62 Spousal One Employee of FWISD and one Other District** $207.75 $217.75 $260.00 $566.75 $268.31 TRS Active Care Rates for employees who do not contribute to TRS 12 checks Employee Only $417.00 $429.00 $525.00 $1,013.00 $569.24 Employee & Spouse $1,176.00 $1,209.00 $1,284.00 $2,402.00 $1,431.08 Employee & Child(ren) $751.00 $772.00 $845.00 $1,507.00 $915.65 Employee Family $1,405.00 $1,445.00 $1,614.00 $2,841.00 $1,647.24 18 Checks Employee Only $278.00 $286.00 $350.00 $675.33 $379.49 Employee & Spouse $784.00 $806.00 $856.00 $1,601.33 $954.05 Employee & Child(ren) $500.67 $514.67 $563.33 $1,004.67 $610.43 Employee Family $936.67 $963.33 $1,076.00 $1,894.00 $1,098.16 24 checks Employee Only $208.50 $214.50 $262.50 $506.50 $284.62 Employee & Spouse $588.00 $604.50 $642.00 $1,201.00 $715.54 Employee & Child(ren) $375.50 $386.00 $422.50 $753.50 $457.83 Employee Family $702.50 $722.50 $807.00 $1,420.50 $823.62
19 NOTES
About this Benefit HSA (Health Savings Account) The earnedinterestinan HSA is tax free. EECU Money withdrawn for income.fallsspendingmedicalneverundertaxable This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Debit Card use your EECU HSA Mastercard® debit card to pay healthcare providers at point of sale or by following the instructions provided on a bill from a medical provider. • Online Bill Pay sign up, at eecu.org, and use EECU’s free online banking and bill pay to make payments to medical providers directly from your HSA. • Online Transfers use EECU’s online banking or mobile app; reimburse yourself for out of pocket expenses by
•
or use our secure email. Member Service is available Monday through Friday from 8:00am 7:00pm CT, Saturdays from 9am 1pm CT and closed on Sunday. • Account Statements monthly statements show all your account activity for that period. You can receive free online statements or pay $2 per printed statement. * Contributions, investment earnings, and distributions are tax free for federal tax purposes if used to pay for qualified medical expenses, and may or may not be
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21 HSA (Health Savings Account) What is an HSA? Health Savings Account (HSA) enables you to save for and conveniently pay for qualified healthcare expenses, while you earn tax free interest and pay no monthly service Openingfees.aHealth Savings Account provides both immediate and long term benefits. The money in your HSA is always yours, even if you change jobs, switch your health plan, become unemployed or retire. Your unused HSA balance rolls over from year to year. And best of all, HSAs have tax free deposits, tax free earnings and tax free withdrawals. And after age 65, you can withdraw funds from your HSA penalty free for any purpose*. EECU HSA Benefits • Save money tax free for healthcare expenses contributions are not subject to federal income taxes and can be made by you, your employer or a third party* • No monthly service fee so you can save more and earn more • Earn competitive dividends on your entire balance compounded daily and paid monthly from deposit to withdrawal • Conveniently pay for qualified healthcare expenses with a free, no annual fee EECU HSA Debit Mastercard® or via EECU’s free online bill pay. (HSA checks are also available upon request, for a nominal fee**) • Free online, mobile and branch access allows you to actively manage your account however you prefer • Comprehensive service and support to assist you in optimizing your healthcare saving and spending • Federally insured to at least $250,000 by NCUA 2022 Annual HSA Contribution Limits Individual: $3,650 Family: $7,300 Catch Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch up contribution of an additional $1,000. • Health Savings accountholder • Age 55 or older (regardless of when in the year an accountholder turns 55) • Not enrolled in Medicare (if an accountholder enrolls in Medicare mid year, catch up contributions should be prorated) Authorized Signers who are 55 or older must have their own HSA in order to make the catch up contribution
How to Use Your Funds HSA making ordered upon request for a fee. You can use these checks to pay healthcare providers and suppliers. To Manage Your Account Online check your balance, pay healthcare providers and arrange deposits; sign up for online banking at www.eecu.org. EECU’s mobile app allows you to manage your account on the go; download “EECU Mobile Banking” in Apple’s App Store and Google Play. Member Service call 817 882 0800 for help with your HSA questions or transactions. You can also chat with us online at eecu.org subject Medical found IRS Publication 502, http://www.irs.gov/ pdf/p502.pdf. As described in IRS publication 969, http://www.irs.gov/pub/irs pdf/ p969.pdf, certain over the counter medications (when prescribed by a doctor) are considered eligible medical expenses for HSA purposes. If an individual is 65 or older, there is no penalty to withdraw HSA funds. However, income taxes will apply if the distribution is not used for qualified medical expenses. For more information consult a tax adviser or state department of revenue. All contributions and distributions are responsibility must be within IRS regulatory limits. Call 817 882 0800 or stop by an EECU branch to order standard checks at no charge (excludes shipping and handling) or order custom checks prices vary. your receipts for all qualified medical expenses. does not verify eligibility. You are responsible for making sure payments are for qualified medical expenses.
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A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows to pay certain qualified expenses on a pre tax basis, thereby reducing taxable income. can set aside a pre established amount of money per plan year in a Flexible Spending Account (FSA). Funds allocated to the FSA/LFSA/DCFSA must be used during the plan year or are forfeited. However, your plan contains an additional two month grace period to spend elected funds through October 31, 2023. Participants have until November 30, 2023 to submit for of pocket expenses incurred with September 1, 2022 October 31, 2023. of this
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The Flexible Spending Accounts & what they reimburse: • Full FSA (FSA) Medical, Dental, Vision expenses and over the counter Items. • Limited FSA (LFSA) Dental and Vision expenses • Dependent Care (DCFSA) Day care, Before & Afterschool care, Day Camps & Elder Day Care This is a general overview of your plan benefits. If the terms
outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd FSA (Flexible Spending Account) HIGGINBOTHAM FLIP TO… PG. 11 FOR HSA VS. FSA COMPARISON
you
Must money be deposited in my account before I pay expenses or file a claim?
A Flexible Spending Account (FSA) is a benefit provided by your employer that lets you set aside a certain amount of your paycheck into an account before paying income taxes. Then during the year, you can use the funds in the account to pay for qualified expenses with untaxed dollars.
The Health FSA is used to pay for expenses not covered by insurance. These include copays, over the glasses, contacts, orthodontics, prescription drugs and more.
What if I don't use all the money in my account?
Your biggest benefit is savings on payroll withholding taxes. You will save $25 to $40 on every $100 you budget to pay for qualified expenses .
Yes, but only in certain situations. For the Health FSA and Dependent Care FSA, you can change your election if you have a change in status or if there's a change in employment for you, your spouse or a dependent.
Why should I participate in the plan?
What is a Flexible Spending Account?
Can I change my contribution during the year?
No. The entire annual amount you elect for the Health Care Spending Account (Health FSA) is available on the first day. However, only amounts contributed to date are available for the Dependent Care Spending Account (Dependent Care FSA). I already have health insurance. Why should I participate in the Health FSA?
You do have the option to enroll in both a HSA and a FSA, however doing so will make your FSA a “Limited” FSA, which means it will only be available for dental and vision expenses. All medical expenses would be processed through your HSA.
I don't use my employer's health insurance. Can I still save? Yes. You can still set aside money before taxes to budget and pay for qualified expenses. But remember, a qualified expense paid from this plan is not eligible for reimbursement from another plan.
What expenses qualify for payment?
If I set aside part of my pay, won't I make less money? No. For every dollar you set aside to pay qualified expenses, you save FICA and federal income tax withholding. Your net take home pay will increase by the tax you save. Plus, when you pay for a qualified expense or receive a cash reimbursement, it's taxfree.
IMPORTANT INFORMATION
Most qualified expenses are for goods or services that you'll buy any way. They include health care costs such as copays, doctors' fees, over the counter items and prescriptions, dental and eye care expenses and day care expenses for dependents so you can work. How do I know how much is available for me to spend, and how do I file a claim?
Contributions that aren't used during the plan year are forfeited back to your employer, “Use It or Lose It”. Check with your employer to learn your options. What happens to my accounts if I terminate Spending Account)
Your balance and claim forms are available 24/7 online at flexservices.higginbotham.net or by calling 866 claims is easy. Just complete a claim form, attach a copy of the bill and then send it to us. You'll receive your tax reimbursement within 72 hours.
FSA (Flexible
24 How FSAs Work When you pay for these expenses with pre tax dollars, you pay no social security or federal income tax on your contributions. Your taxable income and your taxes are reduced. Case Study Let's say you earn $25,000 per year. And you are paid semi monthly, so each paycheck is for gross compensation of $1,041.67. You have insurance premiums and other expenses eligible for payment through the Health FSA of $62.50 per pay period. Here is a comparison of what your paycheck looks like with and without the Flexible Spending Account: When you incur a medical, dental or vision expense, you'll be reimbursed the full amount of the expense at that time, up to your yearly contribution election. Your account information is available online at flexservices.higginbotham.net or by calling 866 419 3519 . FSA (Flexible Spending Account) Without Plan With Plan Gross Earnings $1,041.67 $1,041.67 Plan Contributions $0 $62.50 Taxable Income FICA Federal $1,041.67($79.69) ($105.42) ($74.91)$979.17 ($93.41) Take Home Pay $856.56 $810.85 Health ExpensesCare ($62.50) ($0) Remaining Income $794.06 $810.85 Savings $33.58 $402.96MonthlyAnnually
FOR EXAMPLE: You're going to contribute $500 for the plan year ($41.67 per month). On January
15, you visit your eye doctor and receive your exam and contact lenses for a total charge of $200. Submit that receipt online or by fax, email, mail or the mobile app and receive your full $200 back within 24 72 hours, even though you don't have the $200 in your account at the time. You are entitled to the entire $500 from day one of the plan year. When you pay for your expenses with pre tax dollars, your net income is increased! Orthodontia Expenses If you're currently paying on an orthodontia contract for yourself, your spouse or your children, you can put that payment aside in your Health FSA and use the WeathCare debit card to make the payment each month to your orthodontist. All we need is a copy of your current contract and the first payment receipt made with the WeathCare debit card. Your monthly orthodontic payments will be substantiated automatically for the current plan year.
25 FSA (Flexible Spending Account) Health Care Expenses That Qualify for Reimbursement Only qualified health care expenses NOT reimbursed by insurance can be claimed on a Flexible Spending Account plan. • Acupuncture • Alcoholism treatment • Ambulance • Artificial limbs/teeth • Chiropractics • Christian Science Practitioner’s fees • Contact lenses and solutions • Copayments (doctor, dental, vision, pharmacy) • Costs of physical or mental illness confinement • Crutches • Deductibles • Dental fees (cosmetic procedures not eligible) • Dentures • Diagnostic fees • Drug and medical supplies (syringes, needles, etc.) • Endodontist fees • Eye examination fees • Eyeglasses prescribed by your doctor • Eye surgery (cataracts, LASIK, etc.) • Hearing devices and batteries • Home health care • Hospital bills • Insulin • Laboratory fees • Laser eye surgery • Obstetrics and fertility • Office visits • Oral surgery • Orthodontic fees • Orthopedic devices • Osteopath fees • Oxygen • Periodontist fees • Physician fees (cosmetic procedures not eligible) • Podiatrist fees • Prescribed medicines • Psychiatric care • Psychologist and psychiatrist fees • Radiology • Routine physicals and other non diagnostic services or treatments • Smoking cessation programs • Surgical fees • Wheelchair • Vitamins with doctor’s letter • X rays and MRI Health Care Expenses That Qualify with a Doctor’s Prescription • Bedpans • Boost/Pediasure • Foot spa • Massagers • Massages • Re constructive surgery in connection with birth defect, disease or accident • Ring cushions • Special school for disabled children • Therapeutic support gloves • Weight loss program fees and over the counter drugs pertaining to a specific disease • Wigs for hair loss caused by disease Health Care Expenses That Do Not Qualify for Reimbursement • Concierge medical subscriptions • Cosmetic surgery, procedures and/or medications • Dental bleaching and electronic toothbrushes • Hair restoration (procedures, drugs or medications) • Health club or gym memberships for general health • Mail order prescriptions from another country • Marriage and family counseling • Premiums you or your spouse pay for insurance coverage (payroll deducted premiums sponsored by your employer are eligible under the Premium Only Plan) • Weight loss program food supplements • Weight loss programs for general health or appearance
26 Qualified Over the Counter Expenses REIMBURSEMENTS ARE AS SIMPLE AS 1, 2, 3! 1. Complete a claim form. 2. Provide required documentation. 3. Submit online or by fax, email, mail or the mobile app. FSA (Flexible Spending Account) • AntisepticsAntiseptic wash or ointment for cuts or SublimedIodineFirstBoricBenzocainescrapesswabsacidpowderaidwipestincturesulfurpowder • AsthmaBronchodilator/expectorantMedications tablets/ asthma inhalers • Cold, Flu and Allergy Medications Allergy medications Cold relief, cough relief or flu relief (liquid , tablets or drops) Homeopathic sinus medications Medicated chest rub Nasal decongestant (drops, inhaler, spray or strips) Sinus medications, sinus and allergy nasal spray Vapor patch cough suppressant • Ear/EyeAirplaneCareear protection Ear drops for swimmers Ear water drying aid Ear wax removal drops Homeopathic earache tablets • Health Aids Anti fungal treatments Diuretics and water pills Hemorrhoid relief Lice SleepingRespiratoryMotionMedicatedcontrolbandagessicknesstabletsstimulantammoniaaids • PainArthritisRelief pain reliever Bunion and blister treatments Itch Orajelrelief Pain reliever, aspirin and non aspirin Throat pain medications • HealthBandages,Productsgauze and related items Blood pressure monitors Cholesterol test kits and supplies Colorectal cancer screening tests Condoms and other OTC Contactcontraceptiveslenscleaning solutions Crutches , canes , walkers and Denturewheelchairsadhesives Diabetic supplies, including Insulin Feminine hygiene products Fertility monitors First aid kits Hearing aids and batteries Heat wraps and cold packs Home drug tests Hydrogen peroxide Incontinence supplies (Depends and Serenity pads) Latex Occlusalglovesguards (for teeth grinding) Oral Ovulationsyringespredictor kits Pregnancy test kits Reading glasses and other OTC Rubbingeyeglassesalcohol Thermometers • SkinColdAntiAcneCaremedicationsitchlotionsore/feverblister medications Corn and callus removal Eczema Medicatedcreambath products Wart removal medications • Stomach Care Acid AntacidAntacidAntacidreducersgumliquidtablets Anti diarrhea medications Gas prevention (liquid, tablets or UpsetPrilosecPinwormLaxativesIpecacdrops)syruptreatmentstomachmedications • Aromatherapy • Baby bottles and cups • Baby oil • Baby wipes • Blistex/Chapstick • Breast enhancement system • Cosmetics • Cotton swabs • Dental floss • Deodorants • Facial care products • Feminine care fragrances • Hair regrowth • Insoles • Low calorie foods • Low "carb" foods • Mouthwash/oral care/toothbrushes • Petroleum jelly • Shampoo and conditioner • Skin care • Spa salts • Sun clips • Sun tanning products Over the Counter Expenses That Do Not Qualify for Reimbursement
27 FSA (Flexible Spending Account) FSAStore for Eligible Products The thousands of products that are available at FSA Store are all FSA and HSA eligible or eligible with a prescription and can be purchased with your FSA/HSA debit card or any major credit card. Free shipping is offered on orders of at least $50, and prices on brand name products are very competitive. When you take into account that you're using pre tax dollars, you generally save up to 40 percent. Visit FSA Store by logging into www.fsastore.com Over the Counter Prescriptions Easily shop for FSA eligible prescription products using your FSA/HSA debit card. FSAStore makes spending your FSA funds easy. The services channel allows you to search for nearby eligible services, such as acupuncture and chiropractic care. You can browse through a database of more than 300,000 health care providers by zip code. A learning center gives you instant access to common FSA questions and answers and is focused on keeping you informed about ongoing changes to FSA and HSA benefits. ONEYOURSHOPPINGSTOPFORALLOTCNEEDS
28 Health Care Spending Account Worksheet Accurate budgeting of out of pocket medical expenses not reimbursed or covered by insurance is necessary to gain maximum benefit from the Health Care Spending Account. Only expenses that you know you or your family will incur during the plan year can be included in the program. You should consider your cost of deductibles and coinsurance features of any medical and dental insurance policies as well as those costs not covered by insurance. This is only a worksheet and just for your use. Visit flexservices.higginbotham.net for more information. FSA (Flexible Spending Account) PLANNED MEDICAL EXPENSES Known annual medical expenses (not covered by insurance that your entire family will incur during the plan year for the following services): Deductibles Coinsurance Prescriptions and Doctor Visits (Copays) Over the Counter Medications Massage Therapy (RX needed) LASIK Eye Surgery Medical Supplies and Equipment Therapist, Psychologist or Chiropractor Fees Hearing Aids and Supplies Laboratory and X ray Expenses PLANNED DENTAL CARE Your portion of these expenses: Extractions,FillingsDeductiblesandCrownsDentures and Bridgework Oral OrthodonticSurgery Expenses PLANNED VISION CARE Examination Glasses/RX Sunglasses Contact Lenses, Solution and Materials TOTAL $ Total Expenses / (# of pay periods) = $
• Care for spouse or dependents of any age who spend at least eight hours a day in your home and are mentally or physically incapable of self care
Now
Expenses That Do Not Qualify for Reimbursement
The maximum flex deduction per family per year is $5,000 when filing jointly or head of household and $2,500 when married filing separately. However, the maximum limit for the child tax credit on your federal income tax return is $6,000 and $3,000 whatever amount you don't deduct from your Flexible Spending Account, you may be able to deduct the difference (up to $3,000 or $6,000 total) on your income tax return.
You actually get a "tax refund" on every paycheck after electing the benefits because you pay no tax on the money you set aside each pay period. You decide how much money to put into the plan and where and when to spend the money in your account.
This is a great way to budget. A regular amount is deducted from your paycheck, but the entire annual election is always available for you to spend on eligible expenses from day one of the plan year.
Savings
Flexible Spending Accounts aren't just for people who need prescription drugs and have children everyone has medical expenses, not just families. And with the IRS Revenue ruling, anyone who buys overthe counter (OTC) drugs may be reimbursed through the plan. The plan isn't just for prescription drugs. Things like cough syrup, pain relievers, allergy medicine, etc. are included.
You and your spouse must be employed in order to participate, or one of you can be a full time student, actively looking for work or Yourdisabled.careprovider cannot be your dependent. The debit card cannot be used for dependent child care.
• Household service if part of the service is for the care of a qualifying person
Expenses That Qualify for Reimbursement
Reasons to Take Advantage of the Tax
How it Works
• Overnight camps (only day camps can be considered)
29
• Any care for your children whom you claim as tax dependents under the age of 13 (a child may qualify for only part of the year if he/she turns 13 mid year)
You'll save $25 to $40 on every $100 you budget to pay for qualified expenses.
FSA (Flexible Spending Account)
• Kindergarten, unless it can be determined that the educational part is incidental and cannot be separated from the cost of care
Once you have enrolled in the plan, everything you need can be found on the MyWealthCare website. You can even enter your claim online. Then you just print the claim form and submit it along with your detailed receipts. It only takes a few moments to familiarize yourself with the reimbursement plan online. Don't worry that you cannot afford to have any more money taken out of your paycheck. Did you know you can get money out of the plan before you put it in? By joining the plan, you can have it pay your health care expenses in full at the time of service, even before you make your It'scontribution.OKifboth you and your spouse enroll in a similar plan at work. There is no IRS limit on the amount of medical expenses that can be reimbursed per household. Each employer sets the annual limits for the Health FSA plan.
Don't worry about it making your social security benefits smaller. Social security benefits are based on your lifetime earnings history. Yours may be slightly reduced by participating in the plan. However, tax advisors will tell you that the tax savings you earn today will far outweigh any reduction in social security Dobenefits.youtake a deduction for medical expenses on a Form 1040? If so, you can only do so after you spend in excess of 7.5 10 percent of your adjusted gross income for them. The first dollar you pay for unreimbursed medical expenses is not deductible on your Form 1040. But through the Health FSA, the very first dollar you spend will earn you 25 40 percent in tax savings.
Dependent Care Spending Account
• Before and after school care
Taking advantage of the Health FSA and Dependent Care FSA doesn't change what you do at tax time.
Note: Health Care Reform limits the annual election for Health FSAs. Check with your employer to learn the maximum amount you can contribute.
The best document to submit is the EOB from your health insurance provider, as all these details will be included once insurance has been processed.
Keys to Submitting Your Claims to Avoid
THANK YOU FOR YOUR HELP
Because you won't pay social security tax on the amount of gross pay you set aside to pay for qualified expenses, your social security benefits at retirement may be slightly reduced. However, most tax advisors recommend taking advantage of current tax savings opportunities like the Health FSA and Dependent Care FSA. Also, if disability insurance is paid on a pre tax basis, any future benefits you receive will be taxable.
Dependent Care Spending Account
The more you earn, the more you'll save. In addition, you'll also save social security tax (FICA) with a Dependent Care Spending Account. So, don't wait until April 15 to take the credit. You can save taxes on every paycheck now. Which is best for you? Visit flexservices.higginbotham.net and use the easy calculator to determine your savings. Are there any negatives?
On your doctor visit copays, we need the actual statement from the doctor if the charge is anything other than a copay amount. They will print a statement for you. We need date of service, service rendered, patient's name, insurance payments, etc. If the statement is pink or yellow, please make a dark copy before faxing. The pink and yellow copies are not legible when faxed. OTC items are eligible for reimbursement. If your card gets denied at the Provider, pay out of pocket, and submit your receipt for reimbursement. Some of the debit card machines do not have the OTC codes connected to their machines.
Submitting a complete claim request helps us pay all eligible claims in full and will also eliminate letters to you requesting more information regarding the reimbursement!
Mobile Access Benefits at Your Fingertips You can access your employee account information on your smartphone with the mobile app for iPhone and Android. Locating and Loading the Mobile App Simply search for "Higginbotham" on the App Store™ for Apple products or on the Google Play™ Store for Android products, and then load as you would any other app. What You Can Do with the Mobile App • View detailed account and balance information • View card activity • File a claim and upload receipt photos directly from your smartphone • Set up email notifications to keep you up to date on all account and health debit card activity FSA (Flexible Spending Account) How to Use the Mobile App Logging In Use the same username and password you use to log in to Afterflexservices.higginbotham.net.loggingin,youwillbeonthe home page, which will list your options. Getting Help Click the Help button at the bottom right of all pages to access contact information for your administrator, who will be able to provide assistance. Going Home Press the Home button at the bottom left corner of any page to return to the home page and start over.
Denial
I take a dependent care credit on Form 7040. Will the Dependent Care Spending Account save more?
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We need to know the date of service in order to pay the claim when you submit a dental or doctor bill. Please do not submit "balance forward" or "previous balance" statements.
When submitting a statement for a coinsurance, deductible or hospital expense, please make sure the Explanation of Benefits (EOB) states very clearly the date of service, patient name and procedure.
Debit Card FAQs
Can I use the card to pay for over the counter drugs?
Certain recurring, previously approved expenses (i.e. Certainorthodontia).charges that are substantiated at the time of the sale or if the vendors that participate are in the inventory information system
What items are auto substantiated?
• A physician could charge $150 for a consult for cosmetic surgery. The $150 would be approved at the time of purchase, but cosmetic surgery is not a covered item, and the claim is not eligible for reimbursement under IRS guidelines. You would owe the plan $150.
If your card is "suspended" on the last day of your "submission" deadline date, you will be taxed on the amount not substantiated. A letter will be sent to your home on the last day of your plan year to let you know that you will need to substantiate these by submission deadline to avoid being taxed on this amount.
• A member pays $125 for a qualified medical expense. He/she uses the debit card, sends in the form with the required information, and it is marked as eligible in the system.
Yes, your card pays for OTC items if you use the FSA Store. How do I renew my debit card? Your debit card will work for three years initially. Check the expiration date on front of the card.
Purchases(IIAS).atpharmacies and medical providers that don't subscribe to the IIAS are treated as conditionally approved and paid at the time of service; statements must be faxed to substantiate that the purchase was for a qualified expense. i.e.:
If your company has the "grace extension" or "rollover provision" on the prior plan year, the balance will be loaded to your debit card the system will automatically look back at the old plan year and apply these expenses to that plan year first.
Very Important: If you do not submit the documentation within 60 days from the date you receive the email, your debit card will be
However, any time you swipe the card for a dental service or any amount other than a copay, you will need to submit the itemized statement or an EOB.
31 FSA (Flexible Spending Account) Debit Card Access The WealthCare debit card is a quick and easy way to pay for qualified expenses from your Flexible Spending Account. You have no out of pocket expense the money is taken directly out of your account. Plus, you don't have to wait on reimbursement. • Access plan documents, letters and notices, forms, account balances, contributions, investments and other plan information or cafeteria plans, health reimbursement arrangements and transit plans • Change personal information/census data • Find contact information or the administrator • Use 125 tax calculators Go to flexservices.higginbotham.net and request your Flex debit card. Debit Card Procedure • Use your debit card at the time of service (doctor's office, hospital, pharmacy, etc.). • The debit card cannot be used for child care. • Make sure you get an Explanation of Benefits (EOB) or itemized statement for the service rendered. • Hospital: EOB/itemized statement from the doctor with the procedure code and diagnosis code, date of service, name of patient and name and address of the provider • Dental/Vision: EOB/itemized statement with the procedure code, date of service, name of patient and name and address of the provider • Submit the EOB or itemized statement online or by fax, email, mail or the mobile app. • You can either submit the documents after you have received your services, or you can wait until you receive an email from the plan requesting that you send an EOB or itemized statement. You won't get an email for all of your swipes the copays for your doctor visits, prescription copays and vision expenses will automatically substantiate.
suspended until proper substantiation is received.
Certain transactions involving dollar amounts that are consistent with predetermined copay under the plan.
• A dentist office could charge you $200 for teeth bleaching. The $200 would be approved at the time of sale, but the member must submit the statement with the required information. Since teeth bleaching is not a covered expense, the claim would be denied, and the member would pay back $200 to the plan.
UNITED CONCORDIA
About this Benefit
YOUR BENEFITS PACKAGE This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease. Roughly 78% of Americans have had at least one cavity by age 17. 80% of the U.S. population has some form of periodontal disease.
Dental Indemnity
33 Dental Indemnity Dental Benefits Summary for Fort Worth Independent School District Group Numbers: 821479 000/001/002/003 Network: Elite UnitedConcordia.comPlus | 1 800 332 0366 Benefit Category1 CONCORDIA FLEX PLAN In Network2 Non Network2 Class I - Diagnostic/Preventive Services Exams Bitewing X rays All Other X rays Cleanings (3 in 12 months) Sealants & Fluoride Treatments Palliative NonsurgicalTreatmentPeriodontics 100% 100% Class II Basic Services Basic Restorative (Fillings) Simple Extractions Space RepairsMaintainersofCrowns, Inlays, Onlays, Bridges & Dentures SurgicalEndodonticsPeriodontics Complex Oral Surgery 80% 80% Class III Major Services Inlays, Onlays, Crowns Prosthetics (Bridges, Dentures) 50% 50% Orthodontics for dependent children to age 19 Diagnostic, Active, Retention Treatment 50% 50% Included Plan Features Preventive Incentive® Class I services do not count toward your annual maximum Pregnancy Benefit • Covers 1 additional cleaning during pregnancy • Covers 1 additional periodontal maintenance during pregnancy • Scaling and root planing • 4 periodontal surgery procedures Maximums & Deductibles (applies to the combination of services received from network and non network dentists) Annual Program Deductible (per person/per family) $50/$150 (Excludes Class I & Orthodontics) Annual Program Maximum (per person) $1,500 (Excludes Orthodontics) Lifetime Orthodontic Maximum (per person) $1,500 Reimbursement Elite Plus 90th Monthly Rates Employee Only $41.35 Employee & One Adult $83.22 Employee & Child(ren) $92.34 Family $134.02 Representative listing of covered services certificate of coverage provides a detailed description of benefits. 1. Unmarried dependent children covered to age 26. 2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. 3. United Concordia creates out of network charges utilizing FAIR Health data supplemented with our charge data as appropriate. We then calculate the out of network charge at the maximum allowable charge of such data. Non network dentists may bill the member for any difference between our allowance and their fee (also known as balance billing). United Concordia Dental’s standard exclusions and limitations apply. EEM 0161 0514
YOUR BENEFITS PACKAGE About this Benefit Good dental care may improve your overall health. Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby. This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Dental HUMANA
Research shows that oral health, preventive care and regular visits to the dentist is integral to overall health. For example, the Academy of General Dentistry says there is a link between gum disease and heart problems, and the American Academy of Periodontology says severe gum disease can increase blood sugar, increasing the risk among diabetics. The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less doing so. out HumanaDental.com 800 979 4760 anytime for the automated information line or 8 a.m. to 6 p.m. for a Customer Care specialist. 26
Questions? Check
35 DHMO 150 C Plan with Ortho Fort Worth ISD Group # 573701 Use your HumanaDental benefits The HumanaDental C Series dental plan has you covered for any circumstance. Whether you simply need quality routine dental care or unexpected dental treatment, you know what to expect with HumanaDental. • No waiting periods • No claims to file • No annual maximums Know what your plan covers Attached is a summary of HumanaDental C Series plan benefits which are described in detail in your certificate. You can find your certificate at HumanaDental.com or call 1 800 979 4760. Here’s what you can expect: • You have the freedom to select any participating dentist. To select a dental provider from our network, simply visit HumanaDental.com. Once there, you can also check your benefits, email us and get a new or temporary ID card. If you prefer, contact us at 1 800 979 4760. • Life without claim forms! With HumanaDental DHMO plan you pay your dentist directly, when applicable. • Your primary dentist will provide all of your routine dental care and any copayment or discounted charges will be paid at the time of service. Copayments are applicable at either a participating general dentist or a participating specialist. • If you need a specialty dentist, you may receive a 25 percent discount by using certain participating specialty dentists from our network. Visit HumanaDental.com to find a participating specialist who offers the discount on specialty services. Choose HumanaDental benefits
Be healthy
Good oral health means more than just an attractive smile.
