Orange County Transportation Authority- Administrative Group

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1 Group Life Insurance SUMMARY OF BENEFITS Life and AD&D Sponsored by: All Full-Time Administrative Employees and Employees represented by Transportation Communications Union (TCU) Life Employee Amount Two times basic annual earnings, rounded to the next higher $1,000 Minimum Amount $10,000 Maximum Amount $500,000 Guarantee Issue $500,000 AD&D Employee Amount Two times basic annual earnings, rounded to the next higher $1,000 Minimum Amount $10,000 Maximum Amount $500,000 Guarantee Issue $500,000 Reduction Employee s will reduce: 50% at age 75 s terminate at retirement Additional s See Definitions page for: See Definitions page for: See Definitions page for: See Definitions page for: Eligibility Employee Accelerated Death Seat Belt, Airbag, and Common Carrier Conversion Accident Plus Employee All full-time active employees working 20 or more hours per week in an eligible class are eligible for coverage. A delayed effective date will apply if the employee is not actively at work. (Please see other side) GLM Rev. 4/08 Grp_Life-ADD_Seat Belt-Airbag

2 Definitions Accelerated Death AD&D Conversion Guarantee Issue Seat Belt, Airbag, Common Carrier Accident Plus Term Life Accelerated Death provides an option to withdraw a percentage of your life insurance when diagnosed as terminally ill (as defined in the policy). The death benefit will be reduced by the amount withdrawn. To qualify, you have satisfied the Active Work rule and have been covered under this policy for the required amount of time as defined by the policy. Check with your tax advisor or attorney before exercising this option. Accidental Death and Dismemberment (AD&D) insurance provides specified benefits for a covered accidental bodily injury that directly causes dismemberment (e.g., the loss of a hand, foot, or eye). In the event that death occurs from a covered accident, both the life and the AD&D benefit would be payable. If you terminate your employment or become ineligible for this coverage, you have the option to convert all or part of the amount of coverage in force to an individual life policy on the date of termination without Evidence of Insurability. Conversion election must be made within 31 days of your date of termination. For timely entrants enrolled within 31 days of becoming eligible, the Guarantee Issue amount is available without any Evidence of Insurability requirement. Evidence of Insurability will be required for any amounts above this, for late enrollees or increase in insurance and it will be provided at your own expense. If you die as a result of a covered auto accident while wearing a seat belt or in a vehicle equipped with an airbag, benefits are payable up to $10,000 or 10% of the principal sum, whichever is less. If loss occurs for you due to an accident while riding as a passenger in a common carrier, benefits will be double the amount that would otherwise apply as outlined in the certificate. If loss occurs due to an accident, you may also receive the following Accident Plus benefits: Coma: Pays 5% of your principal sum up to a maximum of $5,000 if you are in a coma as a result of an accident covered under the policy and remain in a coma for 31 continuous days. Plegia: Pays 100% of your principal sum for quadriplegia and 50% of your principal sum for paraplegia and hemiplegia. Plegia must be caused by a covered accident. s are doubled if accident is caused by a common carrier. Repatriation: Pays up to $5,000 for preparation and transportation of your body when the accident occurs more than 150 miles away from home. Death must be the result of a covered accident. Education: As a result of your death, this benefit pays 5% of the principal sum up to a maximum of $5,000 for your eligible dependent s post-secondary education. The benefit is paid for up to four years. Spouse Training: As a result of your death, this benefit pays 5% of your principal sum up to a maximum of $5,000 for your spouse and covers the cost of classes taken to retrain or refresh skills needed for employment. s will be paid for one year and enrollment must occur within 365 days of the covered accident. Child Care: As a result of your death, this benefit pays 5% of your principal sum up to a maximum of $5,000 for expenses paid to a licensed childcare facility for an eligible dependent attending on a regular basis. The benefit will be paid for up to four consecutive years, or until your child s 13th birthday, whichever comes first. Coverage provided to the designated beneficiary upon the death of the insured. Coverage is provided for the time period that you are eligible and premium is paid. There is no cash value associated with this product. Additional s BeneficiaryConnect SM Support services for beneficiaries who have experienced a loss. TravelConnect SM Travel assistance services for employees and eligible dependents traveling more than 100 miles from home. For assistance or additional information Contact Lincoln Financial Group at (800) or log on to NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern Lincoln National CorporationGroup Insurance products are issued by The Lincoln National Life Insurance Company (Ft. Wayne, IN), which is not licensed and does not solicit business in New York. In New York, group insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Each affiliate is solely responsible for its own financial and contractual obligations. GLM Rev. 4/08 Grp_Life-ADD_Seat Belt-Airbag

