Life Insurance Underwritten by Prudential Life Insurance Company

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1 Life Insurance Underwritten by Prudential Life Insurance Company Carolyn A. Wilford Eligibility Manager

2 Administrative Responsibility Agency Responsibility Life Insurance files Beneficiary files 3/27/

3 Administrative Responsibility Group Benefits Responsibility Updating employee records for billing 3/27/

4 Prudential Contact Roger F. Donodeo, Jr. Administrative questions only! Do not contact for claims. Telephone: Do not use 800 number. 3/27/

5 Coverage All coverage is Term No Cash Value 3/27/

6 Beneficiary Designation Forms Beneficiary Designation/Change Form Change of Beneficiary or Name Form Marriage Divorce Adoption 3/27/

7 Beneficiary Designation Forms Do not send any beneficiary changes to: Group Benefits, or Prudential 3/27/

8 Processing Enrollments Prudential Enrollment Form New Employees Late Entrants Evidence of Insurability (EOI) required Reinstated Employees (through appeal) Submit only GB-01 to Group Benefits 3/27/

9 Evidence of Insurability (EOI) EOI is required for: Late enrollment Re-enrollment Waived Coverage 3/27/

10 Evidence of Insurability (EOI) Prudential Enrollment Form Complete Employer section Hold in agency s EOI file 3/27/

11 Evidence of Insurability (EOI) Do not begin payroll deductions until: Employee brings Prudential approval letter GB-01- completed, signed, dated, and sent to OGB with approval letter attached Effective - 1st of the month following the date GB-01 is signed 3/27/

12 Medical Underwriting Review Prudential may request: Attending physician's statement Examination Insurance Risk Profile Employee is responsible for fees Set Set by doctors, not Prudential 3/27/

13 Portability (Conversion) Eligibility Employee and spouse under age 70 Dependent children under age 21 Full-time students between 21 and 24 Employee actively at work on the day employment ends 3/27/

14 Employee Death Claims Prudential Life Insurance Claim Form Do not submit without latest beneficiary change document. Beneficiary Statement Certified Death Certificate 3/27/

15 Employee Death Claims Supporting papers Guardianship Estate executor/administrator designation Accidental death notices 3/27/

16 Dependent Death Claims Prudential Life Insurance Claim Form Certified Death Certificate Enrollment Form showing when dependent life was elected - Important! 3/27/

17 Special Beneficiary Situations If the beneficiary is deceased, submit: Death Certificate Info about the contingent beneficiary, or Info about the insured s estate 3/27/

18 Special Beneficiary Situations If the beneficiary is an estate, submit: Certified copy of court order appointing executor or administrator Tax ID number for the estate 3/27/

19 Special Beneficiary Situations If beneficiary is a minor or incompetent, submit: Copy of court order appointing guardian or conservator 3/27/

20 Special Beneficiary Situations If the insurance was assigned, submit: Copy of assignment and beneficiary designation Signed by insured Group contract number Amount of assignment Insured name and SSN 3/27/

21 AD&D Injury Claims AD&D or Blindness Claim Form Complete Employer section Employee and attending physician, complete other applicable sections Include supporting documents OSHA, worker s comp, police reports 3/27/

22 AD&D Death Claims Prudential Life Insurance Claim Forms Only one form if accidental death i.e., Don t submit AD&D or Blindness Claim Form also Complete applicable questions in Section 2 Attach newspaper clippings, official reports, or letter of explanation 3/27/

23 Claims Caution Do not make a commitment to pay regardless of claim type! Employee Death Claims Dependent Death Claims AD&D Injury Claims 3/27/

24 Claims Caution Prudential will review all documents and make the decision to pay, or not to pay. 3/27/

25 Online Forms benefits.org Benefits & Providers Life Insurance 3/27/

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