Dependent Max Age Limit: to Age
Rates Employee $12.66 Employee + Spouse $22.60 Employee + Child(ren) $23.96 Family $31.18 Check your dental IQ anytime Log on to MyDentalIQ.com and take the dental risk assessment that could help trim your total healthcare costs over time. Find out how you can improve your oral and overall health. The dental health risk assessment at MyDentalIQ.com takes minutes to complete, and immediately delivers a scorecard with health tips tailored to you.
Call 1
36 DHMO 150 C Plan with Ortho The HumanaDental DHMO plans focus on maintaining oral health, prevention and cost containment. A member may see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting periods. C plans copayments are applicable at either a participating general dentist or a participating specialist. Member costs listed here are for services provided by your chosen participating primary care dentist (PCD) only. As your dental professional, your PCD may decide that you need to see an contracted dental specialist. No referral is necessary to see a network Specialistsspecialist. services: Should you need a specialist, (i.e., endodontist, oral surgeon, periodontist, pediatric dentist), you may be referred by your participating general dentist, or you may refer yourself to any participating specialist. For C plans and benefits for procedures not listed on the schedule, you may receive a 25 percent discount by visiting certain participating specialists. Visit www.HumanaDental.com to find a participating specialist who offers the discount on specialty services. Summary of services Appointments Member Pays D9310 Consultation (diagnostic service provided by dentist other than practitioner providing treatment) $ 15.00 D9430 Office visit (normal hours) $ 5.00 D9440 Office visit (after regularly scheduled hours) $ 35.00 Diagnostic Member Pays D0120 Periodic oral examination no charge D0140 Limited/comprehensive/detailed and extensive oral eval no charge D0150 Limited/comprehensive/detailed and extensive oral eval no charge D0160 Limited/comprehensive/detailed and extensive oral eval no charge D0180 Comprehensive periodontal evaluation $ 10.00 D0210 X ray intraoral complete series including bitewings no charge D0220 X ray intraoral periapical, first film no charge D0230 X ray intraoral periapical, each additional film no charge D0270 X ray bitewing single film no charge D0272 X ray bitewings two films no charge D0274 Bitewings four films no charge D0330 Panoramic film no charge D0460 Pulp vitality tests no charge D0470 Diagnostic casts no charge Preventive Member Pays D1110 Prophylaxis adult, routine (once every 6 months) no charge D1120 Prophylaxis child, routine (once every 6 months) no charge D1110 Prophylaxis adult/child, (additional) $ 20.00 D1120 Prophylaxis adult/child, (additional) $ 20.00 D1203 Topical application of fluoride (not including prophylaxis) child (up to 16 years of age) no charge D1206 Topical fluoride varnish (for child <16) no charge D1330 Oral hygiene instruction no charge Preventive (cont.) Member Pays D1351 Sealant per tooth $ 10.00 D1510 Space maintainer fixed, unilateral $ 45.00+labΔ D1515 Space maintainer fixed, bilateral $ 45.00+labΔ D1520 Space maintainer removable, unilateral $ 85.00+labΔ D1525 Space maintainer removable, bilateral $ 85.00+labΔ D1550 Recementation of space maintainer $ 10.00 Restorative Member Pays D2140 Amalgam one surface, primary or permanent no charge D2150 Amalgam two surfaces, primary or permanent no charge D2160 Amalgam three surfaces, primary or permanent no charge D2161 Amalgam four or more surfaces, primary or permanent no charge D2940 Sedative filling $ 15.00 D2999 Sedative base (under fillings), by report no charge Member PaysResin Restorative D2330 Resin based composite one surface, anterior $ 35.00 D2331 Resin based composite two surfaces, anterior $ 40.00 D2332 Resin based composite three surfaces, anterior $ 50.00 D2391 Resin based composite one surface, posterior $ 60.00 D2392 Resin based composite two surfaces, posterior $ 80.00 D2393 Resin based composite three surfaces, posterior $ 100.00 D2394 Resin based composite four or more surfaces, posterior $ 120.00 D2510 Inlay metallic, one surface $ 95.00 D2520 Inlay metallic, two surfaces $ 105.00 D2530 Inlay metallic, three or more surfaces $ 130.00
37 DHMO 150 C Plan with Ortho Crown and Bridge Member Pays D2740 Crown porcelain/ceramic substrate $ 280.00+labΔ D2750* Crown porcelain fused to high noble metal $ 280.00 D2751 Crown porcelain fused to predominantly base metal $ 280.00 D2752* Crown porcelain fused to noble metal $ 280.00 D2790* Crown full cast high noble metal $ 280.00 D2791 Crown full cast predominantly base metal $ 280.00 D2792* Crown full cast noble metal $ 280.00 D2910 Recement inlay $ 15.00 D2920 Recement crown $ 15.00 D2930 Prefabricated stainless steel crown primary tooth $ 75.00 D2950 Core buildup, including any pins $ 45.00 D2951 Pin retention per tooth, in addition to restoration $ 15.00 D2952 Cast post and core in addition to crown $ 90.00+labΔ D2953 Each additional cast post same tooth $ 90.00+labΔ D2954 Prefabricated post and core in addition to crown $ 90.00 D2962 Labial veneer (porcelain laminate) laboratory $ 280.00+labΔ Prosthodontics (Fixed) Member Pays D6210* Pontic cast high noble metal $ 280.00 D6211 Pontic cast predominantly base metal $ 280.00 D6212* Pontic cast noble metal $ 280.00 D6240* Pontic porcelain fused to high noble metal $ 280.00 D6241 Pontic porcelain fused to predominantly base metal $ 280.00 D6242* Pontic porcelain fused to noble metal $ 280.00 D6750* Crown porcelain fused to high noble metal $ 280.00 D6751 Crown porcelain fused to predominantly base metal $ 280.00 D6752* Crown porcelain fused to noble metal $ 280.00 D6790* Crown full cast high noble metal $ 280.00 D6791 Crown full cast predominantly base metal $ 280.00 D6792* Crown full cast noble metal $ 280.00 D6930 Recement fixed partial denture (per unit) $ 10.00 Endodontics Member Pays D3220 Therapeutic pulpotomy $ 35.00 D3221 Pulpal debridement, primary and permanent teeth $ 100.00 D3310 Root canal therapy anterior (excluding final restoration) $ 100.00 D3320 Root canal therapy bicuspid (excluding final restoration) $ 200.00 Endodontics Member Pays D3330 Root canal therapy molar (excluding final restoration) $ 250.00 D3410 Apicoectomy/periradicular surgery anterior $ 125.00 Periodontics (Gum Treatment) Member Pays D4210 Gingivectomy/gingivoplasty per quadrant $ 125.00 D4211 Gingivectomy/gingivoplasty per tooth $ 40.00 D4341 Periodontal scaling and root planing, per quadrant $ 50.00 D4342 Periodontal scaling and root planing 1 to 3 teeth per quadrant $ 50.00 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $ 45.00 D4381 Localized delivery of chemotherapeutic agents (per tooth) $ 45.00 D4910 Periodontal maintenance $ 50.00 Prosthodontics Member Pays D5110 Complete denture maxillary $ 300.00+labΔ D5120 Complete denture mandibular $ 300.00+labΔ D5130 Immediate denture maxillary $ 300.00+labΔ D5140 Immediate denture mandibular $ 300.00+labΔ D5211^ Maxillary partial denture resin base $ 300.00+labΔ D5212^ Mandibular partial denture resin base $ 300.00+labΔ D5213^ Maxillary partial denture cast metal framework, resin denture bases $ 300.00+labΔ D5214^ Mandibular partial denture cast metal framework, resin denture bases $ 300.00+labΔ D5410 Adjust complete denture maxillary $ 15.00 D5411 Adjust complete denture mandibular $ 15.00 D5421 Adjust partial denture maxillary $ 15.00 D5422 Adjust partial denture mandibular $ 15.00 Member PaysRepairs to Prosthetics D5510 Repair broken complete denture base $ 15.00+labΔ D5520 Replace missing or broken teeth complete denture (each tooth) $ 15.00+labΔ D5610 Repair resin denture base $ 15.00+labΔ D5630 Repair or replace broken clasp $ 15.00+labΔ D5640 Replace broken teeth per tooth $ 15.00+labΔ D5650 Add tooth to existing partial denture $ 30.00+labΔ D5730 Reline complete maxillary denture (chairside) $ 50.00 D5731 Reline complete mandibular denture (chairside) $ 50.00 D5740 Reline maxillary partial denture (chairside) $ 50.00 D5741 Reline mandibular partial denture (chairside) $ 50.00
38 DHMO 150 C Plan with Ortho Repairs to Prosthetics Member Pays D5750 Reline complete maxillary denture (laboratory) $ 35.00+labΔ D5751 Reline complete mandibular denture (laboratory) $ 35.00+labΔ D5760 Reline maxillary partial denture (laboratory) $ 35.00+labΔ D5761 Reline mandibular partial denture (laboratory) $ 35.00+labΔ D5850 Tissue conditioning maxillary $ 30.00 D5851 Tissue conditioning mandibular $ 30.00 Extractions/Oral & Maxillofacial Surgery Member Pays D7111 Coronal remnants, deciduous tooth no charge D7140 Extraction, erupted tooth or exposed tooth no charge D7210 Surgical removal of erupted tooth $ 40.00 D7220 Removal of impacted tooth soft tissue $ 50.00 D7230 Removal of impacted tooth partially bony $ 70.00 D7240 Removal of impacted tooth completely bony $ 85.00 D7250 Surgical removal of residual tooth roots $ 35.00 D7310 Alveoloplasty in conjunction with extractions per quadrant $ 35.00 D7311 Alveoplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant $ 35.00 D7320 Alveoloplasty not in conjunction with extractions per quadrant $ 70.00 D7321 Alveoplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant $ 70.00 D7510 Incision and drainage of abscess intraoral $ 25.00 Anesthesia Member Pays D9215 Local anesthesia no charge D9230 Analgesia (nitrous oxide), per 15 minutes $ 15.00 Adjunctive General Services Member Pays D9110 Palliative (emergency) treatment $ 25.00 D9450 Case presentation, detailed and extensive treatment planning no charge D9951 Occlusal adjustment limited $ 25.00 D9952 Occlusal adjustment complete $ 150.00 Orthodontics Member Pays D8070 Comprehensive orthodontic treatment of the dentition;transitional/adolescentChildrenupto19years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases Consultation no charge Evaluation $ 35.00 Records/treatment planning $ 250.00 Orthodontic treatment $ 2,300.00 D8080 Comprehensive orthodontic treatment of the dentition;transitional/adolescentChildrenupto19years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II Consultationcases no charge Evaluation $ 35.00 Records/treatment planning $ 250.00 Orthodontic treatment $ 2,300.00 Comprehensive orthodontic treatment of the adult dentition; Adult 19 years of age and over; Up to 24 months of routine orthodontic treatment for Class I and Class II cases D8090 Consultation no charge Evaluation $ 35.00 Records/treatment planning $ 250.00 Orthodontic treatment $ 2,500.00 D8680 Retention $ 450.00 *The above copayments do not include the additional cost of precious (high noble) and semi precious (noble) metal. The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi precious metal. Δ Patient responsible for lab fees. ^ Including any conventional clasps, rests, and teeth. Note: • Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services. • Unlisted procedures are available at certain participating dentists usual fee less 25%. Visit HumanaDental.com to find a participating dentist who offers the discount on non covered services. • When crown and/or bridgework exceeds six units in the same treatment plan, the patient may be charged an additional $50 per unit • If you break your appointment with your dentist without 24 hour advance notice, you will be subject to your dentist’s broken appointment fee. • Additional exclusions and limitations are listed along with full plan information in your certificate of benefits. Insured or administered by DentiCare, Inc. (d/b/a CompBenefits)
Be healthy
39 Advantage Plus 1S Plan Fort Worth ISD Group # 573701 Use your HumanaDental benefits The HumanaDental Advantage Plus S plan has you covered for any circumstance. Whether you simply need quality routine dental care or unexpected dental treatment, you know what to expect. • No deductibles • No claims to file • No need to choose a primary care dentist Know what your plan covers Attached is a summary of HumanaDental Advantage Plus S plan benefits which are described in detail in your certificate. You can find your certificate at HumanaDental.com or call 1 800 979 4760. Here’s what you can expect: • You have the freedom to select any participating dentist. To select a dental provider from our Advantage Plus network, simply visit HumanaDental.com. Once there, you can also check your benefits, email us and get a new or temporary ID card. If you prefer, contact us at 1 800 979 4760. • Life without claim forms! With HumanaDental Advantage Plus S plan you pay your dentist directly, when applicable. • Your Advantage Plus network dentist will provide all of your dental care and any copayment or discounted charges will be paid at the time of service. Except for emergency care, treatment received out of network in not covered. • You also receive a 20 percent discount on services not listed on your schedule of benefits when visiting certain participating dentists. Visit HumanaDental.com to find a participating dentist who offers the discount on unlisted services. Choose HumanaDental benefits
for the
Good oral health means more than just an attractive smile.
Research shows that oral health, preventive care and regular visits to the dentist is integral to overall health. For example, the Academy of General Dentistry says there is a link between gum disease and heart problems, and the American Academy of Periodontology says severe gum disease can increase blood sugar, increasing the risk among diabetics. The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less doing so. out 979 4760 anytime automated information 8 a.m. to 6 p.m. for a Customer Care specialist.
line or
Dependent Max Age Limit: to Age 26 Rates EE Only $18.70 EE + Spouse $38.26 EE + Child(ren) $38.88 Family Coverage $63.90 Check your dental IQ anytime Log on to MyDentalIQ.com and take the dental risk assessment that could help trim your total healthcare costs over time. Find out how you can improve your oral and overall health. The dental health risk assessment at MyDentalIQ.com takes minutes to complete, and immediately delivers a scorecard with health tips tailored to you.
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40 Advantage Plus 1S Plan Advantage Plus plans are network based dental plans that emphasize prevention and cost containment. Members select any participating general dentist in HumanaDental’s Advantage Plus network. Care received from an out of network dentist (except emergency care) is not a covered benefit. S plan copayments for listed procedures are applicable only at participating General Dentist. To find a dentist, call 1 800 979 4760 or look on HumanaDental.com Office visit$5/$15copay Annual maximumNoannual maximum Summary of services Preventive Member Pays D0120aΔ Periodic oral examination no charge D0140a Limited oral evaluation problem focused no charge D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver (limit 1 every 12 months) no charge D0150 Comprehensive oral evaluation new/ established patient (limit 1 every 24 months) no charge D0160 Limited/comprehensive/detailed and extensive oral eval (limit 1 every 12 months) no charge D0170 Re evaluation limited problem focused (limit 1 every 12 months) no charge D0180 Comprehensive periodontal eval new/ established patient (limit 1 every 24 months) no charge D0210 X ray intraoral complete series (limit 1 every 3 years) no charge D0220 X ray intraoral periapical, first film (limit 9 every 12 months includes D0230) no charge D0230 X ray intraoral periapical, each additional film (limit 9 every 12 months includes D0220) no charge D0240 X ray intraoral occlusal film no charge D0250 X ray extraoral, first film no charge D0260 X ray extraoral, each additional film no charge D0270aΔ Bitewing single film no charge D0272aΔ Bitewings two films no charge D0273aΔ Bitewings three films no charge D0274aΔ Bitewings four films no charge D0277aΔ Vertical bitewings 7 to 8 films no charge D0330 Panoramic film (limit 1 every 3 years) no charge D0470 Diagnostic casts no charge D1110aΔ Prophylaxis adult (inclusive of D4910) no charge D1120aΔ Prophylaxis child (inclusive of D4910) no charge D1203aΔ Topical application of fluoride child (for child <16) no charge D1206aΔ Topical fluoride varnish (for child <16) no charge D1351 Sealant per tooth (limit 1 per tooth every 12 months for child <14) no charge Basic Member Pays D1510 Space maintainer fixed, unilateral (limited to child <14) $53.00 D1515 Space maintainer fixed, bilateral (limited to child <14) $70.00 D1520 Space maintainer fixed, bilateral (limited to child <14) $66.00 D1525 Space maintainer removable, bilateral (limited to child <14) $91.00 D1550 Recementation of space maintainer $12.00 D2140 Amalgam one surface primary or permanent $24.00 D2150 Amalgam two surfaces primary or permanent** $31.00 D2160 Amalgam three surfaces primary or permanent* $37.00 D2161 Amalgam four/more surfaces primary/ permanent** $46.00 D2330 Resin based composite one surface, anterior** $24.00 D2331 Resin based composite two surfaces, anterior** $31.00 D2332 Resin based composite three surfaces, anterior** $38.00 D2335 Resin based composite four or more surfaces, involving incisal angle** $45.00 D2390 Resin based composite crown anterior** $49.00 D2391 Resin based composite one surface, posterior** $28.00 D2392 Resin based composite two surfaces, posterior** $37.00 D2393 Resin based composite three surfaces, posterior** $46.00 D2394 Resin based composite four or more surfaces, posterior** $56.00 D4341 Periodontal scaling and root planing per quadrant, four or more teeth (limit 1 per quad every 12 months) $39.00 D4342 Periodontal scaling and root planing per quadrant, 1 3 teeth (limit 1 per quad every 12 months) $21.00 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis (limit 1 every 5 years) $26.00
41 Advantage Plus 1S Plan Basic Member Pays D4910 Periodontal maintenance (limit 1 every 6 months, inclusive of D1110 and D1120) $23.00 D7111 Extraction coronal remnants deciduous tooth $20.00 D7140 Extraction erupted tooth or exposed root $26.00 Major Member Pays D2510b Inlay metallic, one surface $313.00 D2520b Inlay metallic, two surfaces $355.00 D2530b Inlay metallic, three or more surfaces $410.00 D2542b Onlay metallic, two surfaces $402.00 D2543b Onlay metallic, three surfaces $420.00 D2544b Onlay metallic, four or more surfaces $437.00 D2610b Inlay porcelain/ceramic, one surface $368.00 D2620b Inlay porcelain/ceramic, two surfaces $389.00 D2630b Inlay porcelain/ceramic, three or more surfaces $414.00 D2642b Onlay porcelain/ceramic, two surfaces $403.00 D2643b Onlay porcelain/ceramic, three surfaces $434.00 D2644b Onlay porcelain/ceramic, four or more surfaces $461.00 D2650b Inlay resin based composite, one surface $242.00 D2651b Inlay resin based composite, two surfaces $288.00 D2652b Inlay resin based composite, three or more surfaces $303.00 D2662b Onlay resin based composite, two surfaces $263.00 D2663b Onlay resin based composite, three surfaces $310.00 D2664b Onlay resin based ccomposite, four or more surfaces $332.00 D2710b Crown resin based composite, indirect $187.00 D2720b Crown resin with high noble metal $461.00 D2721b Crown resin with predominantly base metal $432.00 D2722b Crown resin with noble metal $441.00 D2740b Crown porcelain/ceramic substrate $473.00 D2750b Crown porcelain fused to high noble metal $466.00 D2751b Crown porcelain fused predom base metal $434.00 D2752b Crown porcelain fused to noble metal $445.00 D2790b Crown full cast high noble metal $450.00 D2791b Crown full cast predom base metal $426.00 D2792b Crown full cast noble metal $434.00 D2910 Recement inlay, onlay or part coverage restoration $41.00 D2920 Recement crown $42.00 Major Member Pays D2930 Crown prefabricated stainless steel, primary tooth $115.00 D2931 Crown prefabricated stainless steel, permanent tooth $131.00 D2932 Crown prefabricated resin $142.00 D2940 Sedative filling $44.00 D2950 Core buildup including any pins $110.00 D2951 Pin retention per tooth addition restoration $23.00 D2952 Cast post and core in addition to crown $168.00 D2954 Prefabricated post and core in addition to crown $139.00 D3220 Therapeutic pulpotomy $75.00 D3310 Root canal therapy anterior $315.00 D3320 Root canal therapy bicuspid $385.00 D3330 Root canal therapy molar $497.00 D3346 Previous root canal therapy anterior $424.00 D3347 Previous root canal therapy bicuspid $500.00 D3348 Previous root canal therapy molar $601.00 D3410 Apicoectomy/periradicular surgery anterior $361.00 D3421 Apicoectomy/periradicular surgery anterior $394.00 D3425 Apicoectomy/periradicular surgery anterior $445.00 D3426 Apicoectomy/periradicular surgery each addtl root $148.00 D3430 Retrograde filling per root $109.00 D4210c Gingivectomy/gingivoplasty four or more teeth, quad $358.00 D4211c Gingivectomy/gingivoplasty 1 to 3 teeth, quad $153.00 D4240c Gingival flap proc four or more teeth, quad $421.00 D4241c Gingival flap proc 1 to 3 teeth, quad $217.00 D4249 Clinical crown lengthening hard tissue $481.00 D4260 Osseous surgery four or more teeth, quad $680.00 D4261 Osseous surgery 1 to 3 teeth, quad $354.00 D5110c Complete denture maxillary $642.00 D5120c Complete denture mandibular $642.00 D5130c Immediate denture maxillary $700.00 D5140d Immediate denture mandibular $700.00 D5211d Maxillary partial denture resin base $542.00 D5212d Mandibular partial denture resin base $629.00 D5213d Maxillary partial denture cast metal resin base $709.00 D5214d Mandibular partial denture cast metal resin base $709.00 D5410c Adjust complete denture maxillary $35.00
42 Advantage Plus 1S Plan Major Member Pays D5411c Adjust complete denture mandibular $35.00 D5421c Adjust partial denture maxillary $35.00 D5422c Adjust partial denture mandibular $35.00 D5510 Repair broken complete denture base $70.00 D5520 Replace missing/broken teeth complete denture $59.00 D5610 Repair resin denture base $76.00 D5620 Repair cast framework $82.00 D5630 Repair or replace broken clasp $100.00 D5640 Replace broken teeth per tooth $64.00 D5650 Add tooth to existing partial denture $88.00 D5660 Add clasp to existing partial denture $105.00 D5710e Rebase complete maxillary denture $261.00 D5711e Rebase complete mandibular denture $249.00 D5720e Rebase maxillary partial denture $246.00 D5721e Rebase mandibular partial denture $246.00 D5730e Reline complete maxillary denture $147.00 D5731e Reline complete mandibular denture $147.00 D5740e Reline maxillary partial denture $135.00 D5741e Reline mandibular partial denture $135.00 D5750e Reline complete maxillary denture $196.00 D5751e Reline complete mandibular denture $196.00 D5760e Reline maxillary partial denture $193.00 D5761e Reline mandibular partial denture $193.00 D5850 Tissue conditioning maxillary $61.00 D5851 Tissue conditioning mandibular $61.00 D6092 Recement implant/abutment supported crown $42.00 D6093 Recement implant/abutment supported fixed partial denture $57.00 D6210f Pontic cast high noble metal $431.00 D6211f Pontic cast predominantly base metal $404.00 D6212f Pontic cast noble metal $420.00 D6240f Pontic porcelain fused to high noble metal $426.00 D6241f Pontic porcelain fused predom base metal $393.00 D6242f Pontic porcelain fused to noble metal $415.00 D6250f Pontic resin with high noble metal $420.00 D6251f Pontic resin with predominantly base metal $388.00 D6252f Pontic resin with noble metal $400.00 D6600f Inlay porcelain/ceramic, two surfaces $355.00 D6601f Inlay porcelain/ceramic, three or more surfaces $373.00 D6602f Inlay cast high noble metal, two surfaces $380.00 Major Member Pays D6603f Inlay cast high noble metal, three or more surfaces $418.00 D6604f Inlay cast predom base metal, two surfaces $372.00 D6605f Inlay cast predom base metal, three or more surfaces $394.00 D6606f Inlay cast noble metal, two surfaces $366.00 D6607f Inlay cast noble metal, three or more surfaces $406.00 D6608f Onlay porcelain/ceramic, two surfaces $386.00 D6609f Onlay porcelain/ceramic, three or more surfaces $403.00 D6610f Onlay cast high noble metal, two surfaces $409.00 D6611f Onlay cast high noble metal, three or more surfaces $448.00 D6612f Onlay cast predom base metal, two surfaces $407.00 D6613f Onlay cast predom base metal, three or more surfaces $426.00 D6614f Onlay cast noble metal, two surfaces $399.00 D6615f Onlay cast noble metal, three or more surfaces $414.00 D6720f Crown resin with high noble metal $474.00 D6721f Crown resin with predom base metal $450.00 D6722f Crown resin with noble metal $458.00 D6740f Crown porcelain/ceramic $499.00 D6750f Crown porcelain fused to high noble metal $486.00 D6751f Crown porcelain fused to predom base metal $453.00 D6752f Crown porcelain fused to noble metal $464.00 D6780f Crown 3/4 cast high noble metal $458.00 D6790f Crown full cast high noble metal $469.00 D6791f Crown full cast predom base metal $445.00 D6792f Crown full cast noble metal $461.00 D6930f Recement fixed partial denture $57.00 D6970f Cast post & core addl fix part denture retainer $157.00 D6972f Prefab post & core addl fix part denture retainer $128.00 D6973f Core build up for retainer including any pins $103.00 D7210 Surgical removal erupted tooth $108.00 D7220 Removal of impacted tooth soft tissue $135.00 D7230 Removal of impacted tooth partially bony $179.00 D7240 Removal of impacted tooth completely bony $211.00 D7241 Remove impacted tooth completely bony w/comp $165.00
Orthodontic
Orthodontic
charge
charge
43 Advantage Plus 1S Plan Major Member Pays D7250 Surgical removal of residual tooth roots $114.00 D7310 Alveoloplasty in conjunction w/ extractions per quad $125.00 D7311 Alveoloplasty in conjunction w/ extractions 1 3 teeth $97.00 D7320 Alveoloplasty not conjunction w/ extractions per quad $181.00 D7321 Alveoloplasty not conjunction w/ extractions 1 3 teeth $153.00 D7510 Incision and drainage of abscess intraoral $120.00 D7520 Incision and drainage of abscess extraoral $570.00 D7960 Frenulectomy separate procedure. $111.00 D7970 Excision of hyperplastic tissue per arch $272.00 D9110 Palliative treatment dental pain minor procedure $45.00 D9215 Local anesthesia no charge D9241 IV conscious sedation/analg 1st 30 minutes $144.00 D9242 IV conscious sedation/analg each addl 15 minutes $60.00 D9310 Professional consultation by non treating dentist $96.00 D9951 Occlusal adjustment limited $58.00 D9952 Occlusal adjustment complete $326.00 Orthodontics Member Pays D8070
Orthodontic
Orthodontic
D8680
Comprehensive Orthodontic treatment of the transitional/adult dentition; Adults 19 years of age and older; Up to 24 months of routine orthodontic treatment for Class I and Class II cases.