3 Group Long-Term Disability Insurance SUMMARY OF BENEFITS Sponsored by: Long-term disability is intended to protect your income for a long duration after you have depleted shortterm disability or any sick leave your company may offer. All Full-Time Administrative Employees And Employees Represented By Transportation Communications Union (TCU) Eligibility Maximum Monthly Maximum Duration Own Occupation Period Elimination Period Accumulation of Elimination Days Pre-Existing Condition Waiver of Premium Survivor Income All full-time active employees working 20 or more hours per week in an eligible class are eligible for coverage. 67% of salary up to $8,000 per month Social Security Normal Retirement Age / Age 65 (whichever is later) 24 Months 90 days The number of days you must be disabled prior to collecting disability benefits. You can satisfy the days of your elimination period with either total (off work entirely) or partial (working some hours at your current job) disability. If you are working on a partial basis, you will have 2x the elimination period days to satisfy the total of 90 days. You may not be eligible for benefits if you have received treatment for a condition within the past 3 months until you have been covered under this plan for 12 months. You will not be required to pay premium during any time of approved total or partial disability. A survivor benefit may be paid to your beneficiary if you should die while receiving qualifying disability payments. EmployeeConnect SM Access to an employee assistance program for the employee or an immediate household family member who may be experiencing personal or workplace issues. Limitations Conversion Mental Illness: 24 months Substance Abuse: 24 months Specified Illness: No Limit If you terminate your employment, you may be able to convert this policy. (Please see other side) GLM Rev. 4/08 LTD_Grp

4 Understanding Your s Own Occupation Total Disability Partial Disability Continuation of Disability Duration Reduction Pre-Existing Condition Exclusions Reductions Termination The occupation trade or profession you were employed in prior to your disability as defined by the US DOL Dictionary of Occupational Titles. You are considered totally disabled if, due to an injury or illness, you are unable to perform each of the main duties of your own occupation. Your own occupation is covered for a specific period of time. Following this, the definition of total disability becomes the inability to perform any occupation for which you are reasonably suited based on your experience, education, or training. You are considered partially disabled if you are unable, due to an injury or illness, to perform the main duties of your regular occupation on a full-time basis. Partial Disability benefits may be payable if you are earning at least 20% of the income you earned prior to becoming disabled, but not more than 99%. Partial disability benefits allow you to work and earn income from your employer as well as continue to receive benefits, which may enable you to receive 100% of your income during your time of disability. If you return to work full-time but become disabled from the same disability within six months of returning to work, you will begin receiving benefits again immediately. Your benefit duration may be reduced if you become disabled after age 65. Any sickness or injury for which you have received medical treatment, consultation, care, or services (including diagnostic measures or the taking of prescribed medications) during the specified months prior to the coverage effective date. A disability arising from any such sickness or injury will be covered only if it begins after you have performed your regular occupation on a full-time basis for the specified months following the coverage effective date. You will not receive benefits in the following circumstances: Your disability is the result of a self-inflicted injury. You are not under the regular care of a doctor when requesting disability benefits. You were involved in a felony commission, act of war, or participation in a riot. Your benefits may be reduced if you are receiving benefits from any of the following sources: Any compulsory benefit act or law (such as state disability plans); Any governmental retirement system earned as a result of working for the current policyholder; Any disability or retirement benefit received under a retirement plan; Any Social Security, or similar plan or act, benefits; Earnings the insured earns or receives from any form of employment; Workers compensation; Salary continuance or employer contributions to an employer sponsored retirement plan. This coverage will terminate when you terminate employment with this policyholder, or at your retirement. For assistance or additional information Contact Lincoln Financial Group at (800) or log on to NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern Lincoln National Corporation Group Insurance products are issued by The Lincoln National Life Insurance Company (Ft. Wayne, IN), which is not licensed and does not solicit business in New York. In New York, group insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Each affiliate is solely responsible for its own financial and contractual obligations. GLM Rev. 4/08 LTD_Grp