D8080
a Limit of one every six months b Limit one per tooth every eight years c Limit one every 12 months d Limit one every five years e Limit of one every three years f Limit of one every eight year Note: • Your participating general dentist and participating specialist office visit co payment amounts, if applicable, are shown on your I.D. card. • Your office visit co payment is applicable for all dates of service and is in addition to the co payment amounts listed for covered dental care services. • Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services. • Unlisted covered dental care services are available at certain participating dentist’s usual fee less 20%. Visit HumanaDental.com to find a participating dentist who offers the discount on unlisted services. • Additional exclusions and limitations are listed along with full plan information in your Certificate of Benefits. Insured or administered by DentiCare, Inc. (d/b/a CompBenefits)
Consultation
D8090 Consultation no Evaluation $35.00 Records/Treatment Planning $250.00 treatment $2300.00 Retention $450.00
Consultation no charge
dentition;
Records/Treatment
Comprehensive treatment of the transitional/adolescent Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases Evaluation $35.00 Planning $250.00 treatment $2100.00 Comprehensive Orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases no Evaluation $35.00 Records/Treatment Planning $250.00 treatment $2100.00
About this Benefit 75% of U.S. residents between age 25 and 64 require some sort of vision correction. This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Vision HUMANA
45 Vision- Humana Vision 130 Vision care services If you use an IN NETWORK provider (Member cost) If you use an OUT OF NETWORK provider (Reimbursement) Exam with dilation as necessary • Retinal imaging 1 Up$10to $39 Up to $30 Not covered Contact lens exam options2 • Standard contact lens fit and follow up • Premium contact lens fit and follow up Up to $40 10% off retail Not covered Not covered Frames3 $130 allowance 20% off balance over $130 $65 allowance Standard plastic lenses4 • Single vision • Bifocal • Trifocal • Lenticular $15$15$15 $15 Up to $25 Up to $40 Up to $60 Up to $100 Covered lens options4 • UV coating $15 Not covered • Tint (solid and gradient) $15 Not covered • Standard scratch resistance $15 Not covered • Standard polycarbonate adults $40 Not covered • Standard polycarbonate children <19 $40 Not covered • Standard anti reflective coating $45 Not covered • Premium anti reflective coating Premium anti reflective coatings Premium anti reflective coatings as follows: as follows: Tier 1 $57 Not covered Tier 2 $68 Not covered Tier 3 80% of charge Not covered • Standard progressive (add on to bifocal) $15 Up to $40 • Premium progressive Premium progressives as follows: Premium progressives as follows: Tier 1 $110 Not covered Tier 2 $120 Not covered Tier 3 $135 Not covered Tier 4 $90 copay, 80% of charge less $120 allowance Not covered • Photochromatic / plastic transitions $75 Not covered • Polarized 20% off retail Not covered Contact lenses5 (applies to materials only) • Conventional $130 allowance, 15% off balance over $130 $104 allowance • Disposable $130 allowance $104 allowance • Medically necessary $0 $200 allowance Frequency • Examination • Lenses or contact lenses • Frame Once every 12 months Once every 12 months Once every 24 months Once every 12 months Once every 12 months Once every 24 months Diabetic Eye Care: care and testing for diabetic members • Examination Up to (2) services per year • Retinal Imaging Up to (2) services per year • Extended Ophthalmoscopy Up to (2) services per year • GonioscopyUpto(2)services per year $0 $0$0$0 Up to $77 Up to $50 Up to $15 Up to $15 • Scanning Laser Up to (2) services per year $0 Up to $33 Optional benefits 1. Member costs may exceed $39 with certain providers. Members may contact their participating provider to determine what costs or discounts are available. 2 Standard contact lens exam fit and follow up costs and premium contact lens exam discounts up to 10% may vary by participating provider. Members may contact their participating provider to determine what costs or discounts are available. 3 Discounts may be available on all frames except when prohibited by the manufacturer. 4 Lens option costs may vary by provider. Members may contact their participating provider to determine if listed costs are available. 5 Plan covers contact lenses or frames, but not both.
• War or any act of war, whether declared or not;
Questions? Check out Humana.com Call 1 866 995 9316 seven days a week: 8 a.m. to 6 p.m. Eastern Time Monday through Saturday and 11 a.m. to 8 p.m. Sunday. Limitations and Exclusions: In addition to the limitations and exclusions listed in your
section, this policy does not provide benefits for the following: 1.
3.
7. Prescription drugs or pre medications, whether dispensed or prescribed.
8. Any service not specifically listed in the Schedule of Benefits.
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Monthly rates* (12 deductions per year) Employee $6.22 Employee + spouse $12.45 Employee + child(ren) $11.84 Family $18.60 This is not a substitute for a quote. Rates must be approved
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35.
• Any conflict involving armed forces of any international authority.
Vision Additional plan discounts •
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• Any act of international armed conflict; or
6. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.
insurer
obligations. Policy Number:
5. Your failure to keep an appointment.
4. Any expense arising from the completion of forms.
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occupational
9. Any service that we determine:
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NOTICE: Your
46 Member may receive a 20% discount on items not covered by the plan at network Providers. Members may contact their participating provider to determine what costs or discounts are available. Discount does not apply to EyeMed Provider's professional services, or contact lenses. Plan discounts cannot be combined with any other discounts or promotional offers. Services or materials provided by any other group benefit plan providing vision care may not be covered. Certain brand name Vision Materials may not be eligible for a discount if the manufacturer imposes a no discount practice. Frame, Lens, & Lens Option discounts apply only when purchasing a complete pair of eyeglasses. If purchased separately, members receive 20% off the retail price. Members may also receive 15% off retail price or 5% off promotional price for LASIK or PRK from the US Laser Network, owned and operated by LCA Vision. Since LASIK or PRK vision correction is an elective procedure, performed by specialty trained providers, this discount may not always be available from a provider in your immediate location. "Vision Benefits" Any expenses incurred while you qualify for any worker's compensation or disease act or law, whether or not you applied for coverage. Services: That are free or that you would not be required to pay for if you did not have this insurance, unless charges are received from and reimbursable to the U.S. government or any of its agencies as required by law; Furnished by, or payable under, any plan or law through any government or any political subdivision (this does not include Medicare or Medicaid); or Furnished by any U.S. government owned or operated hospital/institution/ agency for any service connected with sickness or bodily injury. Any loss caused or contributed by:
33.
Humana Vision underwriting.
Humana
• Is not a visual necessity; • Does not offer a favorable prognosis; • Does not have uniform professional endorsement; or • Is deemed to be experimental or investigational in nature. Orthoptic or vision training. 11. Subnormal vision aids and associated testing. 12. Aniseikonic lenses. 13. Any service we consider cosmetic. 14. Any expense incurred before your effective date or after the date your coverage under this policy terminates. Services provided by someone who ordinarily lives in your home or who is a family member. 16. Charges exceeding the reimbursement limit for the service. 17. Treatment resulting from any intentionally self inflicted injury or bodily 18.illness.Plano lenses. 19. Medical or surgical treatment of eye, eyes, or supporting structures. 20. Replacement of lenses or frames furnished under this plan which are lost or broken, unless otherwise available under the plan. 21. Any examination or material required by an Employer as a condition of 22.employment.Nonprescription sunglasses. 23. Two pair of glasses in lieu of bifocals. 24. Services or materials provided by any other group benefit plans providing vision care. 25. Certain name brands when manufacturer imposes no discount. 26. Corrective vision treatment of an experimental nature. 27. Solutions and/or cleaning products for glasses or contact lenses. 28. Pathological treatment. 29. Non prescription items. Costs associated with securing materials. Pre and Post operative services. Orthokeratology. Routine maintenance of materials. Refitting or change in lens design after initial fitting, unless specifically allowed elsewhere in the certificate. Artistically painted lenses. Vision products insured by Humana Insurance Company, Humana Health Benefit Plan of Louisiana, The Dental Concern, Inc. or Humana Insurance Company of New York. This is not a complete disclosure of the plan qualifications and limitations. Specific limitations and exclusions as contained in the Regulatory and Technical Information Guide will be provided by the agent. Please review this information before applying for coverage. actual expenses for covered services may exceed the stated cost or reimbursement amount because actual provider charges may not be used to determine and member payment TX 70148 019/15et.al. by
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47 written information in other formats
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd YOUR BENEFITS PACKAGE Just over 1 in 4 of today's 20 year -olds will become disabled before they retire. 34.6 months is the duration of the average disability claim. About this Benefit Disability THE HARTFORD
More than half of all personal bankruptcies and mortgage foreclosures are a consequence of disability1 1 Facts from LIMRA, 2016 Disability Insurance Awareness Month
Effective Date Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.
Coverage?
The average worker faces a 1 in 3 chance of suffering a job loss lasting 90 days or more due to a disability2 2Facts from LIMRA, 2016 Disability Insurance Awareness Month
Only 50% of American adults indicate they have enough savings to cover three months of living expenses in the event they’re not earning any income3 3Federal Reserve, Report on the Economic Well Being of U.S. Households in 2018
ELIGIBILITY AND ENROLLMENT Eligibility
You can enroll in coverage within 31 days of your date of hire or during your annual enrollment period.
You must be at work with your Employer on your regularly scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for your usual number of hours. If school is not in session due to normal vacation or school break(s), Actively at Work shall mean you are able to report for work with your Employer, performing all of the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session.
What is Educator Disability Income Insurance?
FEATURES OF THE PLAN
You have the opportunity to purchase Disability Insurance through your employer. This highlight sheet is an overview of your Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.
For those employees electing an elimination period of 30 days or less, if you are confined to a hospital for 24 hours or more due to a disability, the elimination period will be waived, and benefits will be payable from the first day of hospitalization
Benefit Amount
Actively at Work
You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $10,000 that cannot exceed 66 2/3% of your current monthly earnings.
Why do I need Disability Insurance
Educator Disability insurance combines the features of a short term and long term disability plan into one policy. The coverage pays you a portion of your earnings if you cannot work because of a disabling illness or injury. The plan gives you the flexibility to choose a level of coverage to suit your need.
49 Long Term Disability BENEFIT HIGHLIGHTS FOR: Fort Worth Independent School District Policy # 395332 EDUCATOR DISABILITY INSURANCE OVERVIEW
Enrollment
You are eligible if you are an active employee who works at least 10 hours per week on a regularly scheduled basis.
Earnings are defined in The Hartford’s contract with your employer.
Elimination Period
You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Disability benefit payment. The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin.
Benefit Duration is the maximum time for which we pay benefits for disability resulting from sickness or injury. Depending on the schedule selected and the age at which disability occurs, the maximum duration may vary. Please see the applicable schedules below based on your election of either the Premium or Select benefit option.
Prior to 65 5 Years Ages 65 68 To Age 70, but not less than one year Age 69 and over 1 Year
Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services.
Identity Theft Protection An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims.
Travel Assistance Program Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre trip information, emergency medical assistance and emergency personal services.
Maximum Benefit Duration
You can receive benefit payments for Long Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 12 months for all disability periods during your lifetime. Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 12 month lifetime limit.
Premium Option: For the Premium benefit option the table below applies to disabilities resulting from sickness or injury.
Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full time employment.
Other Important Benefits Survivor Benefit If you die while receiving disability benefits, a benefit will be paid to your spouse or child under age 25, equal to three times your last monthly gross benefit.
Select Option: For the Select benefit option the table below applies to disabilities resulting from Ageinjury.Disabled
Mental Illness, Alcoholism and SubstanceDurationAbuse:
Maximum Benefit Duration
Prior to Age 60 To Age 65 Ages 60 64 60 Months Ages 65 67 To Age 70 Age 68 and older 24 months
Long Term Disability
The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability.
Partial Disability Partial Disability is covered provided you have at least a 20% loss of earnings and duties of yourjob.
Maximum Benefit Duration
Select Option: For the Select benefit option the table below applies to disabilities resulting from Agesickness.Disabled
50
YourTerminationbenefitsProvisionscoverageunderthe plan will end if: The group plan ends or is discontinued You voluntarily stop your coverage You are no longer eligible for coverage You do not make the required premium payment Your active employment stops, except as stated in the continuation provision in the policy
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An intentionally self inflicted injury Any case where Your being engaged in an illegal occupation was a contributing cause to your disability You must be under the regular care of a physician to receive
Definition of Disability Disability is defined as The Hartford’s contract with your employer. Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy or other medical conditions covered by the insurance, and as a result, your current monthly earnings are 80% or less of your pre disability earnings. One you have been disabled for 24 months, you must be prevented from performing one or more essential duties of any occupation, and as a result, your monthly earnings are 66 2/3% or less of your pre disability earnings.
Benefit Integration
Your plan includes a minimum benefit of 20% of your elected Generalbenefit.
You cannot receive Disability benefit payments for disabilities that are caused or contributed to by: War or act of war (declared or not) Military service for any country engaged in war or other armed conflict
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Pre Existing Condition Limitation
Your policy limits the benefits you can receive for a disability caused by a pre existing condition. In general, if you were diagnosed or received care for a disabling condition within the 12 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have been insured under this policy for 24 months before your disability beIfgins.your disability is a result of a pre existing condition, we will pay benefits for a maximum of 4 weeks.
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Periods of Recovery during the Elimination Period will not interrupt the Elimination Period, if the number of days You return to work as an Active Employee are less than one half (1/2) the number of days of Your Elimination Period. Any day within such period of Recovery, will not count toward the Elimination Period.
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Continuity of Coverage
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The commission of, or attempt to commit a felony
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The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting company Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the underwriting company listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. This Benefit Highlights Sheet explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this Benefit Highlights Sheet and the policy, the terms of the policy apply. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Benefits are subject to state availability. © 2020 The Hartford.
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as a pension plan)
51 Long Term Disability PROVISIONS OF THE PLAN
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Exclusions
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If you were insured under your district’s prior plan and not receiving benefits the day before this policy is effective, there will not be a loss in coverage and you will get credit for your prior carrier’s Recurrentcoverage.Disability
Your benefit may be reduced by other income you receive or are eligible to receive due to your disability, such as: Social Security Disability Insurance State Teacher Retirement Disability Plans Workers’ Compensation Other employer based disability insurance coverage you may have Unemployment benefits Retirement benefits that your employer fully or partially pays for (such
What happens if I Recover but become Disabled again?
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52 Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 14 Day Elimination Period – Accident and Sickness to Age 65 EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $3,600 $300 $200 $5.64 $6.72 $8.14 $8.98 $10.36 $12.94 $12.98 $12.36 $5,400 $450 $300 $8.46 $10.08 $12.21 $13.47 $15.54 $19.41 $19.47 $18.54 $7,200 $600 $400 $11.28 $13.44 $16.28 $17.96 $20.72 $25.88 $25.96 $24.72 $9,000 $750 $500 $14.10 $16.80 $20.35 $22.45 $25.90 $32.35 $32.45 $30.90 $10,800 $900 $600 $16.92 $20.16 $24.42 $26.94 $31.08 $38.82 $38.94 $37.08 $12,600 $1,050 $700 $19.74 $23.52 $28.49 $31.43 $36.26 $45.29 $45.43 $43.26 $14,400 $1,200 $800 $22.56 $26.88 $32.56 $35.92 $41.44 $51.76 $51.92 $49.44 $16,200 $1,350 $900 $25.38 $30.24 $36.63 $40.41 $46.62 $58.23 $58.41 $55.62 $18,000 $1,500 $1,000 $28.20 $33.60 $40.70 $44.90 $51.80 $64.70 $64.90 $61.80 $19,800 $1,650 $1,100 $31.02 $36.96 $44.77 $49.39 $56.98 $71.17 $71.39 $67.98 $21,600 $1,800 $1,200 $33.84 $40.32 $48.84 $53.88 $62.16 $77.64 $77.88 $74.16 $23,400 $1,950 $1,300 $36.66 $43.68 $52.91 $58.37 $67.34 $84.11 $84.37 $80.34 $25,200 $2,100 $1,400 $39.48 $47.04 $56.98 $62.86 $72.52 $90.58 $90.86 $86.52 $27,000 $2,250 $1,500 $42.30 $50.40 $61.05 $67.35 $77.70 $97.05 $97.35 $92.70 $28,800 $2,400 $1,600 $45.12 $53.76 $65.12 $71.84 $82.88 $103.52 $103.84 $98.88 $30,600 $2,550 $1,700 $47.94 $57.12 $69.19 $76.33 $88.06 $109.99 $110.33 $105.06 $32,400 $2,700 $1,800 $50.76 $60.48 $73.26 $80.82 $93.24 $116.46 $116.82 $111.24 $34,200 $2,850 $1,900 $53.58 $63.84 $77.33 $85.31 $98.42 $122.93 $123.31 $117.42 $36,000 $3,000 $2,000 $56.40 $67.20 $81.40 $89.80 $103.60 $129.40 $129.80 $123.60 $37,800 $3,150 $2,100 $59.22 $70.56 $85.47 $94.29 $108.78 $135.87 $136.29 $129.78 $39,600 $3,300 $2,200 $62.04 $73.92 $89.54 $98.78 $113.96 $142.34 $142.78 $135.96 $41,400 $3,450 $2,300 $64.86 $77.28 $93.61 $103.27 $119.14 $148.81 $149.27 $142.14 $43,200 $3,600 $2,400 $67.68 $80.64 $97.68 $107.76 $124.32 $155.28 $155.76 $148.32 $45,000 $3,750 $2,500 $70.50 $84.00 $101.75 $112.25 $129.50 $161.75 $162.25 $154.50 $46,800 $3,900 $2,600 $73.32 $87.36 $105.82 $116.74 $134.68 $168.22 $168.74 $160.68 $48,600 $4,050 $2,700 $76.14 $90.72 $109.89 $121.23 $139.86 $174.69 $175.23 $166.86 $50,400 $4,200 $2,800 $78.96 $94.08 $113.96 $125.72 $145.04 $181.16 $181.72 $173.04 $52,200 $4,350 $2,900 $81.78 $97.44 $118.03 $130.21 $150.22 $187.63 $188.21 $179.22 $54,000 $4,500 $3,000 $84.60 $100.80 $122.10 $134.70 $155.40 $194.10 $194.70 $185.40 $55,800 $4,650 $3,100 $87.42 $104.16 $126.17 $139.19 $160.58 $200.57 $201.19 $191.58 $57,600 $4,800 $3,200 $90.24 $107.52 $130.24 $143.68 $165.76 $207.04 $207.68 $197.76 $59,400 $4,950 $3,300 $93.06 $110.88 $134.31 $148.17 $170.94 $213.51 $214.17 $203.94 $61,200 $5,100 $3,400 $95.88 $114.24 $138.38 $152.66 $176.12 $219.98 $220.66 $210.12 $63,000 $5,250 $3,500 $98.70 $117.60 $142.45 $157.15 $181.30 $226.45 $227.15 $216.30 $64,800 $5,400 $3,600 $101.52 $120.96 $146.52 $161.64 $186.48 $232.92 $233.64 $222.48 $66,600 $5,550 $3,700 $104.34 $124.32 $150.59 $166.13 $191.66 $239.39 $240.13 $228.66 $68,400 $5,700 $3,800 $107.16 $127.68 $154.66 $170.62 $196.84 $245.86 $246.62 $234.84 $70,200 $5,850 $3,900 $109.98 $131.04 $158.73 $175.11 $202.02 $252.33 $253.11 $241.02 $72,000 $6,000 $4,000 $112.80 $134.40 $162.80 $179.60 $207.20 $258.80 $259.60 $247.20 $73,800 $6,150 $4,100 $115.62 $137.76 $166.87 $184.09 $212.38 $265.27 $266.09 $253.38 $75,600 $6,300 $4,200 $118.44 $141.12 $170.94 $188.58 $217.56 $271.74 $272.58 $259.56 $77,400 $6,450 $4,300 $121.26 $144.48 $175.01 $193.07 $222.74 $278.21 $279.07 $265.74 $79,200 $6,600 $4,400 $124.08 $147.84 $179.08 $197.56 $227.92 $284.68 $285.56 $271.92 $81,000 $6,750 $4,500 $126.90 $151.20 $183.15 $202.05 $233.10 $291.15 $292.05 $278.10 $82,800 $6,900 $4,600 $129.72 $154.56 $187.22 $206.54 $238.28 $297.62 $298.54 $284.28 $84,600 $7,050 $4,700 $132.54 $157.92 $191.29 $211.03 $243.46 $304.09 $305.03 $290.46 $86,400 $7,200 $4,800 $135.36 $161.28 $195.36 $215.52 $248.64 $310.56 $311.52 $296.64 $88,200 $7,350 $4,900 $138.18 $164.64 $199.43 $220.01 $253.82 $317.03 $318.01 $302.82 $90,000 $7,500 $5,000 $141.00 $168.00 $203.50 $224.50 $259.00 $323.50 $324.50 $309.00 $91,800 $7,650 $5,100 $143.82 $171.36 $207.57 $228.99 $264.18 $329.97 $330.99 $315.18
53 Long Term Disability PREMIUM OPTION MONTHLY PREMIUM COST (based on 12 payments per year) 14 Day Elimination Period – Accident and Sickness to Age 65 EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages -34 35Ages -39 40Ages -44 45Ages -49 50Ages -54 55Ages -59 Ages60+ $93,600 $7,800 $5,200 $146.64 $174.72 $211.64 $233.48 $269.36 $336.44 $337.48 $321.36 $95,400 $7,950 $5,300 $149.46 $178.08 $215.71 $237.97 $274.54 $342.91 $343.97 $327.54 $97,200 $8,100 $5,400 $152.28 $181.44 $219.78 $242.46 $279.72 $349.38 $350.46 $333.72 $99,000 $8,250 $5,500 $155.10 $184.80 $223.85 $246.95 $284.90 $355.85 $356.95 $339.90 $100,800 $8,400 $5,600 $157.92 $188.16 $227.92 $251.44 $290.08 $362.32 $363.44 $346.08 $102,600 $8,550 $5,700 $160.74 $191.52 $231.99 $255.93 $295.26 $368.79 $369.93 $352.26 $104,400 $8,700 $5,800 $163.56 $194.88 $236.06 $260.42 $300.44 $375.26 $376.42 $358.44 $106,200 $8,850 $5,900 $166.38 $198.24 $240.13 $264.91 $305.62 $381.73 $382.91 $364.62 $108,000 $9,000 $6,000 $169.20 $201.60 $244.20 $269.40 $310.80 $388.20 $389.40 $370.80 $109,800 $9,150 $6,100 $172.02 $204.96 $248.27 $273.89 $315.98 $394.67 $395.89 $376.98 $111,600 $9,300 $6,200 $174.84 $208.32 $252.34 $278.38 $321.16 $401.14 $402.38 $383.16 $113,400 $9,450 $6,300 $177.66 $211.68 $256.41 $282.87 $326.34 $407.61 $408.87 $389.34 $115,200 $9,600 $6,400 $180.48 $215.04 $260.48 $287.36 $331.52 $414.08 $415.36 $395.52 $117,000 $9,750 $6,500 $183.30 $218.40 $264.55 $291.85 $336.70 $420.55 $421.85 $401.70 $118,800 $9,900 $6,600 $186.12 $221.76 $268.62 $296.34 $341.88 $427.02 $428.34 $407.88 $120,600 $10,050 $6,700 $188.94 $225.12 $272.69 $300.83 $347.06 $433.49 $434.83 $414.06 $122,400 $10,200 $6,800 $191.76 $228.48 $276.76 $305.32 $352.24 $439.96 $441.32 $420.24 $124,200 $10,350 $6,900 $194.58 $231.84 $280.83 $309.81 $357.42 $446.43 $447.81 $426.42 $126,000 $10,500 $7,000 $197.40 $235.20 $284.90 $314.30 $362.60 $452.90 $454.30 $432.60 $127,800 $10,650 $7,100 $200.22 $238.56 $288.97 $318.79 $367.78 $459.37 $460.79 $438.78 $129,600 $10,800 $7,200 $203.04 $241.92 $293.04 $323.28 $372.96 $465.84 $467.28 $444.96 $131,400 $10,950 $7,300 $205.86 $245.28 $297.11 $327.77 $378.14 $472.31 $473.77 $451.14 $133,200 $11,100 $7,400 $208.68 $248.64 $301.18 $332.26 $383.32 $478.78 $480.26 $457.32 $135,000 $11,250 $7,500 $211.50 $252.00 $305.25 $336.75 $388.50 $485.25 $486.75 $463.50 $136,800 $11,400 $7,600 $214.32 $255.36 $309.32 $341.24 $393.68 $491.72 $493.24 $469.68 $138,600 $11,550 $7,700 $217.14 $258.72 $313.39 $345.73 $398.86 $498.19 $499.73 $475.86 $140,400 $11,700 $7,800 $219.96 $262.08 $317.46 $350.22 $404.04 $504.66 $506.22 $482.04 $142,200 $11,850 $7,900 $222.78 $265.44 $321.53 $354.71 $409.22 $511.13 $512.71 $488.22 $144,000 $12,000 $8,000 $225.60 $268.80 $325.60 $359.20 $414.40 $517.60 $519.20 $494.40 $145,800 $12,150 $8,100 $228.42 $272.16 $329.67 $363.69 $419.58 $524.07 $525.69 $500.58 $147,600 $12,300 $8,200 $231.24 $275.52 $333.74 $368.18 $424.76 $530.54 $532.18 $506.76 $149,400 $12,450 $8,300 $234.06 $278.88 $337.81 $372.67 $429.94 $537.01 $538.67 $512.94 $151,200 $12,600 $8,400 $236.88 $282.24 $341.88 $377.16 $435.12 $543.48 $545.16 $519.12 $153,000 $12,750 $8,500 $239.70 $285.60 $345.95 $381.65 $440.30 $549.95 $551.65 $525.30 $154,800 $12,900 $8,600 $242.52 $288.96 $350.02 $386.14 $445.48 $556.42 $558.14 $531.48 $156,600 $13,050 $8,700 $245.34 $292.32 $354.09 $390.63 $450.66 $562.89 $564.63 $537.66 $158,400 $13,200 $8,800 $248.16 $295.68 $358.16 $395.12 $455.84 $569.36 $571.12 $543.84 $160,200 $13,350 $8,900 $250.98 $299.04 $362.23 $399.61 $461.02 $575.83 $577.61 $550.02 $162,000 $13,500 $9,000 $253.80 $302.40 $366.30 $404.10 $466.20 $582.30 $584.10 $556.20 $163,800 $13,650 $9,100 $256.62 $305.76 $370.37 $408.59 $471.38 $588.77 $590.59 $562.38 $165,600 $13,800 $9,200 $259.44 $309.12 $374.44 $413.08 $476.56 $595.24 $597.08 $568.56 $167,400 $13,950 $9,300 $262.26 $312.48 $378.51 $417.57 $481.74 $601.71 $603.57 $574.74 $169,200 $14,100 $9,400 $265.08 $315.84 $382.58 $422.06 $486.92 $608.18 $610.06 $580.92 $171,000 $14,250 $9,500 $267.90 $319.20 $386.65 $426.55 $492.10 $614.65 $616.55 $587.10 $172,800 $14,400 $9,600 $270.72 $322.56 $390.72 $431.04 $497.28 $621.12 $623.04 $593.28 $174,600 $14,550 $9,700 $273.54 $325.92 $394.79 $435.53 $502.46 $627.59 $629.53 $599.46 $176,400 $14,700 $9,800 $276.36 $329.28 $398.86 $440.02 $507.64 $634.06 $636.02 $605.64 $178,200 $14,850 $9,900 $279.18 $332.64 $402.93 $444.51 $512.82 $640.53 $642.51 $611.82 $180,000 $15,000 $10,000 $282.00 $336.00 $407.00 $449.00 $518.00 $647.00 $649.00 $618.00
54 PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 30 Day Elimination Period – Accident and Sickness to Age 65 EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $3,600 $300 $200 $4.86 $5.78 $7.02 $7.82 $9.04 $11.30 $11.22 $10.42 $5,400 $450 $300 $7.29 $8.67 $10.53 $11.73 $13.56 $16.95 $16.83 $15.63 $7,200 $600 $400 $9.72 $11.56 $14.04 $15.64 $18.08 $22.60 $22.44 $20.84 $9,000 $750 $500 $12.15 $14.45 $17.55 $19.55 $22.60 $28.25 $28.05 $26.05 $10,800 $900 $600 $14.58 $17.34 $21.06 $23.46 $27.12 $33.90 $33.66 $31.26 $12,600 $1,050 $700 $17.01 $20.23 $24.57 $27.37 $31.64 $39.55 $39.27 $36.47 $14,400 $1,200 $800 $19.44 $23.12 $28.08 $31.28 $36.16 $45.20 $44.88 $41.68 $16,200 $1,350 $900 $21.87 $26.01 $31.59 $35.19 $40.68 $50.85 $50.49 $46.89 $18,000 $1,500 $1,000 $24.30 $28.90 $35.10 $39.10 $45.20 $56.50 $56.10 $52.10 $19,800 $1,650 $1,100 $26.73 $31.79 $38.61 $43.01 $49.72 $62.15 $61.71 $57.31 $21,600 $1,800 $1,200 $29.16 $34.68 $42.12 $46.92 $54.24 $67.80 $67.32 $62.52 $23,400 $1,950 $1,300 $31.59 $37.57 $45.63 $50.83 $58.76 $73.45 $72.93 $67.73 $25,200 $2,100 $1,400 $34.02 $40.46 $49.14 $54.74 $63.28 $79.10 $78.54 $72.94 $27,000 $2,250 $1,500 $36.45 $43.35 $52.65 $58.65 $67.80 $84.75 $84.15 $78.15 $28,800 $2,400 $1,600 $38.88 $46.24 $56.16 $62.56 $72.32 $90.40 $89.76 $83.36 $30,600 $2,550 $1,700 $41.31 $49.13 $59.67 $66.47 $76.84 $96.05 $95.37 $88.57 $32,400 $2,700 $1,800 $43.74 $52.02 $63.18 $70.38 $81.36 $101.70 $100.98 $93.78 $34,200 $2,850 $1,900 $46.17 $54.91 $66.69 $74.29 $85.88 $107.35 $106.59 $98.99 $36,000 $3,000 $2,000 $48.60 $57.80 $70.20 $78.20 $90.40 $113.00 $112.20 $104.20 $37,800 $3,150 $2,100 $51.03 $60.69 $73.71 $82.11 $94.92 $118.65 $117.81 $109.41 $39,600 $3,300 $2,200 $53.46 $63.58 $77.22 $86.02 $99.44 $124.30 $123.42 $114.62 $41,400 $3,450 $2,300 $55.89 $66.47 $80.73 $89.93 $103.96 $129.95 $129.03 $119.83 $43,200 $3,600 $2,400 $58.32 $69.36 $84.24 $93.84 $108.48 $135.60 $134.64 $125.04 $45,000 $3,750 $2,500 $60.75 $72.25 $87.75 $97.75 $113.00 $141.25 $140.25 $130.25 $46,800 $3,900 $2,600 $63.18 $75.14 $91.26 $101.66 $117.52 $146.90 $145.86 $135.46 $48,600 $4,050 $2,700 $65.61 $78.03 $94.77 $105.57 $122.04 $152.55 $151.47 $140.67 $50,400 $4,200 $2,800 $68.04 $80.92 $98.28 $109.48 $126.56 $158.20 $157.08 $145.88 $52,200 $4,350 $2,900 $70.47 $83.81 $101.79 $113.39 $131.08 $163.85 $162.69 $151.09 $54,000 $4,500 $3,000 $72.90 $86.70 $105.30 $117.30 $135.60 $169.50 $168.30 $156.30 $55,800 $4,650 $3,100 $75.33 $89.59 $108.81 $121.21 $140.12 $175.15 $173.91 $161.51 $57,600 $4,800 $3,200 $77.76 $92.48 $112.32 $125.12 $144.64 $180.80 $179.52 $166.72 $59,400 $4,950 $3,300 $80.19 $95.37 $115.83 $129.03 $149.16 $186.45 $185.13 $171.93 $61,200 $5,100 $3,400 $82.62 $98.26 $119.34 $132.94 $153.68 $192.10 $190.74 $177.14 $63,000 $5,250 $3,500 $85.05 $101.15 $122.85 $136.85 $158.20 $197.75 $196.35 $182.35 $64,800 $5,400 $3,600 $87.48 $104.04 $126.36 $140.76 $162.72 $203.40 $201.96 $187.56 $66,600 $5,550 $3,700 $89.91 $106.93 $129.87 $144.67 $167.24 $209.05 $207.57 $192.77 $68,400 $5,700 $3,800 $92.34 $109.82 $133.38 $148.58 $171.76 $214.70 $213.18 $197.98 $70,200 $5,850 $3,900 $94.77 $112.71 $136.89 $152.49 $176.28 $220.35 $218.79 $203.19 $72,000 $6,000 $4,000 $97.20 $115.60 $140.40 $156.40 $180.80 $226.00 $224.40 $208.40 $73,800 $6,150 $4,100 $99.63 $118.49 $143.91 $160.31 $185.32 $231.65 $230.01 $213.61 $75,600 $6,300 $4,200 $102.06 $121.38 $147.42 $164.22 $189.84 $237.30 $235.62 $218.82 $77,400 $6,450 $4,300 $104.49 $124.27 $150.93 $168.13 $194.36 $242.95 $241.23 $224.03 $79,200 $6,600 $4,400 $106.92 $127.16 $154.44 $172.04 $198.88 $248.60 $246.84 $229.24 $81,000 $6,750 $4,500 $109.35 $130.05 $157.95 $175.95 $203.40 $254.25 $252.45 $234.45 $82,800 $6,900 $4,600 $111.78 $132.94 $161.46 $179.86 $207.92 $259.90 $258.06 $239.66 $84,600 $7,050 $4,700 $114.21 $135.83 $164.97 $183.77 $212.44 $265.55 $263.67 $244.87 $86,400 $7,200 $4,800 $116.64 $138.72 $168.48 $187.68 $216.96 $271.20 $269.28 $250.08 $88,200 $7,350 $4,900 $119.07 $141.61 $171.99 $191.59 $221.48 $276.85 $274.89 $255.29 $90,000 $7,500 $5,000 $121.50 $144.50 $175.50 $195.50 $226.00 $282.50 $280.50 $260.50 $91,800 $7,650 $5,100 $123.93 $147.39 $179.01 $199.41 $230.52 $288.15 $286.11 $265.71 Long Term Disability
55 PREMIUM OPTION MONTHLY PREMIUM COST (based on 12 payments per year) 30 Day Elimination Period – Accident and Sickness to Age 65 EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages -34 35Ages -39 40Ages -44 45Ages -49 50Ages -54 55Ages -59 Ages60+ $93,600 $7,800 $5,200 $126.36 $150.28 $182.52 $203.32 $235.04 $293.80 $291.72 $270.92 $95,400 $7,950 $5,300 $128.79 $153.17 $186.03 $207.23 $239.56 $299.45 $297.33 $276.13 $97,200 $8,100 $5,400 $131.22 $156.06 $189.54 $211.14 $244.08 $305.10 $302.94 $281.34 $99,000 $8,250 $5,500 $133.65 $158.95 $193.05 $215.05 $248.60 $310.75 $308.55 $286.55 $100,800 $8,400 $5,600 $136.08 $161.84 $196.56 $218.96 $253.12 $316.40 $314.16 $291.76 $102,600 $8,550 $5,700 $138.51 $164.73 $200.07 $222.87 $257.64 $322.05 $319.77 $296.97 $104,400 $8,700 $5,800 $140.94 $167.62 $203.58 $226.78 $262.16 $327.70 $325.38 $302.18 $106,200 $8,850 $5,900 $143.37 $170.51 $207.09 $230.69 $266.68 $333.35 $330.99 $307.39 $108,000 $9,000 $6,000 $145.80 $173.40 $210.60 $234.60 $271.20 $339.00 $336.60 $312.60 $109,800 $9,150 $6,100 $148.23 $176.29 $214.11 $238.51 $275.72 $344.65 $342.21 $317.81 $111,600 $9,300 $6,200 $150.66 $179.18 $217.62 $242.42 $280.24 $350.30 $347.82 $323.02 $113,400 $9,450 $6,300 $153.09 $182.07 $221.13 $246.33 $284.76 $355.95 $353.43 $328.23 $115,200 $9,600 $6,400 $155.52 $184.96 $224.64 $250.24 $289.28 $361.60 $359.04 $333.44 $117,000 $9,750 $6,500 $157.95 $187.85 $228.15 $254.15 $293.80 $367.25 $364.65 $338.65 $118,800 $9,900 $6,600 $160.38 $190.74 $231.66 $258.06 $298.32 $372.90 $370.26 $343.86 $120,600 $10,050 $6,700 $162.81 $193.63 $235.17 $261.97 $302.84 $378.55 $375.87 $349.07 $122,400 $10,200 $6,800 $165.24 $196.52 $238.68 $265.88 $307.36 $384.20 $381.48 $354.28 $124,200 $10,350 $6,900 $167.67 $199.41 $242.19 $269.79 $311.88 $389.85 $387.09 $359.49 $126,000 $10,500 $7,000 $170.10 $202.30 $245.70 $273.70 $316.40 $395.50 $392.70 $364.70 $127,800 $10,650 $7,100 $172.53 $205.19 $249.21 $277.61 $320.92 $401.15 $398.31 $369.91 $129,600 $10,800 $7,200 $174.96 $208.08 $252.72 $281.52 $325.44 $406.80 $403.92 $375.12 $131,400 $10,950 $7,300 $177.39 $210.97 $256.23 $285.43 $329.96 $412.45 $409.53 $380.33 $133,200 $11,100 $7,400 $179.82 $213.86 $259.74 $289.34 $334.48 $418.10 $415.14 $385.54 $135,000 $11,250 $7,500 $182.25 $216.75 $263.25 $293.25 $339.00 $423.75 $420.75 $390.75 $136,800 $11,400 $7,600 $184.68 $219.64 $266.76 $297.16 $343.52 $429.40 $426.36 $395.96 $138,600 $11,550 $7,700 $187.11 $222.53 $270.27 $301.07 $348.04 $435.05 $431.97 $401.17 $140,400 $11,700 $7,800 $189.54 $225.42 $273.78 $304.98 $352.56 $440.70 $437.58 $406.38 $142,200 $11,850 $7,900 $191.97 $228.31 $277.29 $308.89 $357.08 $446.35 $443.19 $411.59 $144,000 $12,000 $8,000 $194.40 $231.20 $280.80 $312.80 $361.60 $452.00 $448.80 $416.80 $145,800 $12,150 $8,100 $196.83 $234.09 $284.31 $316.71 $366.12 $457.65 $454.41 $422.01 $147,600 $12,300 $8,200 $199.26 $236.98 $287.82 $320.62 $370.64 $463.30 $460.02 $427.22 $149,400 $12,450 $8,300 $201.69 $239.87 $291.33 $324.53 $375.16 $468.95 $465.63 $432.43 $151,200 $12,600 $8,400 $204.12 $242.76 $294.84 $328.44 $379.68 $474.60 $471.24 $437.64 $153,000 $12,750 $8,500 $206.55 $245.65 $298.35 $332.35 $384.20 $480.25 $476.85 $442.85 $154,800 $12,900 $8,600 $208.98 $248.54 $301.86 $336.26 $388.72 $485.90 $482.46 $448.06 $156,600 $13,050 $8,700 $211.41 $251.43 $305.37 $340.17 $393.24 $491.55 $488.07 $453.27 $158,400 $13,200 $8,800 $213.84 $254.32 $308.88 $344.08 $397.76 $497.20 $493.68 $458.48 $160,200 $13,350 $8,900 $216.27 $257.21 $312.39 $347.99 $402.28 $502.85 $499.29 $463.69 $162,000 $13,500 $9,000 $218.70 $260.10 $315.90 $351.90 $406.80 $508.50 $504.90 $468.90 $163,800 $13,650 $9,100 $221.13 $262.99 $319.41 $355.81 $411.32 $514.15 $510.51 $474.11 $165,600 $13,800 $9,200 $223.56 $265.88 $322.92 $359.72 $415.84 $519.80 $516.12 $479.32 $167,400 $13,950 $9,300 $225.99 $268.77 $326.43 $363.63 $420.36 $525.45 $521.73 $484.53 $169,200 $14,100 $9,400 $228.42 $271.66 $329.94 $367.54 $424.88 $531.10 $527.34 $489.74 $171,000 $14,250 $9,500 $230.85 $274.55 $333.45 $371.45 $429.40 $536.75 $532.95 $494.95 $172,800 $14,400 $9,600 $233.28 $277.44 $336.96 $375.36 $433.92 $542.40 $538.56 $500.16 $174,600 $14,550 $9,700 $235.71 $280.33 $340.47 $379.27 $438.44 $548.05 $544.17 $505.37 $176,400 $14,700 $9,800 $238.14 $283.22 $343.98 $383.18 $442.96 $553.70 $549.78 $510.58 $178,200 $14,850 $9,900 $240.57 $286.11 $347.49 $387.09 $447.48 $559.35 $555.39 $515.79 $180,000 $15,000 $10,000 $243.00 $289.00 $351.00 $391.00 $452.00 $565.00 $561.00 $521.00 Long Term Disability
56 PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 45 Day Elimination Period – Accident and Sickness to Age 65 EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $3,600 $300 $200 $4.06 $4.82 $5.90 $6.66 $7.70 $9.60 $9.46 $8.46 $5,400 $450 $300 $6.09 $7.23 $8.85 $9.99 $11.55 $14.40 $14.19 $12.69 $7,200 $600 $400 $8.12 $9.64 $11.80 $13.32 $15.40 $19.20 $18.92 $16.92 $9,000 $750 $500 $10.15 $12.05 $14.75 $16.65 $19.25 $24.00 $23.65 $21.15 $10,800 $900 $600 $12.18 $14.46 $17.70 $19.98 $23.10 $28.80 $28.38 $25.38 $12,600 $1,050 $700 $14.21 $16.87 $20.65 $23.31 $26.95 $33.60 $33.11 $29.61 $14,400 $1,200 $800 $16.24 $19.28 $23.60 $26.64 $30.80 $38.40 $37.84 $33.84 $16,200 $1,350 $900 $18.27 $21.69 $26.55 $29.97 $34.65 $43.20 $42.57 $38.07 $18,000 $1,500 $1,000 $20.30 $24.10 $29.50 $33.30 $38.50 $48.00 $47.30 $42.30 $19,800 $1,650 $1,100 $22.33 $26.51 $32.45 $36.63 $42.35 $52.80 $52.03 $46.53 $21,600 $1,800 $1,200 $24.36 $28.92 $35.40 $39.96 $46.20 $57.60 $56.76 $50.76 $23,400 $1,950 $1,300 $26.39 $31.33 $38.35 $43.29 $50.05 $62.40 $61.49 $54.99 $25,200 $2,100 $1,400 $28.42 $33.74 $41.30 $46.62 $53.90 $67.20 $66.22 $59.22 $27,000 $2,250 $1,500 $30.45 $36.15 $44.25 $49.95 $57.75 $72.00 $70.95 $63.45 $28,800 $2,400 $1,600 $32.48 $38.56 $47.20 $53.28 $61.60 $76.80 $75.68 $67.68 $30,600 $2,550 $1,700 $34.51 $40.97 $50.15 $56.61 $65.45 $81.60 $80.41 $71.91 $32,400 $2,700 $1,800 $36.54 $43.38 $53.10 $59.94 $69.30 $86.40 $85.14 $76.14 $34,200 $2,850 $1,900 $38.57 $45.79 $56.05 $63.27 $73.15 $91.20 $89.87 $80.37 $36,000 $3,000 $2,000 $40.60 $48.20 $59.00 $66.60 $77.00 $96.00 $94.60 $84.60 $37,800 $3,150 $2,100 $42.63 $50.61 $61.95 $69.93 $80.85 $100.80 $99.33 $88.83 $39,600 $3,300 $2,200 $44.66 $53.02 $64.90 $73.26 $84.70 $105.60 $104.06 $93.06 $41,400 $3,450 $2,300 $46.69 $55.43 $67.85 $76.59 $88.55 $110.40 $108.79 $97.29 $43,200 $3,600 $2,400 $48.72 $57.84 $70.80 $79.92 $92.40 $115.20 $113.52 $101.52 $45,000 $3,750 $2,500 $50.75 $60.25 $73.75 $83.25 $96.25 $120.00 $118.25 $105.75 $46,800 $3,900 $2,600 $52.78 $62.66 $76.70 $86.58 $100.10 $124.80 $122.98 $109.98 $48,600 $4,050 $2,700 $54.81 $65.07 $79.65 $89.91 $103.95 $129.60 $127.71 $114.21 $50,400 $4,200 $2,800 $56.84 $67.48 $82.60 $93.24 $107.80 $134.40 $132.44 $118.44 $52,200 $4,350 $2,900 $58.87 $69.89 $85.55 $96.57 $111.65 $139.20 $137.17 $122.67 $54,000 $4,500 $3,000 $60.90 $72.30 $88.50 $99.90 $115.50 $144.00 $141.90 $126.90 $55,800 $4,650 $3,100 $62.93 $74.71 $91.45 $103.23 $119.35 $148.80 $146.63 $131.13 $57,600 $4,800 $3,200 $64.96 $77.12 $94.40 $106.56 $123.20 $153.60 $151.36 $135.36 $59,400 $4,950 $3,300 $66.99 $79.53 $97.35 $109.89 $127.05 $158.40 $156.09 $139.59 $61,200 $5,100 $3,400 $69.02 $81.94 $100.30 $113.22 $130.90 $163.20 $160.82 $143.82 $63,000 $5,250 $3,500 $71.05 $84.35 $103.25 $116.55 $134.75 $168.00 $165.55 $148.05 $64,800 $5,400 $3,600 $73.08 $86.76 $106.20 $119.88 $138.60 $172.80 $170.28 $152.28 $66,600 $5,550 $3,700 $75.11 $89.17 $109.15 $123.21 $142.45 $177.60 $175.01 $156.51 $68,400 $5,700 $3,800 $77.14 $91.58 $112.10 $126.54 $146.30 $182.40 $179.74 $160.74 $70,200 $5,850 $3,900 $79.17 $93.99 $115.05 $129.87 $150.15 $187.20 $184.47 $164.97 $72,000 $6,000 $4,000 $81.20 $96.40 $118.00 $133.20 $154.00 $192.00 $189.20 $169.20 $73,800 $6,150 $4,100 $83.23 $98.81 $120.95 $136.53 $157.85 $196.80 $193.93 $173.43 $75,600 $6,300 $4,200 $85.26 $101.22 $123.90 $139.86 $161.70 $201.60 $198.66 $177.66 $77,400 $6,450 $4,300 $87.29 $103.63 $126.85 $143.19 $165.55 $206.40 $203.39 $181.89 $79,200 $6,600 $4,400 $89.32 $106.04 $129.80 $146.52 $169.40 $211.20 $208.12 $186.12 $81,000 $6,750 $4,500 $91.35 $108.45 $132.75 $149.85 $173.25 $216.00 $212.85 $190.35 $82,800 $6,900 $4,600 $93.38 $110.86 $135.70 $153.18 $177.10 $220.80 $217.58 $194.58 $84,600 $7,050 $4,700 $95.41 $113.27 $138.65 $156.51 $180.95 $225.60 $222.31 $198.81 $86,400 $7,200 $4,800 $97.44 $115.68 $141.60 $159.84 $184.80 $230.40 $227.04 $203.04 $88,200 $7,350 $4,900 $99.47 $118.09 $144.55 $163.17 $188.65 $235.20 $231.77 $207.27 $90,000 $7,500 $5,000 $101.50 $120.50 $147.50 $166.50 $192.50 $240.00 $236.50 $211.50 $91,800 $7,650 $5,100 $103.53 $122.91 $150.45 $169.83 $196.35 $244.80 $241.23 $215.73 Long Term Disability
57 PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 45 Day Elimination Period – Accident and Sickness to Age 65 EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $93,600 $7,800 $5,200 $105.56 $125.32 $153.40 $173.16 $200.20 $249.60 $245.96 $219.96 $95,400 $7,950 $5,300 $107.59 $127.73 $156.35 $176.49 $204.05 $254.40 $250.69 $224.19 $97,200 $8,100 $5,400 $109.62 $130.14 $159.30 $179.82 $207.90 $259.20 $255.42 $228.42 $99,000 $8,250 $5,500 $111.65 $132.55 $162.25 $183.15 $211.75 $264.00 $260.15 $232.65 $100,800 $8,400 $5,600 $113.68 $134.96 $165.20 $186.48 $215.60 $268.80 $264.88 $236.88 $102,600 $8,550 $5,700 $115.71 $137.37 $168.15 $189.81 $219.45 $273.60 $269.61 $241.11 $104,400 $8,700 $5,800 $117.74 $139.78 $171.10 $193.14 $223.30 $278.40 $274.34 $245.34 $106,200 $8,850 $5,900 $119.77 $142.19 $174.05 $196.47 $227.15 $283.20 $279.07 $249.57 $108,000 $9,000 $6,000 $121.80 $144.60 $177.00 $199.80 $231.00 $288.00 $283.80 $253.80 $109,800 $9,150 $6,100 $123.83 $147.01 $179.95 $203.13 $234.85 $292.80 $288.53 $258.03 $111,600 $9,300 $6,200 $125.86 $149.42 $182.90 $206.46 $238.70 $297.60 $293.26 $262.26 $113,400 $9,450 $6,300 $127.89 $151.83 $185.85 $209.79 $242.55 $302.40 $297.99 $266.49 $115,200 $9,600 $6,400 $129.92 $154.24 $188.80 $213.12 $246.40 $307.20 $302.72 $270.72 $117,000 $9,750 $6,500 $131.95 $156.65 $191.75 $216.45 $250.25 $312.00 $307.45 $274.95 $118,800 $9,900 $6,600 $133.98 $159.06 $194.70 $219.78 $254.10 $316.80 $312.18 $279.18 $120,600 $10,050 $6,700 $136.01 $161.47 $197.65 $223.11 $257.95 $321.60 $316.91 $283.41 $122,400 $10,200 $6,800 $138.04 $163.88 $200.60 $226.44 $261.80 $326.40 $321.64 $287.64 $124,200 $10,350 $6,900 $140.07 $166.29 $203.55 $229.77 $265.65 $331.20 $326.37 $291.87 $126,000 $10,500 $7,000 $142.10 $168.70 $206.50 $233.10 $269.50 $336.00 $331.10 $296.10 $127,800 $10,650 $7,100 $144.13 $171.11 $209.45 $236.43 $273.35 $340.80 $335.83 $300.33 $129,600 $10,800 $7,200 $146.16 $173.52 $212.40 $239.76 $277.20 $345.60 $340.56 $304.56 $131,400 $10,950 $7,300 $148.19 $175.93 $215.35 $243.09 $281.05 $350.40 $345.29 $308.79 $133,200 $11,100 $7,400 $150.22 $178.34 $218.30 $246.42 $284.90 $355.20 $350.02 $313.02 $135,000 $11,250 $7,500 $152.25 $180.75 $221.25 $249.75 $288.75 $360.00 $354.75 $317.25 $136,800 $11,400 $7,600 $154.28 $183.16 $224.20 $253.08 $292.60 $364.80 $359.48 $321.48 $138,600 $11,550 $7,700 $156.31 $185.57 $227.15 $256.41 $296.45 $369.60 $364.21 $325.71 $140,400 $11,700 $7,800 $158.34 $187.98 $230.10 $259.74 $300.30 $374.40 $368.94 $329.94 $142,200 $11,850 $7,900 $160.37 $190.39 $233.05 $263.07 $304.15 $379.20 $373.67 $334.17 $144,000 $12,000 $8,000 $162.40 $192.80 $236.00 $266.40 $308.00 $384.00 $378.40 $338.40 $145,800 $12,150 $8,100 $164.43 $195.21 $238.95 $269.73 $311.85 $388.80 $383.13 $342.63 $147,600 $12,300 $8,200 $166.46 $197.62 $241.90 $273.06 $315.70 $393.60 $387.86 $346.86 $149,400 $12,450 $8,300 $168.49 $200.03 $244.85 $276.39 $319.55 $398.40 $392.59 $351.09 $151,200 $12,600 $8,400 $170.52 $202.44 $247.80 $279.72 $323.40 $403.20 $397.32 $355.32 $153,000 $12,750 $8,500 $172.55 $204.85 $250.75 $283.05 $327.25 $408.00 $402.05 $359.55 $154,800 $12,900 $8,600 $174.58 $207.26 $253.70 $286.38 $331.10 $412.80 $406.78 $363.78 $156,600 $13,050 $8,700 $176.61 $209.67 $256.65 $289.71 $334.95 $417.60 $411.51 $368.01 $158,400 $13,200 $8,800 $178.64 $212.08 $259.60 $293.04 $338.80 $422.40 $416.24 $372.24 $160,200 $13,350 $8,900 $180.67 $214.49 $262.55 $296.37 $342.65 $427.20 $420.97 $376.47 $162,000 $13,500 $9,000 $182.70 $216.90 $265.50 $299.70 $346.50 $432.00 $425.70 $380.70 $163,800 $13,650 $9,100 $184.73 $219.31 $268.45 $303.03 $350.35 $436.80 $430.43 $384.93 $165,600 $13,800 $9,200 $186.76 $221.72 $271.40 $306.36 $354.20 $441.60 $435.16 $389.16 $167,400 $13,950 $9,300 $188.79 $224.13 $274.35 $309.69 $358.05 $446.40 $439.89 $393.39 $169,200 $14,100 $9,400 $190.82 $226.54 $277.30 $313.02 $361.90 $451.20 $444.62 $397.62 $171,000 $14,250 $9,500 $192.85 $228.95 $280.25 $316.35 $365.75 $456.00 $449.35 $401.85 $172,800 $14,400 $9,600 $194.88 $231.36 $283.20 $319.68 $369.60 $460.80 $454.08 $406.08 $174,600 $14,550 $9,700 $196.91 $233.77 $286.15 $323.01 $373.45 $465.60 $458.81 $410.31 $176,400 $14,700 $9,800 $198.94 $236.18 $289.10 $326.34 $377.30 $470.40 $463.54 $414.54 $178,200 $14,850 $9,900 $200.97 $238.59 $292.05 $329.67 $381.15 $475.20 $468.27 $418.77 $180,000 $15,000 $10,000 $203.00 $241.00 $295.00 $333.00 $385.00 $480.00 $473.00 $423.00 Long Term Disability