5 Group Long-Term Disability Insurance SUMMARY OF BENEFITS Sponsored by: Long-term disability is intended to protect your income for a long duration after you have depleted shortterm disability or any sick leave your company may offer. All Part-Time Administrative Employees And Employees Represented By Transportation Communications Union (TCU) Eligibility Maximum Monthly Maximum Duration Own Occupation Period Elimination Period Accumulation of Elimination Days Pre-Existing Condition Waiver of Premium Survivor Income All part-time active employees working 20 or more hours per week in an eligible class are eligible for coverage. 67% of salary up to $8,000 per month Social Security Normal Retirement Age /Age 65 (whichever is later) 24 Months 90 days The number of days you must be disabled prior to collecting disability benefits. You can satisfy the days of your elimination period with either total (off work entirely) or partial (working some hours at your current job) disability. If you are working on a partial basis, you will have 2x the elimination period days to satisfy the total of 90 days. You may not be eligible for benefits if you have received treatment for a condition within the past 3 months until you have been covered under this plan for 12 months. You will not be required to pay premium during any time of approved total or partial disability. A survivor benefit may be paid to your beneficiary if you should die while receiving qualifying disability payments. EmployeeConnect SM Access to an employee assistance program for the employee or an immediate household family member who may be experiencing personal or workplace issues. Limitations Conversion Monthly Premium Calculation Mental Illness: 24 months Substance Abuse: 24 months Specified Illness: No Limit If you terminate your employment, you may be able to convert this policy. Example: John Doe earns $2,500 per month. $2,500 x.0025 = $6.25 x.50 (employee percentage) = $3.13 Monthly premium EXAMPLE John Doe, Age 35 List your monthly earnings $ $2,500 (*Maximum covered payroll is $1,666 monthly) Multiply by Your Estimated Monthly Premium $ $6.25 Multiply by the employee percentage amount not paid by your Employer 50% Your Total Estimated Bi-Weekly Premium $3.13 This is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency. (Please see other side) GLM Rev. 4/08 LTD_Grp

6 Understanding Your s Own Occupation Total Disability Partial Disability Continuation of Disability Duration Reduction Pre-Existing Condition Exclusions Reductions Termination The occupation trade or profession you were employed in prior to your disability as defined by the US DOL Dictionary of Occupational Titles. You are considered totally disabled if, due to an injury or illness, you are unable to perform each of the main duties of your own occupation. Your own occupation is covered for a specific period of time. Following this, the definition of total disability becomes the inability to perform any occupation for which you are reasonably suited based on your experience, education, or training. You are considered partially disabled if you are unable, due to an injury or illness, to perform the main duties of your regular occupation on a full-time basis. Partial Disability benefits may be payable if you are earning at least 20% of the income you earned prior to becoming disabled, but not more than 99%. Partial disability benefits allow you to work and earn income from your employer as well as continue to receive benefits, which may enable you to receive 100% of your income during your time of disability. If you return to work full-time but become disabled from the same disability within six months of returning to work, you will begin receiving benefits again immediately. Your benefit duration may be reduced if you become disabled after age 65. Any sickness or injury for which you have received medical treatment, consultation, care, or services (including diagnostic measures or the taking of prescribed medications) during the specified months prior to the coverage effective date. A disability arising from any such sickness or injury will be covered only if it begins after you have performed your regular occupation on a full-time basis for the specified months following the coverage effective date. You will not receive benefits in the following circumstances: Your disability is the result of a self-inflicted injury. You are not under the regular care of a doctor when requesting disability benefits. You were involved in a felony commission, act of war, or participation in a riot. Your benefits may be reduced if you are receiving benefits from any of the following sources: Any compulsory benefit act or law (such as state disability plans); Any governmental retirement system earned as a result of working for the current policyholder; Any disability or retirement benefit received under a retirement plan; Any Social Security, or similar plan or act, benefits; Earnings the insured earns or receives from any form of employment; Workers compensation; Salary continuance or employer contributions to an employer sponsored retirement plan. This coverage will terminate when you terminate employment with this policyholder, or at your retirement. For assistance or additional information Contact Lincoln Financial Group at (800) or log on to NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern Lincoln National Corporation Group Insurance products are issued by The Lincoln National Life Insurance Company (Ft. Wayne, IN), which is not licensed and does not solicit business in New York. In New York, group insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Each affiliate is solely responsible for its own financial and contractual obligations. GLM Rev. 4/08 LTD_Grp

7 ENROLLMENT FORM FOR GROUP INSURANCE Please Use Ink or Type GROUP ID: OCTRANSPOR A. Employee Information (Complete for ALL Enrollments) Employer Name/Company Name (Please Print) GROUP POLICY #: , , The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE Phone: (800) Fax: (877) Billing Division or Location: County Employer ZIP State Employee Last Name First Name Middle Initial Social Security Number Date of Birth Gender: Male Female Marital Status: Married Single Home Phone Completed By Employer Average Hours Worked Per Week: Occupation: Work Phone Earnings: Hourly Monthly Weekly Yearly $ Date of Full-Time Employment: Rehire Date: B. Product Selection (Complete for ALL Enrollments) Basic Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. Class Effective Date Type of Coverage Amount of Coverage Total Premium Basic Group Life/AD&D Yes No $ Employer Paid Short Term Disability Yes No $ Employer Paid Long Term Disability Yes No $ Employer Paid C. Beneficiary Information (Complete ONLY for Life or AD&D Enrollments) Primary Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Contingent Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper. E. Request for Coverages This coverage has been offered to me and after careful consideration of the benefits, I have decided to: REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby apply for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. NOT ENROLL myself in the Program. I understand that if I apply for coverage at a later date, and if a physical examination or further medical information is required, it will be at my own expense. NOT ENROLL my dependents in the Program. I understand that if I apply for coverage for my dependents at a later date, and if a physical examination or further medical information is required, it will be at my own expense. GLAD 4 11/00 Rev. 04/07 CA

8 NOTICE: CALIFORNIA LAW PROHIBITS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH INSURANCE COMPANIES AS A CONDITION OF OBTAINING HEALTH INSURANCE COVERAGE. FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not actively at work, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. Employee Full Name: Employee Signature: Date: GLAD 4 11/00 CA

9 ENROLLMENT FORM FOR GROUP INSURANCE Please Use Ink or Type GROUP ID: OCTRANSPOR A. Employee Information (Complete for ALL Enrollments) Employer Name/Company Name (Please Print) GROUP POLICY #: , , The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE Phone: (800) Fax: (877) Billing Division or Location: County Employer ZIP State Employee Last Name First Name Middle Initial Social Security Number Date of Birth Gender: Male Female Marital Status: Married Single Home Phone Completed By Employer Average Hours Worked Per Week: Occupation: Work Phone Earnings: Hourly Monthly Weekly Yearly $ Date of Full-Time Employment: Rehire Date: B. Product Selection (Complete for ALL Enrollments) Basic Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. Class Effective Date Type of Coverage Amount of Coverage Total Premium Basic Group Life/AD&D Yes No $ $ Short Term Disability Yes No $ $ Long Term Disability Yes No $ $ C. Beneficiary Information (Complete ONLY for Life or AD&D Enrollments) Primary Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Contingent Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper. E. Request for Coverages This coverage has been offered to me and after careful consideration of the benefits, I have decided to: REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby apply for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. NOT ENROLL myself in the Program. I understand that if I apply for coverage at a later date, and if a physical examination or further medical information is required, it will be at my own expense. NOT ENROLL my dependents in the Program. I understand that if I apply for coverage for my dependents at a later date, and if a physical examination or further medical information is required, it will be at my own expense. GLAD 4 11/00 Rev. 04/07 CA

10 NOTICE: CALIFORNIA LAW PROHIBITS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH INSURANCE COMPANIES AS A CONDITION OF OBTAINING HEALTH INSURANCE COVERAGE. FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not actively at work, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. Employee Full Name: Employee Signature: Date: GLAD 4 11/00 CA

11 The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE Phone: (800) Fax: (877) ENROLLMENT FORM FOR GROUP INSURANCE Please Use Ink or Type GROUP ID: GROUP POLICY #: Billing Division or Location: OCTRANSPOR A. Employee Information (Complete for ALL Enrollments) Employer Name/Company Name (Please Print) County Employer ZIP State Employee Last Name First Name Middle Initial Social Security Number Date of Birth Gender: Male Female Marital Status: Married Single Home Phone Completed By Employer Average Hours Worked Per Week: Occupation: Work Phone Earnings: Hourly Monthly Weekly Yearly $ Date of Full-Time Employment: Rehire Date: B. Product Selection (Complete for ALL Enrollments) Basic Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. Class Effective Date Type of Coverage Amount of Coverage Total Premium Basic Group Life/AD&D Yes No $ Employer Paid C. Beneficiary Information (Complete ONLY for Life or AD&D Enrollments) Primary Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Contingent Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper. NOTICE: CALIFORNIA LAW PROHIBITS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH INSURANCE COMPANIES AS A CONDITION OF OBTAINING HEALTH INSURANCE COVERAGE. FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not actively at work, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. Employee Full Name: Employee Signature: Date: GLAD 4 11/00 Rev. 04/07 CA

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