58 PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 90 Day Elimination Period – Accident and Sickness to Age 65 EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $3,600 $300 $200 $3.52 $4.18 $5.08 $5.78 $6.74 $8.38 $8.26 $7.00 $5,400 $450 $300 $5.28 $6.27 $7.62 $8.67 $10.11 $12.57 $12.39 $10.50 $7,200 $600 $400 $7.04 $8.36 $10.16 $11.56 $13.48 $16.76 $16.52 $14.00 $9,000 $750 $500 $8.80 $10.45 $12.70 $14.45 $16.85 $20.95 $20.65 $17.50 $10,800 $900 $600 $10.56 $12.54 $15.24 $17.34 $20.22 $25.14 $24.78 $21.00 $12,600 $1,050 $700 $12.32 $14.63 $17.78 $20.23 $23.59 $29.33 $28.91 $24.50 $14,400 $1,200 $800 $14.08 $16.72 $20.32 $23.12 $26.96 $33.52 $33.04 $28.00 $16,200 $1,350 $900 $15.84 $18.81 $22.86 $26.01 $30.33 $37.71 $37.17 $31.50 $18,000 $1,500 $1,000 $17.60 $20.90 $25.40 $28.90 $33.70 $41.90 $41.30 $35.00 $19,800 $1,650 $1,100 $19.36 $22.99 $27.94 $31.79 $37.07 $46.09 $45.43 $38.50 $21,600 $1,800 $1,200 $21.12 $25.08 $30.48 $34.68 $40.44 $50.28 $49.56 $42.00 $23,400 $1,950 $1,300 $22.88 $27.17 $33.02 $37.57 $43.81 $54.47 $53.69 $45.50 $25,200 $2,100 $1,400 $24.64 $29.26 $35.56 $40.46 $47.18 $58.66 $57.82 $49.00 $27,000 $2,250 $1,500 $26.40 $31.35 $38.10 $43.35 $50.55 $62.85 $61.95 $52.50 $28,800 $2,400 $1,600 $28.16 $33.44 $40.64 $46.24 $53.92 $67.04 $66.08 $56.00 $30,600 $2,550 $1,700 $29.92 $35.53 $43.18 $49.13 $57.29 $71.23 $70.21 $59.50 $32,400 $2,700 $1,800 $31.68 $37.62 $45.72 $52.02 $60.66 $75.42 $74.34 $63.00 $34,200 $2,850 $1,900 $33.44 $39.71 $48.26 $54.91 $64.03 $79.61 $78.47 $66.50 $36,000 $3,000 $2,000 $35.20 $41.80 $50.80 $57.80 $67.40 $83.80 $82.60 $70.00 $37,800 $3,150 $2,100 $36.96 $43.89 $53.34 $60.69 $70.77 $87.99 $86.73 $73.50 $39,600 $3,300 $2,200 $38.72 $45.98 $55.88 $63.58 $74.14 $92.18 $90.86 $77.00 $41,400 $3,450 $2,300 $40.48 $48.07 $58.42 $66.47 $77.51 $96.37 $94.99 $80.50 $43,200 $3,600 $2,400 $42.24 $50.16 $60.96 $69.36 $80.88 $100.56 $99.12 $84.00 $45,000 $3,750 $2,500 $44.00 $52.25 $63.50 $72.25 $84.25 $104.75 $103.25 $87.50 $46,800 $3,900 $2,600 $45.76 $54.34 $66.04 $75.14 $87.62 $108.94 $107.38 $91.00 $48,600 $4,050 $2,700 $47.52 $56.43 $68.58 $78.03 $90.99 $113.13 $111.51 $94.50 $50,400 $4,200 $2,800 $49.28 $58.52 $71.12 $80.92 $94.36 $117.32 $115.64 $98.00 $52,200 $4,350 $2,900 $51.04 $60.61 $73.66 $83.81 $97.73 $121.51 $119.77 $101.50 $54,000 $4,500 $3,000 $52.80 $62.70 $76.20 $86.70 $101.10 $125.70 $123.90 $105.00 $55,800 $4,650 $3,100 $54.56 $64.79 $78.74 $89.59 $104.47 $129.89 $128.03 $108.50 $57,600 $4,800 $3,200 $56.32 $66.88 $81.28 $92.48 $107.84 $134.08 $132.16 $112.00 $59,400 $4,950 $3,300 $58.08 $68.97 $83.82 $95.37 $111.21 $138.27 $136.29 $115.50 $61,200 $5,100 $3,400 $59.84 $71.06 $86.36 $98.26 $114.58 $142.46 $140.42 $119.00 $63,000 $5,250 $3,500 $61.60 $73.15 $88.90 $101.15 $117.95 $146.65 $144.55 $122.50 $64,800 $5,400 $3,600 $63.36 $75.24 $91.44 $104.04 $121.32 $150.84 $148.68 $126.00 $66,600 $5,550 $3,700 $65.12 $77.33 $93.98 $106.93 $124.69 $155.03 $152.81 $129.50 $68,400 $5,700 $3,800 $66.88 $79.42 $96.52 $109.82 $128.06 $159.22 $156.94 $133.00 $70,200 $5,850 $3,900 $68.64 $81.51 $99.06 $112.71 $131.43 $163.41 $161.07 $136.50 $72,000 $6,000 $4,000 $70.40 $83.60 $101.60 $115.60 $134.80 $167.60 $165.20 $140.00 $73,800 $6,150 $4,100 $72.16 $85.69 $104.14 $118.49 $138.17 $171.79 $169.33 $143.50 $75,600 $6,300 $4,200 $73.92 $87.78 $106.68 $121.38 $141.54 $175.98 $173.46 $147.00 $77,400 $6,450 $4,300 $75.68 $89.87 $109.22 $124.27 $144.91 $180.17 $177.59 $150.50 $79,200 $6,600 $4,400 $77.44 $91.96 $111.76 $127.16 $148.28 $184.36 $181.72 $154.00 $81,000 $6,750 $4,500 $79.20 $94.05 $114.30 $130.05 $151.65 $188.55 $185.85 $157.50 $82,800 $6,900 $4,600 $80.96 $96.14 $116.84 $132.94 $155.02 $192.74 $189.98 $161.00 $84,600 $7,050 $4,700 $82.72 $98.23 $119.38 $135.83 $158.39 $196.93 $194.11 $164.50 $86,400 $7,200 $4,800 $84.48 $100.32 $121.92 $138.72 $161.76 $201.12 $198.24 $168.00 $88,200 $7,350 $4,900 $86.24 $102.41 $124.46 $141.61 $165.13 $205.31 $202.37 $171.50 $90,000 $7,500 $5,000 $88.00 $104.50 $127.00 $144.50 $168.50 $209.50 $206.50 $175.00 $91,800 $7,650 $5,100 $89.76 $106.59 $129.54 $147.39 $171.87 $213.69 $210.63 $178.50 Long Term Disability
59 PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 90 Day Elimination Period Accident and Sickness to Age 65 EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $93,600 $7,800 $5,200 $91.52 $108.68 $132.08 $150.28 $175.24 $217.88 $214.76 $182.00 $95,400 $7,950 $5,300 $93.28 $110.77 $134.62 $153.17 $178.61 $222.07 $218.89 $185.50 $97,200 $8,100 $5,400 $95.04 $112.86 $137.16 $156.06 $181.98 $226.26 $223.02 $189.00 $99,000 $8,250 $5,500 $96.80 $114.95 $139.70 $158.95 $185.35 $230.45 $227.15 $192.50 $100,800 $8,400 $5,600 $98.56 $117.04 $142.24 $161.84 $188.72 $234.64 $231.28 $196.00 $102,600 $8,550 $5,700 $100.32 $119.13 $144.78 $164.73 $192.09 $238.83 $235.41 $199.50 $104,400 $8,700 $5,800 $102.08 $121.22 $147.32 $167.62 $195.46 $243.02 $239.54 $203.00 $106,200 $8,850 $5,900 $103.84 $123.31 $149.86 $170.51 $198.83 $247.21 $243.67 $206.50 $108,000 $9,000 $6,000 $105.60 $125.40 $152.40 $173.40 $202.20 $251.40 $247.80 $210.00 $109,800 $9,150 $6,100 $107.36 $127.49 $154.94 $176.29 $205.57 $255.59 $251.93 $213.50 $111,600 $9,300 $6,200 $109.12 $129.58 $157.48 $179.18 $208.94 $259.78 $256.06 $217.00 $113,400 $9,450 $6,300 $110.88 $131.67 $160.02 $182.07 $212.31 $263.97 $260.19 $220.50 $115,200 $9,600 $6,400 $112.64 $133.76 $162.56 $184.96 $215.68 $268.16 $264.32 $224.00 $117,000 $9,750 $6,500 $114.40 $135.85 $165.10 $187.85 $219.05 $272.35 $268.45 $227.50 $118,800 $9,900 $6,600 $116.16 $137.94 $167.64 $190.74 $222.42 $276.54 $272.58 $231.00 $120,600 $10,050 $6,700 $117.92 $140.03 $170.18 $193.63 $225.79 $280.73 $276.71 $234.50 $122,400 $10,200 $6,800 $119.68 $142.12 $172.72 $196.52 $229.16 $284.92 $280.84 $238.00 $124,200 $10,350 $6,900 $121.44 $144.21 $175.26 $199.41 $232.53 $289.11 $284.97 $241.50 $126,000 $10,500 $7,000 $123.20 $146.30 $177.80 $202.30 $235.90 $293.30 $289.10 $245.00 $127,800 $10,650 $7,100 $124.96 $148.39 $180.34 $205.19 $239.27 $297.49 $293.23 $248.50 $129,600 $10,800 $7,200 $126.72 $150.48 $182.88 $208.08 $242.64 $301.68 $297.36 $252.00 $131,400 $10,950 $7,300 $128.48 $152.57 $185.42 $210.97 $246.01 $305.87 $301.49 $255.50 $133,200 $11,100 $7,400 $130.24 $154.66 $187.96 $213.86 $249.38 $310.06 $305.62 $259.00 $135,000 $11,250 $7,500 $132.00 $156.75 $190.50 $216.75 $252.75 $314.25 $309.75 $262.50 $136,800 $11,400 $7,600 $133.76 $158.84 $193.04 $219.64 $256.12 $318.44 $313.88 $266.00 $138,600 $11,550 $7,700 $135.52 $160.93 $195.58 $222.53 $259.49 $322.63 $318.01 $269.50 $140,400 $11,700 $7,800 $137.28 $163.02 $198.12 $225.42 $262.86 $326.82 $322.14 $273.00 $142,200 $11,850 $7,900 $139.04 $165.11 $200.66 $228.31 $266.23 $331.01 $326.27 $276.50 $144,000 $12,000 $8,000 $140.80 $167.20 $203.20 $231.20 $269.60 $335.20 $330.40 $280.00 $145,800 $12,150 $8,100 $142.56 $169.29 $205.74 $234.09 $272.97 $339.39 $334.53 $283.50 $147,600 $12,300 $8,200 $144.32 $171.38 $208.28 $236.98 $276.34 $343.58 $338.66 $287.00 $149,400 $12,450 $8,300 $146.08 $173.47 $210.82 $239.87 $279.71 $347.77 $342.79 $290.50 $151,200 $12,600 $8,400 $147.84 $175.56 $213.36 $242.76 $283.08 $351.96 $346.92 $294.00 $153,000 $12,750 $8,500 $149.60 $177.65 $215.90 $245.65 $286.45 $356.15 $351.05 $297.50 $154,800 $12,900 $8,600 $151.36 $179.74 $218.44 $248.54 $289.82 $360.34 $355.18 $301.00 $156,600 $13,050 $8,700 $153.12 $181.83 $220.98 $251.43 $293.19 $364.53 $359.31 $304.50 $158,400 $13,200 $8,800 $154.88 $183.92 $223.52 $254.32 $296.56 $368.72 $363.44 $308.00 $160,200 $13,350 $8,900 $156.64 $186.01 $226.06 $257.21 $299.93 $372.91 $367.57 $311.50 $162,000 $13,500 $9,000 $158.40 $188.10 $228.60 $260.10 $303.30 $377.10 $371.70 $315.00 $163,800 $13,650 $9,100 $160.16 $190.19 $231.14 $262.99 $306.67 $381.29 $375.83 $318.50 $165,600 $13,800 $9,200 $161.92 $192.28 $233.68 $265.88 $310.04 $385.48 $379.96 $322.00 $167,400 $13,950 $9,300 $163.68 $194.37 $236.22 $268.77 $313.41 $389.67 $384.09 $325.50 $169,200 $14,100 $9,400 $165.44 $196.46 $238.76 $271.66 $316.78 $393.86 $388.22 $329.00 $171,000 $14,250 $9,500 $167.20 $198.55 $241.30 $274.55 $320.15 $398.05 $392.35 $332.50 $172,800 $14,400 $9,600 $168.96 $200.64 $243.84 $277.44 $323.52 $402.24 $396.48 $336.00 $174,600 $14,550 $9,700 $170.72 $202.73 $246.38 $280.33 $326.89 $406.43 $400.61 $339.50 $176,400 $14,700 $9,800 $172.48 $204.82 $248.92 $283.22 $330.26 $410.62 $404.74 $343.00 $178,200 $14,850 $9,900 $174.24 $206.91 $251.46 $286.11 $333.63 $414.81 $408.87 $346.50 $180,000 $15,000 $10,000 $176.00 $209.00 $254.00 $289.00 $337.00 $419.00 $413.00 $350.00 Long Term Disability
60 SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 14 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $3,600 $300 $200 $4.44 $5.24 $6.34 $6.66 $7.46 $9.34 $10.04 $11.52 $5,400 $450 $300 $6.66 $7.86 $9.51 $9.99 $11.19 $14.01 $15.06 $17.28 $7,200 $600 $400 $8.88 $10.48 $12.68 $13.32 $14.92 $18.68 $20.08 $23.04 $9,000 $750 $500 $11.10 $13.10 $15.85 $16.65 $18.65 $23.35 $25.10 $28.80 $10,800 $900 $600 $13.32 $15.72 $19.02 $19.98 $22.38 $28.02 $30.12 $34.56 $12,600 $1,050 $700 $15.54 $18.34 $22.19 $23.31 $26.11 $32.69 $35.14 $40.32 $14,400 $1,200 $800 $17.76 $20.96 $25.36 $26.64 $29.84 $37.36 $40.16 $46.08 $16,200 $1,350 $900 $19.98 $23.58 $28.53 $29.97 $33.57 $42.03 $45.18 $51.84 $18,000 $1,500 $1,000 $22.20 $26.20 $31.70 $33.30 $37.30 $46.70 $50.20 $57.60 $19,800 $1,650 $1,100 $24.42 $28.82 $34.87 $36.63 $41.03 $51.37 $55.22 $63.36 $21,600 $1,800 $1,200 $26.64 $31.44 $38.04 $39.96 $44.76 $56.04 $60.24 $69.12 $23,400 $1,950 $1,300 $28.86 $34.06 $41.21 $43.29 $48.49 $60.71 $65.26 $74.88 $25,200 $2,100 $1,400 $31.08 $36.68 $44.38 $46.62 $52.22 $65.38 $70.28 $80.64 $27,000 $2,250 $1,500 $33.30 $39.30 $47.55 $49.95 $55.95 $70.05 $75.30 $86.40 $28,800 $2,400 $1,600 $35.52 $41.92 $50.72 $53.28 $59.68 $74.72 $80.32 $92.16 $30,600 $2,550 $1,700 $37.74 $44.54 $53.89 $56.61 $63.41 $79.39 $85.34 $97.92 $32,400 $2,700 $1,800 $39.96 $47.16 $57.06 $59.94 $67.14 $84.06 $90.36 $103.68 $34,200 $2,850 $1,900 $42.18 $49.78 $60.23 $63.27 $70.87 $88.73 $95.38 $109.44 $36,000 $3,000 $2,000 $44.40 $52.40 $63.40 $66.60 $74.60 $93.40 $100.40 $115.20 $37,800 $3,150 $2,100 $46.62 $55.02 $66.57 $69.93 $78.33 $98.07 $105.42 $120.96 $39,600 $3,300 $2,200 $48.84 $57.64 $69.74 $73.26 $82.06 $102.74 $110.44 $126.72 $41,400 $3,450 $2,300 $51.06 $60.26 $72.91 $76.59 $85.79 $107.41 $115.46 $132.48 $43,200 $3,600 $2,400 $53.28 $62.88 $76.08 $79.92 $89.52 $112.08 $120.48 $138.24 $45,000 $3,750 $2,500 $55.50 $65.50 $79.25 $83.25 $93.25 $116.75 $125.50 $144.00 $46,800 $3,900 $2,600 $57.72 $68.12 $82.42 $86.58 $96.98 $121.42 $130.52 $149.76 $48,600 $4,050 $2,700 $59.94 $70.74 $85.59 $89.91 $100.71 $126.09 $135.54 $155.52 $50,400 $4,200 $2,800 $62.16 $73.36 $88.76 $93.24 $104.44 $130.76 $140.56 $161.28 $52,200 $4,350 $2,900 $64.38 $75.98 $91.93 $96.57 $108.17 $135.43 $145.58 $167.04 $54,000 $4,500 $3,000 $66.60 $78.60 $95.10 $99.90 $111.90 $140.10 $150.60 $172.80 $55,800 $4,650 $3,100 $68.82 $81.22 $98.27 $103.23 $115.63 $144.77 $155.62 $178.56 $57,600 $4,800 $3,200 $71.04 $83.84 $101.44 $106.56 $119.36 $149.44 $160.64 $184.32 $59,400 $4,950 $3,300 $73.26 $86.46 $104.61 $109.89 $123.09 $154.11 $165.66 $190.08 $61,200 $5,100 $3,400 $75.48 $89.08 $107.78 $113.22 $126.82 $158.78 $170.68 $195.84 $63,000 $5,250 $3,500 $77.70 $91.70 $110.95 $116.55 $130.55 $163.45 $175.70 $201.60 $64,800 $5,400 $3,600 $79.92 $94.32 $114.12 $119.88 $134.28 $168.12 $180.72 $207.36 $66,600 $5,550 $3,700 $82.14 $96.94 $117.29 $123.21 $138.01 $172.79 $185.74 $213.12 $68,400 $5,700 $3,800 $84.36 $99.56 $120.46 $126.54 $141.74 $177.46 $190.76 $218.88 $70,200 $5,850 $3,900 $86.58 $102.18 $123.63 $129.87 $145.47 $182.13 $195.78 $224.64 $72,000 $6,000 $4,000 $88.80 $104.80 $126.80 $133.20 $149.20 $186.80 $200.80 $230.40 $73,800 $6,150 $4,100 $91.02 $107.42 $129.97 $136.53 $152.93 $191.47 $205.82 $236.16 $75,600 $6,300 $4,200 $93.24 $110.04 $133.14 $139.86 $156.66 $196.14 $210.84 $241.92 $77,400 $6,450 $4,300 $95.46 $112.66 $136.31 $143.19 $160.39 $200.81 $215.86 $247.68 $79,200 $6,600 $4,400 $97.68 $115.28 $139.48 $146.52 $164.12 $205.48 $220.88 $253.44 $81,000 $6,750 $4,500 $99.90 $117.90 $142.65 $149.85 $167.85 $210.15 $225.90 $259.20 $82,800 $6,900 $4,600 $102.12 $120.52 $145.82 $153.18 $171.58 $214.82 $230.92 $264.96 $84,600 $7,050 $4,700 $104.34 $123.14 $148.99 $156.51 $175.31 $219.49 $235.94 $270.72 $86,400 $7,200 $4,800 $106.56 $125.76 $152.16 $159.84 $179.04 $224.16 $240.96 $276.48 $88,200 $7,350 $4,900 $108.78 $128.38 $155.33 $163.17 $182.77 $228.83 $245.98 $282.24 $90,000 $7,500 $5,000 $111.00 $131.00 $158.50 $166.50 $186.50 $233.50 $251.00 $288.00 $91,800 $7,650 $5,100 $113.22 $133.62 $161.67 $169.83 $190.23 $238.17 $256.02 $293.76 Long Term Disability
61 SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 14 Day Elimination Period Accident to Age 65 and Sickness 5 Yr EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $93,600 $7,800 $5,200 $115.44 $136.24 $164.84 $173.16 $193.96 $242.84 $261.04 $299.52 $95,400 $7,950 $5,300 $117.66 $138.86 $168.01 $176.49 $197.69 $247.51 $266.06 $305.28 $97,200 $8,100 $5,400 $119.88 $141.48 $171.18 $179.82 $201.42 $252.18 $271.08 $311.04 $99,000 $8,250 $5,500 $122.10 $144.10 $174.35 $183.15 $205.15 $256.85 $276.10 $316.80 $100,800 $8,400 $5,600 $124.32 $146.72 $177.52 $186.48 $208.88 $261.52 $281.12 $322.56 $102,600 $8,550 $5,700 $126.54 $149.34 $180.69 $189.81 $212.61 $266.19 $286.14 $328.32 $104,400 $8,700 $5,800 $128.76 $151.96 $183.86 $193.14 $216.34 $270.86 $291.16 $334.08 $106,200 $8,850 $5,900 $130.98 $154.58 $187.03 $196.47 $220.07 $275.53 $296.18 $339.84 $108,000 $9,000 $6,000 $133.20 $157.20 $190.20 $199.80 $223.80 $280.20 $301.20 $345.60 $109,800 $9,150 $6,100 $135.42 $159.82 $193.37 $203.13 $227.53 $284.87 $306.22 $351.36 $111,600 $9,300 $6,200 $137.64 $162.44 $196.54 $206.46 $231.26 $289.54 $311.24 $357.12 $113,400 $9,450 $6,300 $139.86 $165.06 $199.71 $209.79 $234.99 $294.21 $316.26 $362.88 $115,200 $9,600 $6,400 $142.08 $167.68 $202.88 $213.12 $238.72 $298.88 $321.28 $368.64 $117,000 $9,750 $6,500 $144.30 $170.30 $206.05 $216.45 $242.45 $303.55 $326.30 $374.40 $118,800 $9,900 $6,600 $146.52 $172.92 $209.22 $219.78 $246.18 $308.22 $331.32 $380.16 $120,600 $10,050 $6,700 $148.74 $175.54 $212.39 $223.11 $249.91 $312.89 $336.34 $385.92 $122,400 $10,200 $6,800 $150.96 $178.16 $215.56 $226.44 $253.64 $317.56 $341.36 $391.68 $124,200 $10,350 $6,900 $153.18 $180.78 $218.73 $229.77 $257.37 $322.23 $346.38 $397.44 $126,000 $10,500 $7,000 $155.40 $183.40 $221.90 $233.10 $261.10 $326.90 $351.40 $403.20 $127,800 $10,650 $7,100 $157.62 $186.02 $225.07 $236.43 $264.83 $331.57 $356.42 $408.96 $129,600 $10,800 $7,200 $159.84 $188.64 $228.24 $239.76 $268.56 $336.24 $361.44 $414.72 $131,400 $10,950 $7,300 $162.06 $191.26 $231.41 $243.09 $272.29 $340.91 $366.46 $420.48 $133,200 $11,100 $7,400 $164.28 $193.88 $234.58 $246.42 $276.02 $345.58 $371.48 $426.24 $135,000 $11,250 $7,500 $166.50 $196.50 $237.75 $249.75 $279.75 $350.25 $376.50 $432.00 $136,800 $11,400 $7,600 $168.72 $199.12 $240.92 $253.08 $283.48 $354.92 $381.52 $437.76 $138,600 $11,550 $7,700 $170.94 $201.74 $244.09 $256.41 $287.21 $359.59 $386.54 $443.52 $140,400 $11,700 $7,800 $173.16 $204.36 $247.26 $259.74 $290.94 $364.26 $391.56 $449.28 $142,200 $11,850 $7,900 $175.38 $206.98 $250.43 $263.07 $294.67 $368.93 $396.58 $455.04 $144,000 $12,000 $8,000 $177.60 $209.60 $253.60 $266.40 $298.40 $373.60 $401.60 $460.80 $145,800 $12,150 $8,100 $179.82 $212.22 $256.77 $269.73 $302.13 $378.27 $406.62 $466.56 $147,600 $12,300 $8,200 $182.04 $214.84 $259.94 $273.06 $305.86 $382.94 $411.64 $472.32 $149,400 $12,450 $8,300 $184.26 $217.46 $263.11 $276.39 $309.59 $387.61 $416.66 $478.08 $151,200 $12,600 $8,400 $186.48 $220.08 $266.28 $279.72 $313.32 $392.28 $421.68 $483.84 $153,000 $12,750 $8,500 $188.70 $222.70 $269.45 $283.05 $317.05 $396.95 $426.70 $489.60 $154,800 $12,900 $8,600 $190.92 $225.32 $272.62 $286.38 $320.78 $401.62 $431.72 $495.36 $156,600 $13,050 $8,700 $193.14 $227.94 $275.79 $289.71 $324.51 $406.29 $436.74 $501.12 $158,400 $13,200 $8,800 $195.36 $230.56 $278.96 $293.04 $328.24 $410.96 $441.76 $506.88 $160,200 $13,350 $8,900 $197.58 $233.18 $282.13 $296.37 $331.97 $415.63 $446.78 $512.64 $162,000 $13,500 $9,000 $199.80 $235.80 $285.30 $299.70 $335.70 $420.30 $451.80 $518.40 $163,800 $13,650 $9,100 $202.02 $238.42 $288.47 $303.03 $339.43 $424.97 $456.82 $524.16 $165,600 $13,800 $9,200 $204.24 $241.04 $291.64 $306.36 $343.16 $429.64 $461.84 $529.92 $167,400 $13,950 $9,300 $206.46 $243.66 $294.81 $309.69 $346.89 $434.31 $466.86 $535.68 $169,200 $14,100 $9,400 $208.68 $246.28 $297.98 $313.02 $350.62 $438.98 $471.88 $541.44 $171,000 $14,250 $9,500 $210.90 $248.90 $301.15 $316.35 $354.35 $443.65 $476.90 $547.20 $172,800 $14,400 $9,600 $213.12 $251.52 $304.32 $319.68 $358.08 $448.32 $481.92 $552.96 $174,600 $14,550 $9,700 $215.34 $254.14 $307.49 $323.01 $361.81 $452.99 $486.94 $558.72 $176,400 $14,700 $9,800 $217.56 $256.76 $310.66 $326.34 $365.54 $457.66 $491.96 $564.48 $178,200 $14,850 $9,900 $219.78 $259.38 $313.83 $329.67 $369.27 $462.33 $496.98 $570.24 $180,000 $15,000 $10,000 $222.00 $262.00 $317.00 $333.00 $373.00 $467.00 $502.00 $576.00 Long Term Disability
62 SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 30 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $3,600 $300 $200 $3.68 $4.34 $5.26 $5.56 $6.20 $7.78 $8.34 $9.60 $5,400 $450 $300 $5.52 $6.51 $7.89 $8.34 $9.30 $11.67 $12.51 $14.40 $7,200 $600 $400 $7.36 $8.68 $10.52 $11.12 $12.40 $15.56 $16.68 $19.20 $9,000 $750 $500 $9.20 $10.85 $13.15 $13.90 $15.50 $19.45 $20.85 $24.00 $10,800 $900 $600 $11.04 $13.02 $15.78 $16.68 $18.60 $23.34 $25.02 $28.80 $12,600 $1,050 $700 $12.88 $15.19 $18.41 $19.46 $21.70 $27.23 $29.19 $33.60 $14,400 $1,200 $800 $14.72 $17.36 $21.04 $22.24 $24.80 $31.12 $33.36 $38.40 $16,200 $1,350 $900 $16.56 $19.53 $23.67 $25.02 $27.90 $35.01 $37.53 $43.20 $18,000 $1,500 $1,000 $18.40 $21.70 $26.30 $27.80 $31.00 $38.90 $41.70 $48.00 $19,800 $1,650 $1,100 $20.24 $23.87 $28.93 $30.58 $34.10 $42.79 $45.87 $52.80 $21,600 $1,800 $1,200 $22.08 $26.04 $31.56 $33.36 $37.20 $46.68 $50.04 $57.60 $23,400 $1,950 $1,300 $23.92 $28.21 $34.19 $36.14 $40.30 $50.57 $54.21 $62.40 $25,200 $2,100 $1,400 $25.76 $30.38 $36.82 $38.92 $43.40 $54.46 $58.38 $67.20 $27,000 $2,250 $1,500 $27.60 $32.55 $39.45 $41.70 $46.50 $58.35 $62.55 $72.00 $28,800 $2,400 $1,600 $29.44 $34.72 $42.08 $44.48 $49.60 $62.24 $66.72 $76.80 $30,600 $2,550 $1,700 $31.28 $36.89 $44.71 $47.26 $52.70 $66.13 $70.89 $81.60 $32,400 $2,700 $1,800 $33.12 $39.06 $47.34 $50.04 $55.80 $70.02 $75.06 $86.40 $34,200 $2,850 $1,900 $34.96 $41.23 $49.97 $52.82 $58.90 $73.91 $79.23 $91.20 $36,000 $3,000 $2,000 $36.80 $43.40 $52.60 $55.60 $62.00 $77.80 $83.40 $96.00 $37,800 $3,150 $2,100 $38.64 $45.57 $55.23 $58.38 $65.10 $81.69 $87.57 $100.80 $39,600 $3,300 $2,200 $40.48 $47.74 $57.86 $61.16 $68.20 $85.58 $91.74 $105.60 $41,400 $3,450 $2,300 $42.32 $49.91 $60.49 $63.94 $71.30 $89.47 $95.91 $110.40 $43,200 $3,600 $2,400 $44.16 $52.08 $63.12 $66.72 $74.40 $93.36 $100.08 $115.20 $45,000 $3,750 $2,500 $46.00 $54.25 $65.75 $69.50 $77.50 $97.25 $104.25 $120.00 $46,800 $3,900 $2,600 $47.84 $56.42 $68.38 $72.28 $80.60 $101.14 $108.42 $124.80 $48,600 $4,050 $2,700 $49.68 $58.59 $71.01 $75.06 $83.70 $105.03 $112.59 $129.60 $50,400 $4,200 $2,800 $51.52 $60.76 $73.64 $77.84 $86.80 $108.92 $116.76 $134.40 $52,200 $4,350 $2,900 $53.36 $62.93 $76.27 $80.62 $89.90 $112.81 $120.93 $139.20 $54,000 $4,500 $3,000 $55.20 $65.10 $78.90 $83.40 $93.00 $116.70 $125.10 $144.00 $55,800 $4,650 $3,100 $57.04 $67.27 $81.53 $86.18 $96.10 $120.59 $129.27 $148.80 $57,600 $4,800 $3,200 $58.88 $69.44 $84.16 $88.96 $99.20 $124.48 $133.44 $153.60 $59,400 $4,950 $3,300 $60.72 $71.61 $86.79 $91.74 $102.30 $128.37 $137.61 $158.40 $61,200 $5,100 $3,400 $62.56 $73.78 $89.42 $94.52 $105.40 $132.26 $141.78 $163.20 $63,000 $5,250 $3,500 $64.40 $75.95 $92.05 $97.30 $108.50 $136.15 $145.95 $168.00 $64,800 $5,400 $3,600 $66.24 $78.12 $94.68 $100.08 $111.60 $140.04 $150.12 $172.80 $66,600 $5,550 $3,700 $68.08 $80.29 $97.31 $102.86 $114.70 $143.93 $154.29 $177.60 $68,400 $5,700 $3,800 $69.92 $82.46 $99.94 $105.64 $117.80 $147.82 $158.46 $182.40 $70,200 $5,850 $3,900 $71.76 $84.63 $102.57 $108.42 $120.90 $151.71 $162.63 $187.20 $72,000 $6,000 $4,000 $73.60 $86.80 $105.20 $111.20 $124.00 $155.60 $166.80 $192.00 $73,800 $6,150 $4,100 $75.44 $88.97 $107.83 $113.98 $127.10 $159.49 $170.97 $196.80 $75,600 $6,300 $4,200 $77.28 $91.14 $110.46 $116.76 $130.20 $163.38 $175.14 $201.60 $77,400 $6,450 $4,300 $79.12 $93.31 $113.09 $119.54 $133.30 $167.27 $179.31 $206.40 $79,200 $6,600 $4,400 $80.96 $95.48 $115.72 $122.32 $136.40 $171.16 $183.48 $211.20 $81,000 $6,750 $4,500 $82.80 $97.65 $118.35 $125.10 $139.50 $175.05 $187.65 $216.00 $82,800 $6,900 $4,600 $84.64 $99.82 $120.98 $127.88 $142.60 $178.94 $191.82 $220.80 $84,600 $7,050 $4,700 $86.48 $101.99 $123.61 $130.66 $145.70 $182.83 $195.99 $225.60 $86,400 $7,200 $4,800 $88.32 $104.16 $126.24 $133.44 $148.80 $186.72 $200.16 $230.40 $88,200 $7,350 $4,900 $90.16 $106.33 $128.87 $136.22 $151.90 $190.61 $204.33 $235.20 $90,000 $7,500 $5,000 $92.00 $108.50 $131.50 $139.00 $155.00 $194.50 $208.50 $240.00 $91,800 $7,650 $5,100 $93.84 $110.67 $134.13 $141.78 $158.10 $198.39 $212.67 $244.80 Long Term Disability
63 SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 30 Day Elimination Period Accident to Age 65 and Sickness 5 Yr EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $93,600 $7,800 $5,200 $95.68 $112.84 $136.76 $144.56 $161.20 $202.28 $216.84 $249.60 $95,400 $7,950 $5,300 $97.52 $115.01 $139.39 $147.34 $164.30 $206.17 $221.01 $254.40 $97,200 $8,100 $5,400 $99.36 $117.18 $142.02 $150.12 $167.40 $210.06 $225.18 $259.20 $99,000 $8,250 $5,500 $101.20 $119.35 $144.65 $152.90 $170.50 $213.95 $229.35 $264.00 $100,800 $8,400 $5,600 $103.04 $121.52 $147.28 $155.68 $173.60 $217.84 $233.52 $268.80 $102,600 $8,550 $5,700 $104.88 $123.69 $149.91 $158.46 $176.70 $221.73 $237.69 $273.60 $104,400 $8,700 $5,800 $106.72 $125.86 $152.54 $161.24 $179.80 $225.62 $241.86 $278.40 $106,200 $8,850 $5,900 $108.56 $128.03 $155.17 $164.02 $182.90 $229.51 $246.03 $283.20 $108,000 $9,000 $6,000 $110.40 $130.20 $157.80 $166.80 $186.00 $233.40 $250.20 $288.00 $109,800 $9,150 $6,100 $112.24 $132.37 $160.43 $169.58 $189.10 $237.29 $254.37 $292.80 $111,600 $9,300 $6,200 $114.08 $134.54 $163.06 $172.36 $192.20 $241.18 $258.54 $297.60 $113,400 $9,450 $6,300 $115.92 $136.71 $165.69 $175.14 $195.30 $245.07 $262.71 $302.40 $115,200 $9,600 $6,400 $117.76 $138.88 $168.32 $177.92 $198.40 $248.96 $266.88 $307.20 $117,000 $9,750 $6,500 $119.60 $141.05 $170.95 $180.70 $201.50 $252.85 $271.05 $312.00 $118,800 $9,900 $6,600 $121.44 $143.22 $173.58 $183.48 $204.60 $256.74 $275.22 $316.80 $120,600 $10,050 $6,700 $123.28 $145.39 $176.21 $186.26 $207.70 $260.63 $279.39 $321.60 $122,400 $10,200 $6,800 $125.12 $147.56 $178.84 $189.04 $210.80 $264.52 $283.56 $326.40 $124,200 $10,350 $6,900 $126.96 $149.73 $181.47 $191.82 $213.90 $268.41 $287.73 $331.20 $126,000 $10,500 $7,000 $128.80 $151.90 $184.10 $194.60 $217.00 $272.30 $291.90 $336.00 $127,800 $10,650 $7,100 $130.64 $154.07 $186.73 $197.38 $220.10 $276.19 $296.07 $340.80 $129,600 $10,800 $7,200 $132.48 $156.24 $189.36 $200.16 $223.20 $280.08 $300.24 $345.60 $131,400 $10,950 $7,300 $134.32 $158.41 $191.99 $202.94 $226.30 $283.97 $304.41 $350.40 $133,200 $11,100 $7,400 $136.16 $160.58 $194.62 $205.72 $229.40 $287.86 $308.58 $355.20 $135,000 $11,250 $7,500 $138.00 $162.75 $197.25 $208.50 $232.50 $291.75 $312.75 $360.00 $136,800 $11,400 $7,600 $139.84 $164.92 $199.88 $211.28 $235.60 $295.64 $316.92 $364.80 $138,600 $11,550 $7,700 $141.68 $167.09 $202.51 $214.06 $238.70 $299.53 $321.09 $369.60 $140,400 $11,700 $7,800 $143.52 $169.26 $205.14 $216.84 $241.80 $303.42 $325.26 $374.40 $142,200 $11,850 $7,900 $145.36 $171.43 $207.77 $219.62 $244.90 $307.31 $329.43 $379.20 $144,000 $12,000 $8,000 $147.20 $173.60 $210.40 $222.40 $248.00 $311.20 $333.60 $384.00 $145,800 $12,150 $8,100 $149.04 $175.77 $213.03 $225.18 $251.10 $315.09 $337.77 $388.80 $147,600 $12,300 $8,200 $150.88 $177.94 $215.66 $227.96 $254.20 $318.98 $341.94 $393.60 $149,400 $12,450 $8,300 $152.72 $180.11 $218.29 $230.74 $257.30 $322.87 $346.11 $398.40 $151,200 $12,600 $8,400 $154.56 $182.28 $220.92 $233.52 $260.40 $326.76 $350.28 $403.20 $153,000 $12,750 $8,500 $156.40 $184.45 $223.55 $236.30 $263.50 $330.65 $354.45 $408.00 $154,800 $12,900 $8,600 $158.24 $186.62 $226.18 $239.08 $266.60 $334.54 $358.62 $412.80 $156,600 $13,050 $8,700 $160.08 $188.79 $228.81 $241.86 $269.70 $338.43 $362.79 $417.60 $158,400 $13,200 $8,800 $161.92 $190.96 $231.44 $244.64 $272.80 $342.32 $366.96 $422.40 $160,200 $13,350 $8,900 $163.76 $193.13 $234.07 $247.42 $275.90 $346.21 $371.13 $427.20 $162,000 $13,500 $9,000 $165.60 $195.30 $236.70 $250.20 $279.00 $350.10 $375.30 $432.00 $163,800 $13,650 $9,100 $167.44 $197.47 $239.33 $252.98 $282.10 $353.99 $379.47 $436.80 $165,600 $13,800 $9,200 $169.28 $199.64 $241.96 $255.76 $285.20 $357.88 $383.64 $441.60 $167,400 $13,950 $9,300 $171.12 $201.81 $244.59 $258.54 $288.30 $361.77 $387.81 $446.40 $169,200 $14,100 $9,400 $172.96 $203.98 $247.22 $261.32 $291.40 $365.66 $391.98 $451.20 $171,000 $14,250 $9,500 $174.80 $206.15 $249.85 $264.10 $294.50 $369.55 $396.15 $456.00 $172,800 $14,400 $9,600 $176.64 $208.32 $252.48 $266.88 $297.60 $373.44 $400.32 $460.80 $174,600 $14,550 $9,700 $178.48 $210.49 $255.11 $269.66 $300.70 $377.33 $404.49 $465.60 $176,400 $14,700 $9,800 $180.32 $212.66 $257.74 $272.44 $303.80 $381.22 $408.66 $470.40 $178,200 $14,850 $9,900 $182.16 $214.83 $260.37 $275.22 $306.90 $385.11 $412.83 $475.20 $180,000 $15,000 $10,000 $184.00 $217.00 $263.00 $278.00 $310.00 $389.00 $417.00 $480.00 Long Term Disability
64 SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 45 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $3,600 $300 $200 $2.92 $3.42 $4.18 $4.44 $4.94 $6.20 $6.62 $7.66 $5,400 $450 $300 $4.38 $5.13 $6.27 $6.66 $7.41 $9.30 $9.93 $11.49 $7,200 $600 $400 $5.84 $6.84 $8.36 $8.88 $9.88 $12.40 $13.24 $15.32 $9,000 $750 $500 $7.30 $8.55 $10.45 $11.10 $12.35 $15.50 $16.55 $19.15 $10,800 $900 $600 $8.76 $10.26 $12.54 $13.32 $14.82 $18.60 $19.86 $22.98 $12,600 $1,050 $700 $10.22 $11.97 $14.63 $15.54 $17.29 $21.70 $23.17 $26.81 $14,400 $1,200 $800 $11.68 $13.68 $16.72 $17.76 $19.76 $24.80 $26.48 $30.64 $16,200 $1,350 $900 $13.14 $15.39 $18.81 $19.98 $22.23 $27.90 $29.79 $34.47 $18,000 $1,500 $1,000 $14.60 $17.10 $20.90 $22.20 $24.70 $31.00 $33.10 $38.30 $19,800 $1,650 $1,100 $16.06 $18.81 $22.99 $24.42 $27.17 $34.10 $36.41 $42.13 $21,600 $1,800 $1,200 $17.52 $20.52 $25.08 $26.64 $29.64 $37.20 $39.72 $45.96 $23,400 $1,950 $1,300 $18.98 $22.23 $27.17 $28.86 $32.11 $40.30 $43.03 $49.79 $25,200 $2,100 $1,400 $20.44 $23.94 $29.26 $31.08 $34.58 $43.40 $46.34 $53.62 $27,000 $2,250 $1,500 $21.90 $25.65 $31.35 $33.30 $37.05 $46.50 $49.65 $57.45 $28,800 $2,400 $1,600 $23.36 $27.36 $33.44 $35.52 $39.52 $49.60 $52.96 $61.28 $30,600 $2,550 $1,700 $24.82 $29.07 $35.53 $37.74 $41.99 $52.70 $56.27 $65.11 $32,400 $2,700 $1,800 $26.28 $30.78 $37.62 $39.96 $44.46 $55.80 $59.58 $68.94 $34,200 $2,850 $1,900 $27.74 $32.49 $39.71 $42.18 $46.93 $58.90 $62.89 $72.77 $36,000 $3,000 $2,000 $29.20 $34.20 $41.80 $44.40 $49.40 $62.00 $66.20 $76.60 $37,800 $3,150 $2,100 $30.66 $35.91 $43.89 $46.62 $51.87 $65.10 $69.51 $80.43 $39,600 $3,300 $2,200 $32.12 $37.62 $45.98 $48.84 $54.34 $68.20 $72.82 $84.26 $41,400 $3,450 $2,300 $33.58 $39.33 $48.07 $51.06 $56.81 $71.30 $76.13 $88.09 $43,200 $3,600 $2,400 $35.04 $41.04 $50.16 $53.28 $59.28 $74.40 $79.44 $91.92 $45,000 $3,750 $2,500 $36.50 $42.75 $52.25 $55.50 $61.75 $77.50 $82.75 $95.75 $46,800 $3,900 $2,600 $37.96 $44.46 $54.34 $57.72 $64.22 $80.60 $86.06 $99.58 $48,600 $4,050 $2,700 $39.42 $46.17 $56.43 $59.94 $66.69 $83.70 $89.37 $103.41 $50,400 $4,200 $2,800 $40.88 $47.88 $58.52 $62.16 $69.16 $86.80 $92.68 $107.24 $52,200 $4,350 $2,900 $42.34 $49.59 $60.61 $64.38 $71.63 $89.90 $95.99 $111.07 $54,000 $4,500 $3,000 $43.80 $51.30 $62.70 $66.60 $74.10 $93.00 $99.30 $114.90 $55,800 $4,650 $3,100 $45.26 $53.01 $64.79 $68.82 $76.57 $96.10 $102.61 $118.73 $57,600 $4,800 $3,200 $46.72 $54.72 $66.88 $71.04 $79.04 $99.20 $105.92 $122.56 $59,400 $4,950 $3,300 $48.18 $56.43 $68.97 $73.26 $81.51 $102.30 $109.23 $126.39 $61,200 $5,100 $3,400 $49.64 $58.14 $71.06 $75.48 $83.98 $105.40 $112.54 $130.22 $63,000 $5,250 $3,500 $51.10 $59.85 $73.15 $77.70 $86.45 $108.50 $115.85 $134.05 $64,800 $5,400 $3,600 $52.56 $61.56 $75.24 $79.92 $88.92 $111.60 $119.16 $137.88 $66,600 $5,550 $3,700 $54.02 $63.27 $77.33 $82.14 $91.39 $114.70 $122.47 $141.71 $68,400 $5,700 $3,800 $55.48 $64.98 $79.42 $84.36 $93.86 $117.80 $125.78 $145.54 $70,200 $5,850 $3,900 $56.94 $66.69 $81.51 $86.58 $96.33 $120.90 $129.09 $149.37 $72,000 $6,000 $4,000 $58.40 $68.40 $83.60 $88.80 $98.80 $124.00 $132.40 $153.20 $73,800 $6,150 $4,100 $59.86 $70.11 $85.69 $91.02 $101.27 $127.10 $135.71 $157.03 $75,600 $6,300 $4,200 $61.32 $71.82 $87.78 $93.24 $103.74 $130.20 $139.02 $160.86 $77,400 $6,450 $4,300 $62.78 $73.53 $89.87 $95.46 $106.21 $133.30 $142.33 $164.69 $79,200 $6,600 $4,400 $64.24 $75.24 $91.96 $97.68 $108.68 $136.40 $145.64 $168.52 $81,000 $6,750 $4,500 $65.70 $76.95 $94.05 $99.90 $111.15 $139.50 $148.95 $172.35 $82,800 $6,900 $4,600 $67.16 $78.66 $96.14 $102.12 $113.62 $142.60 $152.26 $176.18 $84,600 $7,050 $4,700 $68.62 $80.37 $98.23 $104.34 $116.09 $145.70 $155.57 $180.01 $86,400 $7,200 $4,800 $70.08 $82.08 $100.32 $106.56 $118.56 $148.80 $158.88 $183.84 $88,200 $7,350 $4,900 $71.54 $83.79 $102.41 $108.78 $121.03 $151.90 $162.19 $187.67 $90,000 $7,500 $5,000 $73.00 $85.50 $104.50 $111.00 $123.50 $155.00 $165.50 $191.50 $91,800 $7,650 $5,100 $74.46 $87.21 $106.59 $113.22 $125.97 $158.10 $168.81 $195.33 Long Term Disability
65 SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 45 Day Elimination Period Accident to Age 65 and Sickness 5 Yr EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $93,600 $7,800 $5,200 $75.92 $88.92 $108.68 $115.44 $128.44 $161.20 $172.12 $199.16 $95,400 $7,950 $5,300 $77.38 $90.63 $110.77 $117.66 $130.91 $164.30 $175.43 $202.99 $97,200 $8,100 $5,400 $78.84 $92.34 $112.86 $119.88 $133.38 $167.40 $178.74 $206.82 $99,000 $8,250 $5,500 $80.30 $94.05 $114.95 $122.10 $135.85 $170.50 $182.05 $210.65 $100,800 $8,400 $5,600 $81.76 $95.76 $117.04 $124.32 $138.32 $173.60 $185.36 $214.48 $102,600 $8,550 $5,700 $83.22 $97.47 $119.13 $126.54 $140.79 $176.70 $188.67 $218.31 $104,400 $8,700 $5,800 $84.68 $99.18 $121.22 $128.76 $143.26 $179.80 $191.98 $222.14 $106,200 $8,850 $5,900 $86.14 $100.89 $123.31 $130.98 $145.73 $182.90 $195.29 $225.97 $108,000 $9,000 $6,000 $87.60 $102.60 $125.40 $133.20 $148.20 $186.00 $198.60 $229.80 $109,800 $9,150 $6,100 $89.06 $104.31 $127.49 $135.42 $150.67 $189.10 $201.91 $233.63 $111,600 $9,300 $6,200 $90.52 $106.02 $129.58 $137.64 $153.14 $192.20 $205.22 $237.46 $113,400 $9,450 $6,300 $91.98 $107.73 $131.67 $139.86 $155.61 $195.30 $208.53 $241.29 $115,200 $9,600 $6,400 $93.44 $109.44 $133.76 $142.08 $158.08 $198.40 $211.84 $245.12 $117,000 $9,750 $6,500 $94.90 $111.15 $135.85 $144.30 $160.55 $201.50 $215.15 $248.95 $118,800 $9,900 $6,600 $96.36 $112.86 $137.94 $146.52 $163.02 $204.60 $218.46 $252.78 $120,600 $10,050 $6,700 $97.82 $114.57 $140.03 $148.74 $165.49 $207.70 $221.77 $256.61 $122,400 $10,200 $6,800 $99.28 $116.28 $142.12 $150.96 $167.96 $210.80 $225.08 $260.44 $124,200 $10,350 $6,900 $100.74 $117.99 $144.21 $153.18 $170.43 $213.90 $228.39 $264.27 $126,000 $10,500 $7,000 $102.20 $119.70 $146.30 $155.40 $172.90 $217.00 $231.70 $268.10 $127,800 $10,650 $7,100 $103.66 $121.41 $148.39 $157.62 $175.37 $220.10 $235.01 $271.93 $129,600 $10,800 $7,200 $105.12 $123.12 $150.48 $159.84 $177.84 $223.20 $238.32 $275.76 $131,400 $10,950 $7,300 $106.58 $124.83 $152.57 $162.06 $180.31 $226.30 $241.63 $279.59 $133,200 $11,100 $7,400 $108.04 $126.54 $154.66 $164.28 $182.78 $229.40 $244.94 $283.42 $135,000 $11,250 $7,500 $109.50 $128.25 $156.75 $166.50 $185.25 $232.50 $248.25 $287.25 $136,800 $11,400 $7,600 $110.96 $129.96 $158.84 $168.72 $187.72 $235.60 $251.56 $291.08 $138,600 $11,550 $7,700 $112.42 $131.67 $160.93 $170.94 $190.19 $238.70 $254.87 $294.91 $140,400 $11,700 $7,800 $113.88 $133.38 $163.02 $173.16 $192.66 $241.80 $258.18 $298.74 $142,200 $11,850 $7,900 $115.34 $135.09 $165.11 $175.38 $195.13 $244.90 $261.49 $302.57 $144,000 $12,000 $8,000 $116.80 $136.80 $167.20 $177.60 $197.60 $248.00 $264.80 $306.40 $145,800 $12,150 $8,100 $118.26 $138.51 $169.29 $179.82 $200.07 $251.10 $268.11 $310.23 $147,600 $12,300 $8,200 $119.72 $140.22 $171.38 $182.04 $202.54 $254.20 $271.42 $314.06 $149,400 $12,450 $8,300 $121.18 $141.93 $173.47 $184.26 $205.01 $257.30 $274.73 $317.89 $151,200 $12,600 $8,400 $122.64 $143.64 $175.56 $186.48 $207.48 $260.40 $278.04 $321.72 $153,000 $12,750 $8,500 $124.10 $145.35 $177.65 $188.70 $209.95 $263.50 $281.35 $325.55 $154,800 $12,900 $8,600 $125.56 $147.06 $179.74 $190.92 $212.42 $266.60 $284.66 $329.38 $156,600 $13,050 $8,700 $127.02 $148.77 $181.83 $193.14 $214.89 $269.70 $287.97 $333.21 $158,400 $13,200 $8,800 $128.48 $150.48 $183.92 $195.36 $217.36 $272.80 $291.28 $337.04 $160,200 $13,350 $8,900 $129.94 $152.19 $186.01 $197.58 $219.83 $275.90 $294.59 $340.87 $162,000 $13,500 $9,000 $131.40 $153.90 $188.10 $199.80 $222.30 $279.00 $297.90 $344.70 $163,800 $13,650 $9,100 $132.86 $155.61 $190.19 $202.02 $224.77 $282.10 $301.21 $348.53 $165,600 $13,800 $9,200 $134.32 $157.32 $192.28 $204.24 $227.24 $285.20 $304.52 $352.36 $167,400 $13,950 $9,300 $135.78 $159.03 $194.37 $206.46 $229.71 $288.30 $307.83 $356.19 $169,200 $14,100 $9,400 $137.24 $160.74 $196.46 $208.68 $232.18 $291.40 $311.14 $360.02 $171,000 $14,250 $9,500 $138.70 $162.45 $198.55 $210.90 $234.65 $294.50 $314.45 $363.85 $172,800 $14,400 $9,600 $140.16 $164.16 $200.64 $213.12 $237.12 $297.60 $317.76 $367.68 $174,600 $14,550 $9,700 $141.62 $165.87 $202.73 $215.34 $239.59 $300.70 $321.07 $371.51 $176,400 $14,700 $9,800 $143.08 $167.58 $204.82 $217.56 $242.06 $303.80 $324.38 $375.34 $178,200 $14,850 $9,900 $144.54 $169.29 $206.91 $219.78 $244.53 $306.90 $327.69 $379.17 $180,000 $15,000 $10,000 $146.00 $171.00 $209.00 $222.00 $247.00 $310.00 $331.00 $383.00 Long Term Disability
66 SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 90 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $3,600 $300 $200 $2.38 $2.76 $3.38 $3.56 $3.98 $4.98 $5.44 $6.20 $5,400 $450 $300 $3.57 $4.14 $5.07 $5.34 $5.97 $7.47 $8.16 $9.30 $7,200 $600 $400 $4.76 $5.52 $6.76 $7.12 $7.96 $9.96 $10.88 $12.40 $9,000 $750 $500 $5.95 $6.90 $8.45 $8.90 $9.95 $12.45 $13.60 $15.50 $10,800 $900 $600 $7.14 $8.28 $10.14 $10.68 $11.94 $14.94 $16.32 $18.60 $12,600 $1,050 $700 $8.33 $9.66 $11.83 $12.46 $13.93 $17.43 $19.04 $21.70 $14,400 $1,200 $800 $9.52 $11.04 $13.52 $14.24 $15.92 $19.92 $21.76 $24.80 $16,200 $1,350 $900 $10.71 $12.42 $15.21 $16.02 $17.91 $22.41 $24.48 $27.90 $18,000 $1,500 $1,000 $11.90 $13.80 $16.90 $17.80 $19.90 $24.90 $27.20 $31.00 $19,800 $1,650 $1,100 $13.09 $15.18 $18.59 $19.58 $21.89 $27.39 $29.92 $34.10 $21,600 $1,800 $1,200 $14.28 $16.56 $20.28 $21.36 $23.88 $29.88 $32.64 $37.20 $23,400 $1,950 $1,300 $15.47 $17.94 $21.97 $23.14 $25.87 $32.37 $35.36 $40.30 $25,200 $2,100 $1,400 $16.66 $19.32 $23.66 $24.92 $27.86 $34.86 $38.08 $43.40 $27,000 $2,250 $1,500 $17.85 $20.70 $25.35 $26.70 $29.85 $37.35 $40.80 $46.50 $28,800 $2,400 $1,600 $19.04 $22.08 $27.04 $28.48 $31.84 $39.84 $43.52 $49.60 $30,600 $2,550 $1,700 $20.23 $23.46 $28.73 $30.26 $33.83 $42.33 $46.24 $52.70 $32,400 $2,700 $1,800 $21.42 $24.84 $30.42 $32.04 $35.82 $44.82 $48.96 $55.80 $34,200 $2,850 $1,900 $22.61 $26.22 $32.11 $33.82 $37.81 $47.31 $51.68 $58.90 $36,000 $3,000 $2,000 $23.80 $27.60 $33.80 $35.60 $39.80 $49.80 $54.40 $62.00 $37,800 $3,150 $2,100 $24.99 $28.98 $35.49 $37.38 $41.79 $52.29 $57.12 $65.10 $39,600 $3,300 $2,200 $26.18 $30.36 $37.18 $39.16 $43.78 $54.78 $59.84 $68.20 $41,400 $3,450 $2,300 $27.37 $31.74 $38.87 $40.94 $45.77 $57.27 $62.56 $71.30 $43,200 $3,600 $2,400 $28.56 $33.12 $40.56 $42.72 $47.76 $59.76 $65.28 $74.40 $45,000 $3,750 $2,500 $29.75 $34.50 $42.25 $44.50 $49.75 $62.25 $68.00 $77.50 $46,800 $3,900 $2,600 $30.94 $35.88 $43.94 $46.28 $51.74 $64.74 $70.72 $80.60 $48,600 $4,050 $2,700 $32.13 $37.26 $45.63 $48.06 $53.73 $67.23 $73.44 $83.70 $50,400 $4,200 $2,800 $33.32 $38.64 $47.32 $49.84 $55.72 $69.72 $76.16 $86.80 $52,200 $4,350 $2,900 $34.51 $40.02 $49.01 $51.62 $57.71 $72.21 $78.88 $89.90 $54,000 $4,500 $3,000 $35.70 $41.40 $50.70 $53.40 $59.70 $74.70 $81.60 $93.00 $55,800 $4,650 $3,100 $36.89 $42.78 $52.39 $55.18 $61.69 $77.19 $84.32 $96.10 $57,600 $4,800 $3,200 $38.08 $44.16 $54.08 $56.96 $63.68 $79.68 $87.04 $99.20 $59,400 $4,950 $3,300 $39.27 $45.54 $55.77 $58.74 $65.67 $82.17 $89.76 $102.30 $61,200 $5,100 $3,400 $40.46 $46.92 $57.46 $60.52 $67.66 $84.66 $92.48 $105.40 $63,000 $5,250 $3,500 $41.65 $48.30 $59.15 $62.30 $69.65 $87.15 $95.20 $108.50 $64,800 $5,400 $3,600 $42.84 $49.68 $60.84 $64.08 $71.64 $89.64 $97.92 $111.60 $66,600 $5,550 $3,700 $44.03 $51.06 $62.53 $65.86 $73.63 $92.13 $100.64 $114.70 $68,400 $5,700 $3,800 $45.22 $52.44 $64.22 $67.64 $75.62 $94.62 $103.36 $117.80 $70,200 $5,850 $3,900 $46.41 $53.82 $65.91 $69.42 $77.61 $97.11 $106.08 $120.90 $72,000 $6,000 $4,000 $47.60 $55.20 $67.60 $71.20 $79.60 $99.60 $108.80 $124.00 $73,800 $6,150 $4,100 $48.79 $56.58 $69.29 $72.98 $81.59 $102.09 $111.52 $127.10 $75,600 $6,300 $4,200 $49.98 $57.96 $70.98 $74.76 $83.58 $104.58 $114.24 $130.20 $77,400 $6,450 $4,300 $51.17 $59.34 $72.67 $76.54 $85.57 $107.07 $116.96 $133.30 $79,200 $6,600 $4,400 $52.36 $60.72 $74.36 $78.32 $87.56 $109.56 $119.68 $136.40 $81,000 $6,750 $4,500 $53.55 $62.10 $76.05 $80.10 $89.55 $112.05 $122.40 $139.50 $82,800 $6,900 $4,600 $54.74 $63.48 $77.74 $81.88 $91.54 $114.54 $125.12 $142.60 $84,600 $7,050 $4,700 $55.93 $64.86 $79.43 $83.66 $93.53 $117.03 $127.84 $145.70 $86,400 $7,200 $4,800 $57.12 $66.24 $81.12 $85.44 $95.52 $119.52 $130.56 $148.80 $88,200 $7,350 $4,900 $58.31 $67.62 $82.81 $87.22 $97.51 $122.01 $133.28 $151.90 $90,000 $7,500 $5,000 $59.50 $69.00 $84.50 $89.00 $99.50 $124.50 $136.00 $155.00 $91,800 $7,650 $5,100 $60.69 $70.38 $86.19 $90.78 $101.49 $126.99 $138.72 $158.10 Long Term Disability
67 SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 90 Day Elimination Period Accident to Age 65 and Sickness 5 Yr EarningsAnnual MonthlyEarnings MonthlyBenefit AgeUnder30 30Ages34 35Ages39 40Ages44 45Ages49 50Ages54 55Ages59 Ages60+ $93,600 $7,800 $5,200 $61.88 $71.76 $87.88 $92.56 $103.48 $129.48 $141.44 $161.20 $95,400 $7,950 $5,300 $63.07 $73.14 $89.57 $94.34 $105.47 $131.97 $144.16 $164.30 $97,200 $8,100 $5,400 $64.26 $74.52 $91.26 $96.12 $107.46 $134.46 $146.88 $167.40 $99,000 $8,250 $5,500 $65.45 $75.90 $92.95 $97.90 $109.45 $136.95 $149.60 $170.50 $100,800 $8,400 $5,600 $66.64 $77.28 $94.64 $99.68 $111.44 $139.44 $152.32 $173.60 $102,600 $8,550 $5,700 $67.83 $78.66 $96.33 $101.46 $113.43 $141.93 $155.04 $176.70 $104,400 $8,700 $5,800 $69.02 $80.04 $98.02 $103.24 $115.42 $144.42 $157.76 $179.80 $106,200 $8,850 $5,900 $70.21 $81.42 $99.71 $105.02 $117.41 $146.91 $160.48 $182.90 $108,000 $9,000 $6,000 $71.40 $82.80 $101.40 $106.80 $119.40 $149.40 $163.20 $186.00 $109,800 $9,150 $6,100 $72.59 $84.18 $103.09 $108.58 $121.39 $151.89 $165.92 $189.10 $111,600 $9,300 $6,200 $73.78 $85.56 $104.78 $110.36 $123.38 $154.38 $168.64 $192.20 $113,400 $9,450 $6,300 $74.97 $86.94 $106.47 $112.14 $125.37 $156.87 $171.36 $195.30 $115,200 $9,600 $6,400 $76.16 $88.32 $108.16 $113.92 $127.36 $159.36 $174.08 $198.40 $117,000 $9,750 $6,500 $77.35 $89.70 $109.85 $115.70 $129.35 $161.85 $176.80 $201.50 $118,800 $9,900 $6,600 $78.54 $91.08 $111.54 $117.48 $131.34 $164.34 $179.52 $204.60 $120,600 $10,050 $6,700 $79.73 $92.46 $113.23 $119.26 $133.33 $166.83 $182.24 $207.70 $122,400 $10,200 $6,800 $80.92 $93.84 $114.92 $121.04 $135.32 $169.32 $184.96 $210.80 $124,200 $10,350 $6,900 $82.11 $95.22 $116.61 $122.82 $137.31 $171.81 $187.68 $213.90 $126,000 $10,500 $7,000 $83.30 $96.60 $118.30 $124.60 $139.30 $174.30 $190.40 $217.00 $127,800 $10,650 $7,100 $84.49 $97.98 $119.99 $126.38 $141.29 $176.79 $193.12 $220.10 $129,600 $10,800 $7,200 $85.68 $99.36 $121.68 $128.16 $143.28 $179.28 $195.84 $223.20 $131,400 $10,950 $7,300 $86.87 $100.74 $123.37 $129.94 $145.27 $181.77 $198.56 $226.30 $133,200 $11,100 $7,400 $88.06 $102.12 $125.06 $131.72 $147.26 $184.26 $201.28 $229.40 $135,000 $11,250 $7,500 $89.25 $103.50 $126.75 $133.50 $149.25 $186.75 $204.00 $232.50 $136,800 $11,400 $7,600 $90.44 $104.88 $128.44 $135.28 $151.24 $189.24 $206.72 $235.60 $138,600 $11,550 $7,700 $91.63 $106.26 $130.13 $137.06 $153.23 $191.73 $209.44 $238.70 $140,400 $11,700 $7,800 $92.82 $107.64 $131.82 $138.84 $155.22 $194.22 $212.16 $241.80 $142,200 $11,850 $7,900 $94.01 $109.02 $133.51 $140.62 $157.21 $196.71 $214.88 $244.90 $144,000 $12,000 $8,000 $95.20 $110.40 $135.20 $142.40 $159.20 $199.20 $217.60 $248.00 $145,800 $12,150 $8,100 $96.39 $111.78 $136.89 $144.18 $161.19 $201.69 $220.32 $251.10 $147,600 $12,300 $8,200 $97.58 $113.16 $138.58 $145.96 $163.18 $204.18 $223.04 $254.20 $149,400 $12,450 $8,300 $98.77 $114.54 $140.27 $147.74 $165.17 $206.67 $225.76 $257.30 $151,200 $12,600 $8,400 $99.96 $115.92 $141.96 $149.52 $167.16 $209.16 $228.48 $260.40 $153,000 $12,750 $8,500 $101.15 $117.30 $143.65 $151.30 $169.15 $211.65 $231.20 $263.50 $154,800 $12,900 $8,600 $102.34 $118.68 $145.34 $153.08 $171.14 $214.14 $233.92 $266.60 $156,600 $13,050 $8,700 $103.53 $120.06 $147.03 $154.86 $173.13 $216.63 $236.64 $269.70 $158,400 $13,200 $8,800 $104.72 $121.44 $148.72 $156.64 $175.12 $219.12 $239.36 $272.80 $160,200 $13,350 $8,900 $105.91 $122.82 $150.41 $158.42 $177.11 $221.61 $242.08 $275.90 $162,000 $13,500 $9,000 $107.10 $124.20 $152.10 $160.20 $179.10 $224.10 $244.80 $279.00 $163,800 $13,650 $9,100 $108.29 $125.58 $153.79 $161.98 $181.09 $226.59 $247.52 $282.10 $165,600 $13,800 $9,200 $109.48 $126.96 $155.48 $163.76 $183.08 $229.08 $250.24 $285.20 $167,400 $13,950 $9,300 $110.67 $128.34 $157.17 $165.54 $185.07 $231.57 $252.96 $288.30 $169,200 $14,100 $9,400 $111.86 $129.72 $158.86 $167.32 $187.06 $234.06 $255.68 $291.40 $171,000 $14,250 $9,500 $113.05 $131.10 $160.55 $169.10 $189.05 $236.55 $258.40 $294.50 $172,800 $14,400 $9,600 $114.24 $132.48 $162.24 $170.88 $191.04 $239.04 $261.12 $297.60 $174,600 $14,550 $9,700 $115.43 $133.86 $163.93 $172.66 $193.03 $241.53 $263.84 $300.70 $176,400 $14,700 $9,800 $116.62 $135.24 $165.62 $174.44 $195.02 $244.02 $266.56 $303.80 $178,200 $14,850 $9,900 $117.81 $136.62 $167.31 $176.22 $197.01 $246.51 $269.28 $306.90 $180,000 $15,000 $10,000 $119.00 $138.00 $169.00 $178.00 $199.00 $249.00 $272.00 $310.00 Long Term Disability
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About this Benefit
Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well being of your Accidentalfamily.Death
About this Benefit cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking. Motor vehicle crashes are the
& Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.
#1
73 Life and AD&D
your coverage amount. For Your Children*Dependent $5,000, $10,000 or $15,000 *Child(ren)’s Eligibility: Dependent children ages from birth to age 26 are eligible for coverage, regardless of student status. • Air Bag • Seat Belt • Common Carrier • Child Care Center • Child Education • Spouse Education • Hospitalization
you
Standard Additional Benefits Include Some of the standard additional benefits included in your coverage that may increase the amounts payable to you and/or defray additional expenses that result from accidental injury or loss of life are: What Is Not Covered by AD&D?
Note:
coverage,
Please note that a reduction schedule may apply. Please see your employer or certificate for specific details
Accidental Death & Dismemberment Coverage Options
*All
Basic Term Life Insurance
elected
• Your Supplemental AD&D amount is equal to your Supplemental Term Life amount.
your application. For You An
Additional Coverage
How
Your employer provides you with Basic Term Life insurance coverage in the amount of $15,000.
Covered Losses
What’s Not Covered?
Supplemental and Dependent Life Insurance does not provide payment of benefits for death caused by suicide within the first two years (one year for group policies issued in Missouri, North Dakota and Colorado) of the effective date of the certificate or an increase in coverage. This exclusionary period is one year for residents of Missouri and North Dakota. If the group policy was issued in Massachusetts, the suicide exclusion does not apply to dependent life coverage. The suicide exclusion does not apply to residents of Washington, or to individuals covered under a group policy issued in Washington.
The maximum amount payable for all Covered Losses sustained in any one accident is capped at 100% of the Full Amount.
Accidental Death & Dismemberment (AD&D) coverage complements your Supplemental Life insurance coverage and helps protect you 24 hours a day, 365 days a year.
This AD&D insurance pays benefits for covered losses that are the result of an accidental injury or loss of life. The full amount of AD&D coverage you select is called the “Full Amount” and is equal to the benefit payable for the loss of life. Benefits for other losses are payable as a predetermined percentage of the Full Amount and will be listed in your coverage in a table of Covered Losses. Such losses include loss of limbs, sight, speech and hearing, various forms of paralysis, brain damage and coma.
Supplemental Term Life Insurance Coverage Options
AD&D insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained or from food poisoning; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over the counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or active participation in a riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs. Information to Apply* online at www.mybenefitshub.com/fortworthisd today!
you
*Child(ren)’s Eligibility: Dependent children ages from birth to 26, regardless of student status.
Apply
Supplemental AD&D Coverage Amounts for You
Be sure to indicate your Beneficiary. Act Now During the Enrollment Period. If you do not wish to make a change to your you do not need to do anything. applications are subject to review and approval by Metropolitan Life Insurance Company. Based on the plan design and the amount of coverage requested, a Statement of Health may need to be submitted to complete amount elected by that is a multiple of $10,000 to a maximum of $500,000 amount by that is a multiple of $10,000 to a maximum of $100,000, up to 100% of
Fort Worth Independent School District Active Employee Life Plan Summary Life insurance is a cost effective way to protect your family and your finances. It helps ensure your short and long term financial obligations could be met if something unforeseen happens to Exploreyou. the coverage that makes it easy to give yourself and your loved ones more security today and in the future.
For Your Spouse An
Like most insurance plans, this plan has exclusions.
• You are enrolling for spouse coverage equal to/less than $50,000 and enrolling for child(ren) coverage equal to/ less than $15,000.
• You are requesting to increase existing coverage by one increment, and the total amount of coverage does not exceed $250,000.
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In addition, your spouse and eligible child(ren) must not be home or hospital confined or receiving or applying to receive disability benefits from any source when their coverage becomes effective.
For New Hires
• You are enrolling for coverage equal to/less than $250,000
•
You can select any beneficiary(ies) other than your employer for your Basic and Supplemental coverages, and you may change your beneficiary(ies) at any time. You can also designate more than one beneficiary. You are the beneficiary for your Dependent coverage.
If Actively at Work requirements are met, coverage will become effective on date of hire for Basic Life and on the first of the month following the receipt of your completed application for Supplemental and Dependent Life requests that do not require additional medical information. A request for your amount that requires additional medical information and is not approved by the date listed above will not be effective until the later of the date that notice is received that MetLife has approved the coverage or increase if you meet Actively at Work requirements on that date, or the date that Actively at Work requirements are met after MetLife has approved the coverage or increase. The coverage for your spouse and eligible child(ren) will take effect on the date they are no longer confined, receiving or applying for disability benefits from any source or hospitalized.
•
• If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form.
You must be covered in order to obtain coverage for your spouse and child(ren). Your spouse and dependent children do not need to provide medical information as long as: For Annual Enrollment
For New Hires
The enrollment takes place within 31 days from the date you become eligible for benefits, and
For Annual Enrollment
• You are continuing the coverage you had in the last year, or
• If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form.
•
The enrollment takes place prior to the enrollment deadline, and
Enrollment in this Supplemental Term Life insurance plan is available without providing medical information as long as:
You have the option to purchase Supplemental Term Life Insurance. Listed below are your monthly rates (based on your age as of your last birthday) as well as those for your spouse (based on your spouse’
You must be Actively at Work on the date your coverage becomes effective. Your coverage must be in effect in order for your spouse and eligible children’s coverage to take effect.
The enrollment takes place within 31 days from the date you become eligible for benefits, and
s age as of his/her last birthday). Rates to cover your child(ren) are also shown Life and AD&D Age Monthly Cost Per $1,000 of CoverageEmployee Monthly Cost Per $1,000 of Spouse Coverage 0 39 $0.076 $0.076 40 44 $0.235 $0.235 45 49 $0.235 $0.235 50 54 $0.311 $0.311 55 59 $0.625 $0.625 60 64 $0.879 $0.879 65+ $0.956 $0.956 $ 5,000 $1.335 $10,000 $2.670 $15,000 $4.005 Cost for your Child(ren)† † Covers all eligible children *Note: rates are subject to the policy’s right to change premium rates, and the employer’s right to change employee contributions.
Monthly Costs* for Supplemental Term Life and Dependent Term Life with Accidental Death and Dismemberment Insurance
For Dependent Coverage†
About Your Coverage Effective Date
The enrollment takes place prior to the enrollment deadline, and
• You are continuing the coverage you had for your spouse and child(ren) in the last year
Who Can Be A Designated Beneficiary?
• You are requesting to increase existing coverage for your spouse by one increment, and the total amount of coverage does not exceed $50,000.
•
For Employee Coverage
To help ensure your decisions are carried out
Life Settlement Account
7
• A will lets you define your most important decisions, such as who will care for your children or inherit your property.
Call 1 800 821 6400 and a Client Service Representative will assist you. You also have the flexibility of using an attorney who is not participating in the MetLife Legal Plans, Inc. network and being reimbursed for covered services according to a set fee schedule. In that case you will be responsible for any attorney’s fees that exceed the reimbursed amount.
Will Preparation
Use the table below to calculate your premium based on the amount of life insurance you will need.
When you enroll for supplemental term life coverage, you will automatically receive access to Will Preparation Services at no extra cost to you. Both you and your spouse will have unlimited in person or telephone access to one of MetLife Legal Plans, Inc nationwide network of 14,000+ participating attorneys for preparation of or updating a will, living will or power of attorney.* When you use a participating plan attorney, there will be no charge for the services.* Like life insurance, a carefully prepared will (simple or complex), living will and power of attorney are important.
Example: $100,000 Supplemental Life Coverage Repeat the three easy steps above to determine the cost for each coverage selected.
Once Enrolled, You have Access to MetLife AdvantagesSM Services to Help Navigate What Life May Bring Grief Counseling (all states except NY)1 To help you, your dependents, and your beneficiaries cope with loss You, your dependents, and your beneficiaries have access to grief counseling1 sessions and funeral related concierge services to help cope with a loss at no extra cost. Grief counseling services provide confidential and professional support during a difficult time to help address personal and funeral planning needs. At your time of need, you and your dependents have 24/7 access to a work/life counselor. You simply call a dedicated 24/7 toll free number to speak with a licensed professional experienced in helping individuals who have suffered a loss. Sessions can either take place in person or by phone. You can have up to five face to face grief counseling sessions per event to discuss any situation you perceive as a major loss, including but not limited to death, bankruptcy, divorce, terminal illness, or losing a pet.1 In addition, you have access to funeral assistance for locating funeral homes and cemetery options, obtaining funeral cost estimates and comparisons, and more. You can access these services by calling 1 888 319 7819 or log on to www.metlifegc.lifeworks.com (Username: metlifeassist; Password: support). Download this helpful Funeral Planning Guide at https://www.metlife.com/ funeralplanning/funeral guide/.
• A living will ensures your wishes are carried out and protects your loved ones from having to make very difficult and personal medical decisions by themselves. Also called an “advanced directive,” it is a document authorized by statutes in all states that allows you to provide written instructions regarding use of extraordinary life support measures and to appoint someone as your proxy or representative to make decisions on maintaining extraordinary life support if you should become incapacitated and unable to communicate your wishes. Powers of attorney allow you to plan ahead by designating someone you know and trust to act on your behalf in the event of unexpected occurrences or if you become incapacitated
1. Enter the rate from the table (example age 36) $0.076 $ ________ 2. Enter the amount of insurance in thousands of dollars (Example: for $100,000 of coverage enter $100) $100 $ ________ 2. Monthly premium (1) x (2) $7.60 $ ________
*
Beneficiary Claim Assistance3 For support when beneficiaries need it most This program is designed to help beneficiaries sort through the details and serious questions about claims and financial needs during a difficult time. MetLife has arranged for Massachusetts Mutual Life Insurance Company (Mass Mutual) financial professionals to be available for assistance in person or by telephone to help with filing life insurance claims, government benefits and help with financial questions.
The Total Control Account® (TCA) settlement option provides your loved ones with a safe and convenient way to manage the proceeds of a life or accidental death and dismemberment claim payment of $5,000 or more, backed by the financial strength and claims paying ability of Metropolitan Life Insurance Company. TCA death claim payments relieve beneficiaries of the need to make immediate decisions about what to do with a lump sum check and enable them to have the flexibility to access funds as needed while earning a guaranteed minimum interest rate on the proceeds as they assess their financial situations. Call 1 800 638 7283 for more information about options available to you.
75 Life and AD&D
For immediate access to death proceeds
5
•
Life and AD&D Estate Resolution ServicesSM7 (ERS) Personal service and compassion assistance to help probate your and your spouse’s estates.
10
Offering continued coverage when you need it most If you become Totally Disabled, you may qualify to continue certain insurance. You may also be eligible for waiver of your supplemental term life insurance premium until you reach age
benefits including: • Group
•
Please note that conversion is not available on AD&D coverage. If you experience an event that makes you eligible to convert your coverage, please call 1 877 275 6387 to begin the conversion process. Please contact your employer for more information.
Please note that if you experience an event that makes you eligible for portable coverage, please call a MetLife representative at 1 888 252 3607 or contact your employer for more Transitioninformation.Solutions identifying solutions for your financial situations Solutions provides assistance for important, time benefit financial decisions due to change in Life Insurance Continuation Options sum distributions
Benefits Option is also available to spouses insured under Dependent Life insurance plans. This option is not available for dependent child coverage.
Conversion is available on all group life insurance coverages.
MetLife Estate Resolution ServicesSM provides probate services in person or over the phone to the representative (executor or administrator) of the deceased employee's estate and the estate of the employee's spouse Estate Resolution Services include preparation of documents and representation at court proceedings needed to transfer the probate assets from the estate to the heirs and completion of correspondence necessary to transfer non probate assets.
10
Accelerated Benefits Option
•
3 Assistance
sensitive
This insurance offering from your employer and MetLife comes with additional features that can provide assistance to you and your family.
• Lump
WillsCenter.com8 Self service online legal document preparation Employees and spouses have access to WillsCenter.com, an online document service to prepare and update a will, living will, power of attorney, funeral directive, memorandum of wishes or HIPAA authorization form in a secure 24/7 environment at no additional cost. This service is available with all life coverages. Log on to www.willscenter.com to register as a new user. you can keep your coverage even if you leave your current employer Should you leave Fort Worth Independent School District for any reason, and your Basic, Supplemental and Dependent Term Life and Supplemental and Dependent Accidental Death and Dismemberment insurance under this plan terminates, you will have an opportunity to continue group term coverage (“portability”) under a different policy, subject to plan design and state availability. Rates will be based on the experience of the ported group and MetLife will bill you directly. Rates may be higher than your current rates. To take advantage of this feature, you must have coverage of at least $10,000 up to a maximum of Portability$2,000,000.is also available on coverage you’ve selected for your spouse and dependent child(ren). The maximum amount of coverage for spouse is $250,000; the maximum amount of dependent child coverage is $25,000. Increases, decreases and maximums are subject to state availability. there is no minimum time for you to be covered by the plan before you can take advantage of the portability feature. Please see your employer or certificate for specific details.
Portability So
or bankruptcy • Define Contribution Plan termination • Retiree Group Life elimination
and
76
ERS covers participating plan attorneys’ fees for telephone and face to face consultations or for the administrator or executor to discuss general questions about the probate process.
Transition
Accelerated Benefits Option is not the same as long term care insurance (LTC). LTC provides nursing home care, home health care, personal or adult day care for individuals above age 65 or with chronic or disabling conditions that require constant Thesupervision.Accelerated
Additional Features
The accelerated life insurance benefits offered under your certificate are intended to qualify for favorable tax treatment under Section 101(g) of the Internal Revenue Code (26 U.S.C.Sec 101(g)).
Waiver of Premiums for Total Disability (Continued Protection)
For access to funds during a difficult time If you become terminally ill and are diagnosed with 24 months or less to live, you have the option to receive up to 80% of your life insurance proceeds. This can go a long way towards helping your family meet medical and other expenses at a difficult time.
Amounts not accelerated will continue under your employer’s plan for as long as you remain eligible per the certificate requirements and the group policy remains in effect.
Conversion For protection after your coverage terminates You can generally convert your group term life insurance benefits to an individual whole life insurance policy if your coverage terminates in whole or in part due to your retirement, termination of employment, or change in employee class.
Reduction in benefits for active or retired employees Benefits coordination due to layoffs, merger, acquisition
Generally,
1 (Not available in NY) Grief Counseling services are provided through an agreement with LifeWorks US Inc. LifeWorks is not an affiliate of MetLife, and the services LifeWorks provides are separate and apart from the insurance provided by MetLife. LifeWorks has a nationwide network of over 30,000 counselors. Counselors have master’s or doctoral degrees and are licensed professionals. The Grief Counseling program does not provide support for issues such as: domestic issues, parenting issues, or marital/relationship issues (other than a finalized divorce). For such issues, members should inquire with their human resources department about available company resources. This program is available to insureds, their dependents and beneficiaries who have received a serious medical diagnosis or suffered a loss. Events that may result in a loss are not covered under this program unless and until such loss has occurred. Services are not available in all jurisdictions and are subject to regulatory approval. Not available on all policy 3forms.MetLife administers the programs, but has arranged for specially trained financial professionals offer financial education and, upon request, provide personal guidance to employees and former employees of companies providing these programs through MetLife.
10 The Accelerated Benefits Option is subject to state availability and regulation.
Total Disability or Totally Disabled means you are unable to do your job and any other job for which you are fit by education, training or experience due to injury or sickness. The Total Disability must begin before age 60, and your waiver will begin after you have satisfied a 9 month waiting period of continuous disability. The waiver of premium will end when you turn age 65, die, or recover. Please note that this benefit is only available after you have participated in the supplemental term life plan for 12 months and it is not available on dependent coverage.
The accelerated life insurance benefits offered under your certificate are intended to qualify for favorable federal tax treatment. If the accelerated benefits qualify for favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation. This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are complex and limitations may apply. You are advised to consult with and rely on an independent tax advisor about your own particular circumstances.
Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminate when your employment ceases, when your Life and AD&D contributions cease, or upon termination of the group contract. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent or when your coverage terminates. Should your life insurance coverage terminate for reasons other than non payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability. Life Insurance Company
77
Metropolitan
Receipt of accelerated benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to consult with social service agencies concerning the effect that receipt of accelerated benefits will have on public assistance eligibility for you, your spouse or your family. This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and Fort Worth Independent School District and are subject to each state’s laws and availability. Specific details regarding these provisions can be found in the booklet certificate.
Life and AD&D 65, die, or recover from your disability, whichever is sooner.
Regardless of the investment experience of such assets, the interest credited to TCAs will never fall below the guaranteed minimum rate. Guarantees are subject to the financial strength and claims paying ability of MetLife.
| 200 Park Avenue | New York, NY L1220009460[exp1221][All10166 States] © 2020 MetLife Services and Solutions, LLC LI ALL SUPP
If you become totally disabled, your employer will continue to make premium payments on your behalf for 12 months in order to keep your Basic Life coverage active. Your disability status will be determined by your employer. This provision allows coverage for you as a disabled employee to be continued as if you were still active.
Premium Pay Continued premium payments during a total disability
5 The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing TCAs are maintained in MetLife’s general account and are subject to claims of MetLife’s creditors. MetLife bears the investment risk of the assets backing TCAs, and expects to receive a profit.
8 WillsCenter.com is a document service provided by SmartLegalForms, Inc., an affiliate of Epoq Group, Ltd. SmartLegalForms, Inc. is not affiliated with MetLife and the WillsCenter.com service is separate and apart from any insurance or service provided by MetLife. The WillsCenter.com service does not provide access to an attorney, does not provide legal advice, and may not be suitable for your specific needs. Please consult with your financial, legal, and tax advisors for advice with respect to such matters.
Experts recommend at least your gross annual income in coverage when purchasing life insurance. x 10 This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
This policy includes, at no additional premium, an Accelerated Death Benefit Due to Terminal Illness Rider (Form ICC07 ULABR 07). See details on next Individualpage.
Permanent Life Insurance Coverage
a. Pay the higher premium(s) required to continue coverage; or, b. Surrender the policy and receive a partial refund of premium equal to 120 times the minimum monthly premium due at issue (ten years worth of Table Premium). You are eligible for this refund if the actual cash value equals or exceeds the Benchmark Cash Value and you have taken no prior partial surrenders.
79 Permanent Life
Guaranteed Limited Right to Partial Refund of Premium
Guaranteed Continuous,Periodtimely, and uninterrupted payment of the Table Premium guarantees coverage for the Guaranteed Period shown. Texas Life (We) cannot legally predict the premium required to continue coverage after the Guaranteed Period. It may be lower, the same, or higher than the Table Premium. However, if the premium to continue coverage is ever higher, We guarantee a limited right to a partial refund of premium (described below).
Interim Insurance Interim insurance will be in force on the application date if these conditions are met: (1) the insurance is purchased through payroll deduction; (2) the Salary Deduction Authorization is signed; and, (3) the proposed insured is insurable at standard rates under Our rules and usual practice. Interim insurance remains in effect until the earlier of: (a) the Policy Date; (b) the date We decline the application; (c) the date We notify the applicant that s/he is ineligible for interim insurance; or, (d) the 180th day after the application date.
Minimal Cash Values Buy this policy for its life insurance protection, not its cash value. The primary benefit is life insurance.
Unlike group term life insurance, PureLife plus is a personally owned, permanent individual life insurance policy to age 121 that can never be canceled or reduced as long as you pay the necessary premiums, even if your health changes.
and Family Coverage is Easy to Apply For Subject to age and amount restrictions, you may apply for an individual policy on your life or your spouse’s life (see chart next page for spouse’s minimum/maximum amounts). An individual policy for $25,000 is also available on each of your children ages 15 days 26, and even on each of your grandchildren ages 15 days 18. Proof of insurability is required. Most policies are issued based upon the answers to three work and health related application questions.
Portable, Individual Life Insurance for Employees and Their Families
Payment of the Table Premium produces a small cash value (Benchmark Cash Value).
Death Benefit Due to Terminal Illness Rider
Permanent,
OncePortableissued, continued employment is not a condition to continue coverage. Coverage is guaranteed as long as required premiums are paid, even after you retire or terminate employment. When employment ends, you can pay equivalent monthly premiums directly or by bank draft (for monthly direct payments we add a monthly fee not to exceed $2.00). Other modes are Acceleratedavailable.
As an employee, you can apply for valuable life insurance protection on you and your family under eligibility guidelines established for your employer. Your employer has conveniently agreed to permit you to pay premiums through payroll deduction. This is a summary only. Policy provisions prevail. This brochure is not a contract or an offer to contract.
If a pre mium higher than the Table Premium is ever required to continue coverage after the Guaranteed Period, you have the choice to:
Tax laws related to the acceleration of life insurance benefits are complex. The information presented in this Summary is general in nature. You should consult a qualified tax or legal advisor to determine the effect of receiving this benefit. Texas Life Insurance Company and its agents do not provide tax or legal Receiptadvice.
A Summary of the Accelerated Death Benefit Rider Terminal Illness included at no additional cost
80
Important Notices
Permanent Life Policy Mechanics and Other Important Details Premiums are flexible. However, we highly recommend payment of the Table Premium during the Guaranteed Period, and no partial surrenders or policy loans. Table Premium produces a small cash value (Benchmark Cash Value). Paying a lesser premium results in an actual cash value which is less than Benchmark Cash Value, causing the policy to lapse. Premiums less a premium load create cash value to pay monthly administrative loads and cost of insurance. Cash value is currently credited at the guaranteed interest rate of 2.00% per year. We may, at any time, credit higher than the guaranteed interest rate. Likewise, We may charge cost of insurance rates which are less than the policy’s maximum rates, but only when actual cash value equals or exceeds Benchmark Cash Value. No surrender charges apply. Loads include 10.00% of premium, $2.03 per month and monthly administrative loads. Two year suicide and contestable clauses apply. The policy loan rate is 7.40% in advance. Surrenders and loans may be deferred for up to six months.
of any accelerated death benefit under your policy may affect your, your spouse’s and your family’s eligibility for medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), Supplemental Social Security Income (SSI), and drug assistance programs. You should consult with a qualified tax or legal advisor and the relevant social service agencies to determine how receiving the benefit may affect your, your spouse’s, and your family’s eligibility for public assistance.
An accelerated death benefit is not long term care insurance. This summary provides a general description of any accelerated death benefit under your policy. Your policy and riders contain certain exclusions, limitations, and exceptions. Please refer to your policy and rider for details. The right to accelerate benefits under any accelerated death benefit does not extend to any Child Term Life Insurance Rider. However, if the accelerated death benefit under any rider is paid, any coverage provided un der the Child Term Life Insurance Rider attached to this policy becomes a paid up term insurance policy on each covered child. This paid up coverage on each child will terminate on each covered child’s 25th birthday. Payment under any accelerated death benefit rider terminates the policy and all other optional benefits/riders and reduces all insurance proceeds, cash values and loan values to zero.
The policy includes an Accelerated Death Benefit Due to Terminal Illness Rider. If the Insured has a terminal illness, in lieu of the insurance proceeds otherwise payable at death, you may elect to claim an accelerated benefit while the Insured is still alive. The single sum benefit is 92% of the insurance proceeds less an administrative fee of the lesser of $150 or 7% of the insurance proceeds. Terminal Illness is an injury or sickness diagnosed and certified by a qualifying physician that, despite the appropriate medical care, is reasonably expected to result in death within 12 months. This benefit is intended to qualify for favorable income tax treatment and may not be subject to federal income tax. (See Important Notices below.)
81 Representation of benefit payable Terminal Illness The following chart shows the effect of exercising an accelerated benefit on the base policy. This example is using a $50,000 policy with a $2,000 policy loan balance and all premiums are current. This chart is for representation purposes only. Your benefits may be higher or lower, depending on your face amount of coverage, any unpaid policy loan balance, and any overdue premiums. . This is a summary only. Policy provisions prevail. This is information is not a contract or an offer to contract. Policy Form: ICC18 PRFNG NI 18. Terminal Illness Death Benefit $50,000 Policy Loan Balance $2,000 Available for Acceleration = $48,000 Acceleration Percentage x 92% Gross Benefit = $44,160 Administration Fee $150 Overdue Premiums $0 Accelerated Benefit Payable = $44,010 Permanent Life
of American workers report they always or usually live paycheck to paycheck. This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Rehabilitation Package We pay cash benefits for Admission, Daily Confinement and Recovery! Whether you are released to a Rehabilitation Center following a hospital stay or you recover at home, we pay a daily recovery benefit to help with your transition. Here’s How Accident Benefits Work: Chubb Accident helps pay for unexpected costs of accidental injury. If your child breaks a leg at soccer practice here's how benefits may stack up: The Sports Package increases the total benefit payment by $573. This example is for illustrative purposes only should not be compared to an actual claim. an injury is covered depends on the circumstances of the loss. to the certificate of
Chubb Accident Benefits include First Accident Pays you $100 soon after you report your first claim for covered benefits! If you get injured, we can begin processing your claim right over the phone so you can get cash fast.
83 No one plans on getting injured… but just in case. we've got you covered. You do everything you can to stay active and healthy, but accidents happen every day, including sports related accidents. An injury that hurts an arm or a leg can hurt your finances too. That's where Chubb Accident can help.
Whether
and
Sports Package Your benefits increase 25%, up to $1,000 per person per year, for injuries resulting from participating in organized sports! Playing sports can lead to injuries and unwelcome expenses. We'll increase your benefits to help pay those expenses
insurance or policy for terms and conditions. Schedule of Benefits No occupational Coverage Gold & Diamond Plans Accident First Accident $100 Ambulance $200 ER Visit $200 X Ray $40 Fracture $1,000 Crutches $100 Physical Therapy $500 Follow up Visits $150 Subtotal $2,290 PLUS Sports Package $573 Total Payment 2$2,863 Initial Care GOLD DIAMOND AmbulanceGround $120 $200 Air $1,000 $2,000 Emergency Room $100 $200 Initial Doctor's Office Visit $50 $100 Urgent Care $50 $100 Emergency Dental Crown $200 $400 Extraction $50 $100 Hospital and Rehabilitation Hospital Admission $500 $1,500 ICU Admission $1,000 $3,000 Rehabilitation Admission $500 $1,500 Hospital Confinement per day, up to 365 days $150 $250 ICUperConfinementday,upto30 days $300 $500 Rehabilitation Confinement per day, up to 30 days $90 $150 Recovery per day, up to seven days $50 $100 Follow up Care & Treatment Abdominal or Thoracic Surgery $750 $1,500 Appliances $75 $100 Blood, Plasma, Platelets $200 $300 Chiropractic Care per visit, up to three visits $25 $25 Concussion $60 $100 Monthly Premiums GOLD DIAMOND Employee Only $9.40 $16.48 Employee + Spouse $17.16 $30.12 Employee + Child(ren) $19.32 $33.64 Family $27.08 $47.28
Chubb Accident pays cash benefits directly to you or anyone you choose regardless of any other coverage you have. And Chubb Accident pays extra benefits for injuries resulting from participating in organized sports. Let Chubb Accident help take care of your bills so you can take care of yourself and your family.
Refer
84 Accident Features You do everything you can to keep your family safe, but accidents happen, and when they do, it’s good to know Chubb has you covered. Date of Application Coverage Coverage becomes effective as soon as your application is signed, you have authorized payment and the Initial Eligibility requirements are met. Guaranteed Issue No medical history is required for coverage to be issued. Guaranteed Renewable Your coverage cannot be cancelled as long as your premiums are paid as due. Fully Portable You can keep your coverage even if you change jobs or retire. HSA Compatible Initial Eligibility Employee • Actively employed working at least 10 hours per week • Ages 18 and up Spouse • Ages 18 and up Dependent children/grandchildren • Ages to 26 • No student status required • Coverage will continue for incapacitated dependent children regardless of age. Follow up Care & Treatment GOLD DIAMOND Follow up Treatment per visit, up to three visits $25 $50 Lodgingfortreatment 100 miles or more away; per night, up to 30 nights $100 $150 Major Diagnostic Exam (CT, MRI, etc.) $100 $200 Organ Loss $2,500 $2,500 Outpatient Surgery Facility $25 $25 Physical Therapy per visit up to 10 visits $25 $50 Prosthetics $500 $1,500 Tendon, Ligament, or Rotator Cuff Surgery $400 $750 forTransportationtreatment100 miles or more away; per trip, up to three trips $300 $600 X ray $20 $40 Injuries GOLD DIAMOND Burns Level 1 $750 $1,000 Level 2 $1,500 $2,000 Level 3 $7,500 $10,000 Skin raft 25% of the burn benefit Coma $7,500 $12,500 DislocationsOpenreduction, up to… $3,600 $4,800 Closed reduction, up to $1,800 $2,400 Eye $200 $300 Fractures Open reduction, up to… $5,000 $7,000 Closed reduction, up to... $2,500 $3,500 Herniated Disc $400 $750 Knee Cartilage Torn $400 $750 Lacerations $20 $300 $30 $500 Loss of Hands, Feet or Sight $10,000 $20,000 Loss of Fingers or Toes $1,200 $2,000 Additional Benefits GOLD DIAMOND First Accident once per policy $100 $100 Sports Package Benefits are 25% higher when accident is due to participation in organized sports. Up to $1,000 per person per year. Accidental Death Employee & Spouse $20,000 $50,000 Child $4,000 $10,000 Catastrophic Accident Prior to Age 70 Employee & Spouse $20,000 $50,000 Child $10,000 $25,000 On or after Age 70 50% 50% Family Care for each child in a child care center; per day, up to 30 days $25 $25 Wellness per person, once per year 90 days waiting period $50 $50 Benefits may vary by state. Benefits are paid once per accident unless otherwise noted.
is Accident Only Insurance.
Committing or attempting to commit suicide or intentionally injuring himself or Havingherself;dental treatment, except for such care or treatment due to injury to sound natural teeth within twelve (12) months of the Covered Accident; Being exposed to war or any act of war, declared or undeclared, or serving in any of the armed forces or units auxiliary thereto; or Participation in any contest using any type of motorized vehicle. No benefits will be paid for an injury incurred while working for pay or profit. This is a supplement to health insurance and is not a substitute for Major Medical, or other minimal essential, coverage.
She continues to defy the odds In neonatology, it's the little things that matter. That's why Cook Children's nationally recognized Level IV NICU provides the highest level of care. But our care and attention doesn't end Thethere.Cook Children's NEST Developmental Follow up Center, created in 2013 with donor support, helps babies and their family's transition from hospital to home.
The NEST Center begins supporting the family before a baby is discharged from the NICU, and then monitors the child's growth and development through 5 years of age giving our babies the best chance to soar. Avery: www.facebook.com/64714594575/posts/101555033691199576https://
Avery went home dependent on oxygen and a feeding tube and continued to receive care and support form our NEST Development Follow Up Center.
Children, in partnership with Combined Insurance Company of America, will donate $10 to Cook Children’s for each qualified employee attending an employee benefit enrollment meeting.
*Benefits That Benefit Children is a cause marketing program, created by National Benefit Partners. †Combined Insurance Company of America, a Chubb company, will make a $10 donation to Cook Children’s for each qualified employee that attends an employee benefit enrollment meeting even if no products are purchased. No employee purchase of enrollment necessary. Purchase of a product will not increase the charitable donation.
†By attending the meeting, the contribution is made without any obligation to purchase coverage.
Meet Avery
Avery was born 14 weeks early weighing only 1lb 5 oz. Avery spent 234 days in Cook Children’s Neonatal Intensive Care Unit (NICU), with specialized care that helped Avery celebrate her first birthday a milestone her parents weren’t always sure would be possible.
85 Accident Accident Benefits Summary TypeName:of Coverage: _________________ Employee Employee + Spouse Employee + Child(ren) Family Payroll Deduction: $________________ExclusionsE & Limitations
Support from programs like Benefits that Benefit Children, a voluntary benefit cause marketing program, enable Cook Children’s to provide the highly specialized intensive care services and attention that medically fragile babies, like Avery, Benefitsneed.
Participating in an illegal activity or attempting to commit or actually committing a felony ("felony" is as defined by the law of the jurisdiction in which the activity takes place);
This No benefits will be paid for services rendered by a member of the Immediate Family of a Covered Person. No benefits will be payable for sickness or infection including physical or mental condition that is not caused solely by or as a direct result of a Covered Accident. No benefits will be paid for an injury that is caused by, contributed to, or occurs as a result of a covered person's: Being intoxicated, or under the influence of alcohol or any narcotic or other prescription drug unless administered on the advice of a Physician and taken according to the Physician's instructions (the term "intoxicated" means the minimum blood alcohol level required to be considered operating an automobile under the influence of alcohol in the jurisdiction in which the accident occurred);
This document is a brief description of Form Nos. Cl4059R or 14185 (or applicable state version). Refer to your certificate of insurance or policy for specific details about benefits, exclusions and limitations.
For Avery, the NICU was the first stop on a long medical journey.
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That Benefit Children provides donations to Cook Children’s when companies like yours offer certain best in class voluntary benefits from top ranked providers. Through the Benefits That Benefit Children* program, you have an opportunity to help Cook Children’s in their ongoing commitment to saving children’s lives. Benefits That Benefit
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
an affordable, qualified lawyer on your side can be an invaluable asset. Legal plans provide valuable benefits that cover the most common legal needs you may encounter like creating a standard will, living will, healthcare power of attorney or buying a home. This plan also provides access to quality law firms for advice, consultation and Benefitrepresentation.isnotpayroll deducted. To enroll, click LEGAL SERVICES on the Fort Worth ISD benefits portal, and select the QUICK LINK that says Enroll Now. About this Benefit Legal Services Is the average cost of a basic will and estate planning package. The average yearly premium paid by Texas Legal Members
only $300. $1,500 TEXAS LEGAL
Having is
87 Legal Services Texas Legal Legal Insurance Built for Texans Every year, 70 percent of people have a legal problem and need a lawyer’s help. Estate planning, Identity theft, bankruptcy, divorce, DWIs the list goes on and on. But with the average lawyer charging $250 an hour, many people can’t afford the protection they need and deserve. Save Money and Protect Your Family with Legal Insurance From Texas Legal Legal insurance from Texas Legal lets you save money on legal services that everyone needs, such as estate planning, while protecting you from serious legal challenges that can come with life’s unknowns, including family, civil, consumer, and criminal issues. Texas Legal is a non profit founded by the State Legislature of Texas over 40 years ago. Our charter is simple protect everyday Texans from financial hardship that can come with legal challenges. Available only to Texans, we offer the most comprehensive legal insurance plan on the market. As a member of Texas Legal, you can get high quality legal help without the high price tag. How You’ll Save With Texas Legal: • PROBLEM: You need a will, but it costs too much. • SOLUTION: A Texas Legal membership covers estate planning 100%, plus dozens of other legal issues • $1,500 the average cost of a basic will and estate planning package • $300 the average yearly premium paid by Texas Legal SAVED:Members$1,200 GAINED: Priceless Peace of Mind. Our Legal Insurance Plans Cover: ✔ Estate Planning ✔ Divorce ✔ Bankruptcy ✔ Consumer Law ✔ Criminal Defense And Much More! Coverages* Select Plan Preferred Plan AnnuallyMonthly $100/$150$10/$15 $195/$290$20/$30 Estate Planning ✔ ✔ AllClear ID® Identity Theft Monitoring ✔ ✔ AllClear ID® Identity Theft Restoration ✔ ✔ Family DivorceLawOR Modification/Establishment or Enforcements 10 Hours Covered ✔ ChapterBankruptcy7OR Chapter 13 25% Discount ✔ Choose the Texas Legal Plan that Best Meets Your Needs: Texas Legal’s Vital Statistics: • Non profit Founded in 1972 • Protects Tens of Thousands of Texans • Built by the Lawyers of Texas to Help Texans • Created and Endorsed by State Bar of Texas • Over 500 Texas Attorneys In Network • Most Comprehensive Legal Plan on the Market “ Texas Legal has saved us thousands of dollars and gives me peace of mind not to worry about things. When I called for help on my last problem, I felt like I had the event under my control.” ~ Charlotte R. Texas Legal Member
88 Coverages* Select Plan Preferred Plan Traffic Tickets 25% Discount ✔ Financial Counseling ✔ Family Immigration Assistance 25% Discount ✔ Prenuptial or Postnuptial Agreement 25% Discount ✔ Defense of Misdemeanor Charge 25% Discount ✔ Defense of DWI/DUI 25% Discount ✔ Adoption 25% Discount ✔ Defense of Civil Action 8 Hours Covered ✔ Defense of Insanity or Infirmity 25% Discount ✔ Defense of Juvenile/Children's Court 25% Discount ✔ Habeas Corpus 25% Discount ✔ Defense of Felony Charge 25% Discount ✔ Defense of Driving Privileges 25% Discount ✔ General Legal Services 2 Hours Covered 6 Hours Covered Consumer Protection Consultations & Negotiations Only ✔ Uncontested Name Change ✔ ✔ Attorney Consultation 2 Consultations Covered 4 Consultations Covered Probate Proceeding 25% Discount ✔ Residential Real Estate Transaction 25% Discount ✔ Expunction & Order of Nondisclosure 25% Discount ✔ Public Intoxication 25% Discount ✔ Guardianship of Adult or Minor 25% Discount ✔ Protective Order 25% Discount ✔ Legal Access Services ✔ ✔ Legal Services *Limitations and exclusions apply. This information is for illustrative purposes only and is not a contract. Benefits may be subject to limitations and exclusions. For terms, benefits or exclusions, please see plan documents. Don’t risk expensive legal fees or put off legal issues another day. Visit TexasLegal.org and become a member today or Call 1 800 252 9346.
89 Texas Legal Membership Advantages As a Member, you are joining thousands of Texans that benefit from legal coverage made available by Texas Legal. Our plans offer freedom of choice to choose an attorney for legal services when you need it the most. And when you choose a Participating Attorney, we will pay the attorney directly, with no copays or deductibles. We’ve been helping Texans like you for over 40 years! What’s Covered? From life events to unexpected events, Texas Legal has you covered. A legal benefits plan provided by Texas Legal is like homeowners insurance you may never have to use the full array of benefits, but comprehensive coverage is available in case the unexpected happens. Texas Legal Preferred Plan Texas Legal membership offers benefits across most areas of law, including: CONSUMER LAW Consumer law covers issues like breach of contract, as well as laws pertaining to common issues of consumer fraud. Areas include: • Civil Action (Defense) • Consumer Protection • Contracts • Creditors Rights & Collections • Identity Theft Restoration • Identity Theft Monitoring FAMILY LAW Family law encompasses matters such as adoption, divorce, custody, and child support. Areas include: • Adoption • Divorce • Establish a Family Court Order (Child Support, Custody, Visitation) • Guardianship • LGBT specific Family Law • Modify/Enforce Family Court Order (Child Support, Custody, Visitation) • Prenuptial or Postnuptial Agreements • Name Change • Family Immigration Assistance • Protective Orders • Grandparents’ Rights FINANCIAL LAW Financial law pertains to personal money issues. Areas include: • Chapter 7 Bankruptcy • Chapter 13 Bankruptcy • Foreclosures • Loan Agreements • Real Estate • Social Security/Disability • Tax Law • Financial Counseling CRIMINAL LAW Criminal law covers a range of activities that vary in severity. Typical issues include matters of constitutional law, juvenile crimes, felonies, and more. Areas include: • DWI/DUI (Defense) • Expunge/Seal Records • Felony (Defense) • Habeas Corpus • Insanity/Infirmity (Defense) • Jail Release • Juvenile Court (Defense) • License Suspension Revocation (Defense) • Misdemeanor (Defense) • Public Intoxication • Traffic Tickets ESTATE PLANNING Estate planning is primarily focused on inheritance planning, but also pertains to charitable planning, incapacity planning, and special needs planning. Areas include: • Powers of Attorney • Probate • Trusts • Wills/Codicils MISCELLANEOUS There’s a wide range of legal issues that don’t fall into a specific legal category but are common, such as: • Document Preparation • Employment Law (limited to Independent Policies only) • Tenant Rights • Mediation • Medicaid/Medicare • Veteran's Benefits • Consultation • Legal Access Telephone Assistance Texas Legal Select Plan How Texas Legal Works • Become a Member Choose a plan and pay an affordable monthly premium. • Find an WheneverAttorneyyouneed legal help, we’ll help you find a Texas Legal attorney close to you who can assist with your legal issue. Legal Services
Texas Legal Preferred Plan
Yes. If the legal matter is not covered, you may still use a Texas Legal Participating Attorney. However, the attorney will provide you a written contract for services provided and may bill you at a 25% discounted rate of their usual and customary rates.
Referral services are highly regulated in Texas, which prohibits us from being able to recommend any particular attorney. You can locate a Texas Legal Participating Attorney by using our Attorney Finder at www.TexasLegal.org
Texas Legal Select Plan
Most benefits are available the first date of your policy. Divorce, modification, enforcement, or establishment of a family court order all have a six month waiting period.
What about non covered legal matters? Can I still use a Texas Legal Participating Attorney?
Bankruptcy has a 90 day waiting period. Divorce, modification, enforcement, or establishment of a family court order all have a six month waiting period.
What cost can I expect when I meet with an attorney?
Do you cover pre existing matters?
90 Legal Services • Meet with Your Attorney You choose which attorney you want to work with and meet with them to resolve your legal problem. • Problem WhetherSolved!it ’s writing a will, declaring bankruptcy or defending yourself in small claims court, your attorney will provide you with professional, helpful service. • Attorney Fees Paid Your attorney bills Texas Legal for their time and we pay them directly. No deductibles or co pays! Texas Legal membership offers benefits across most areas of law, including: CONSUMER LAW Consumer law covers issues like breach of contract, as well as laws pertaining to common issues of consumer fraud. Areas include: • Civil Action (Defense) • Consumer Protection FAMILY LAW Family law encompasses matters such as adoption, divorce, custody, and child support. Areas include: • Divorce • Establish a Family Court Order (Child Support, Custody, Visitation) • LGBT specific Family Law • Modify/Enforce Family Court Order (Child Support, Custody, Visitation) • Name Change ESTATE PLANNING Estate planning is primarily focused on inheritance planning, but also pertains to charitable planning, incapacity planning, and special needs planning. Areas include: • Powers of Attorney • Trusts • Wills/Codicils MISCELLANEOUS There’s a wide range of legal issues that don’t fall into a specific legal category but are common, such as: • General Consultation • Legal Access Telephone Assistance • Document Preparation & Review • Medicaid/Medicare • Veteran’s Benefits
Most benefits are available to each family member listed on your policy. However, the following are only available to the Named Policyholder: Residential Real Estate Transactions, Family Immigration Assistance, Identity Theft Monitoring, Divorce, Modification, Enforcement, or Establishment of a family court order. Please note: Once you or your dependent uses a benefit, you cannot use that same benefit again until your plan year renews.
Do you provide attorney recommendations?
Texas Legal Preferred Plan
No. You must be a member of Texas Legal at the time the legal matter occurs.
Frequently Asked Questions
Are all benefits available to each member of my family?
Most benefits are available the first date of your policy.
When are my benefits available? Do any benefits have waiting periods?
Your policy will pay for the attorney’s time to work on your legal matter up to certain limitations. You will not be responsible for any copays or deductibles. Please refer to the Certificate of Coverage for details. Please note, you may be responsible for any incidentals such as court costs, filing fees, copy fees, postage fees, and/or travel costs.
91 Texas Legal Select Plan Are all benefits available to each member of my family? Most benefits are available to each family member listed on your policy. However, the following are only available to the Named Policyholder: Divorce, Modification, Enforcement, or Establishment of a family court order. Please note: Once you or your dependent uses a benefit, you cannot use that same benefit again until your plan year renews. Can I use this plan for my business? No. Texas Legal benefit plans are only available for personal or individual legal matters, not for business related matters. Can I use my plan outside of Texas? Texas Legal does have out of network benefits when using a non participating attorney. Contact us for more information. Limitations and exclusions apply. Legal insurance products/memberships are provided by Texas Legal and are in compliance with the provisions of the Texas Department of Insurance. Services are only available through membership in Texas Legal. Membership does not cover previously established or filed legal issues or disputes. This information is for illustrative purposes only and is not a contract. For terms, benefits or exclusions, see your plan documents. If you have questions or would like to join, call Member Services toll free at 1 800 252 9346 Legal Services Go online to www.TexasLegal.org and use our Attorney Finder to choose a trusted lawyer from our network of Participating Attorneys. Texas Legal 7500 Rialto Boulevard 1 800 252 9346 Building One, Suite 120 members@texaslegal.org Austin, Texas 78735 www.TexasLegal.org Access to the best legal coverage in the Lone Star State is at your fingertips!
About this Benefit Tips for Saving Money YOUR BENEFITS PACKAGE • Save your loose change. • Keep track of your spending. • Never purchase expensive items on impulse. • Create a budget. • Aim for short term savings goals • Save money by buying items online, in bulk. January Savings Plan FORT WORTH ISD
93 January Savings Plan Voluntary enrollment in the January Savings Plan will only be allowed during Benefits Open Enrollment. No interest will be earned on the deduction amount. Deductions will be taken each payday as shown below: The minimum monthly deduction is $10.00. If a semi monthly employee selects $10.00 monthly, $5.00 will be taken each pay period marked in the table above. If a monthly employee selects $10.00 monthly, $10.00 will be taken each pay period marked in the table above. Disbursement of the total amount deducted through December will be direct deposited on January 6, 2023. There will be NO early disbursements of funds. Funds in this account will NOT incur interest. Monthly Dates Semi Monthly Dates September 28, 2022 September 30, 2022 October 28, 2022 October 14, 2022 October 31, 2022 November 18, 2022 November 15, 2022 November 30, 2022 December 14, 2022 December 15, 2022
About this Benefit Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out of pocket costs that are not covered by insurance. It includes emergency transportation via ground ambulance, air ambulance and helicopter. can cost up to $2,400 and a transportationhelicopterfeecan cost over $30,000 This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisdFort Worth ISD Benefits Website:
A MASA MTS Membership provides the ultimate peace of mind at an affordable rate for emergency ground and air transportation service within the United States and Canada, regardless of whether the provider is in or out of a given group healthcare benefits network. If a member has a high deductible health plan that is compatible with a health savings account, benefits will become available under the MASA membership for expenses incurred for medical care (as defined under Internal Revenue Code (“IRC”) section 213 (d)) once a member satisfies the applicable statutory minimum deductible under IRC section 223(c) for high deductible health plan coverage that is compatible with a health savings account.
all,
transports. Usually,
opposite is true, leaving you with financially crippling bills. When is your next medical emergency planned? Are you prepared? BENEFIT $14/mo.EMERGENTPLUSor$160/yr $39/mo.PLATINUMor$468/yr Emergent Ground Transportation U.S./Canada U.S./Canada Emergent Air Transportation U.S./Canada U.S./Canada Non Emergent Air Transportation U.S./Canada Worldwide Repatriation U.S./Canada Worldwide Escort Transportation Worldwide Mortal Remains Transportation Worldwide Visitor Transportation BCA* Minor Children/ Grandchildren Return BCA* Vehicle Return BCA* Pet Return BCA* Organ Retrieval U.S. Only Organ Recipient Transportation U.S. Only *Basic Coverage Area (BCA) includes U.S., Canada, Mexico, and Caribbean (excluding Cuba) Coverage available for spouses/domestic partners and dependents up to age 26.
• Emergent
•
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• Most people
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• Easy
their
95 Medical Transport
•
•
insurance
• Anyone can join Facts You Should Know • Emergent
are
MASA MTS provides peace of mind. Any Ground. Any Air. Anywhere Coverage against unplanned medical emergencies is surprisingly the unexpected with a MASA membership. No matter where you live, you could have access to vital emergency medical transportation for a minimal monthly fee. That membership could one day save your life, and, every day, it will give you peace of mind like nothing else.
MASA MTS protects you when your insurance falls short. One low fee for peace of mind for emergent transport costs No deductibles claim process health questions Ground Ambulance transports can easily surpass $2,000 and can reach as high as $5,000. Air Ambulance transports frequently cost more than $40,000, reaching as high as $70,000. If you in need of specialized care and can be transported on an non emergent basis, it is common for a medically equipped plane to cost more than $20,000. assume that health will cover most, if not of the costs for these the
Mortal TransportRemains
TransportationReturn
Escort Transportation
Pet Return
Platinum Membership Benefits
MASA MTS will return vehicles such as cars, vans, RVs or trucks owned or rented by the member when illness, injury or death requires use of the air ambulance services provided by MASA MTS. The vehicle will be carried to the member's place of residence or rental vehicles will be returned to the nearest rental company office or agent. (Basic Coverage Area Only*)
If a member is hospitalized while away from home, MASA MTS will fly them back to a hospital closer to home to recuperate in familiar surroundings. (Worldwide Coverage)
If a member requires emergency air transport, MASA MTS will fly the member's spouse, family member or friend to accompany them in the air. (Worldwide Coverage)
Recuperation / Repatriation
Non Emergent Air Transportation
Emergency Air Medical Transportation
MASA MTS will arrange transport on a commercial carrier to a commercial airport closest to member’s residence after being discharged from a hospitalization of at least 24 hours. (Worldwide Coverage)
Minor Children / Grandchildren Return
Organ Transportation**Recipient
Emergency Ground Transportation
Organ Retrieval**
(Basic
In the event a member dies while away from his/her place of residence, MASA Assist will return his/her remains to the commercial airport nearest his/her residence. (Worldwide Coverage)
MASA MTS will return the Member’s dog, cat or smaller animal, should the Member be flown to a hospital near their residence on an air ambulance arranged by the MASA MTS. Coverage Area Only*)
Visitor Transport
Should a member suffer serious life or limb threatening emergency that requires immediate transport by fixed wing or helicopter air ambulance of that member to the nearest most appropriate medical facility capable of providing required emergency medical treatments, also referred to as “golden hour transports”, MASA MTS will cover the out of pocket expenses resulting from that transport. (U.S. and Canada Only)
96
MASA MTS will provide air transportation of an organ to be used in an organ transplant. (U.S. Only)
Vehicle Return
When minor children or grandchildren are left unattended as a result of a member using MASA MTS air ambulance service, MASA MTS will provide one way common carrier air transport for return of the children to the commercial airport nearest the place of residence of the children. (Basic Coverage Only*)
Should a member suffer a serious illness or injury resulting in hospitalization and if the member is in need of specialized treatment not available locally but such transportation is not immediately needed for life or limb saving treatment and such transportation can be arranged by MASA, then MASA MTS will coordinate transport to the nearest appropriate medical facility capable of providing such specialized treatment. (Worldwide Coverage)
If a member is hospitalized while away from his/her home for more than 7 days, the member may select a family member to visit them during confinement. MASA MTS will provide round trip, common carrier air transportation for the person selected. (Basic Coverage Area Only*)
**One (1) year waiting period if pre existing condition requiring transplant. There is a 90 day waiting period on pre existing conditions. This clause is WAIVED for emergent ground and air transports Dependents are covered up until age 26.
Should a member suffer a life or limb emergency requiring emergent ground transport from the site of serious illness or injury, or from a transferring medical facility that is unable to provide services required, to the nearest most appropriate medical facility capable of attending to the member’s medical needs MASA MTS will cover the out of pocket expenses resulting from that transport. (U.S. and Canada Only)
MASA MTS will fly a member to the commercial airport nearest the medical facility where an organ transplant is scheduled to happen. (U.S. Only)
*Basic Coverage Area includes U.S., Canada, Mexico, and Caribbean (excluding Cuba).
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WWW.MYBENEFITSHUB.COM/FORTWORTHISD
