GROUP SELF-ADMINISTRATION MANUAL

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1 GROUP SELF-ADMINISTRATION MANUAL Greater Georgia Life Insurance Company THANK YOU... for selecting Greater Georgia Life Insurance Company to provide benefits for your employees. This manual is not a part of the policy and should not be viewed as such. The coverage provided under this plan is governed at all times by the terms of your policy, and you should refer to your Group Insurance Policy and Certificate for rate amounts and plan provisions. You have selected Greater Georgia Life Insurance Company to provide benefits for your most important asset... your employees. We are dedicated to that commitment. Greater Georgia Life Insurance Company, Inc. is a wholly owned subsidiary of Blue Cross and Blue Shield of Georgia, an Independent Licensee of the Blue Cross Blue Shield Association. Registered Mark of the Blue Cross Blue Shield Association.

2 TABLE OF CONTENTS CUSTOMER SERVICE 3 GROUP ADMINISTRATION GUIDELINES 4 ELIGIBILITY 5 BILLING - General Information 11 VOLUNTARY BENEFITS - General Information 14 TERMINATING THE GROUP POLICY 15 LIFE CLAIMS 16 SHORT TERM DISABILITY CLAIMS 20 LONG TERM DISABILITY CLAIMS 21 FORMS 23 2

3 CUSTOMER SERVICE Greater Georgia Life Insurance Company, Inc. (hereinafter GGLIC) is committed to satisfying our customers. We at GGLIC want to make the administration of your plan a successful experience. This manual has been designed to assist you in the administration of your insurance program. Business Hours: 8:00 a.m. to 5:00 p.m. Main Telephone Number: Fax Numbers: Operations Marketing/Sales Underwriting General Mailing Address: Greater Georgia Life Insurance Company P.O. Box 4445 Atlanta, Georgia

4 GROUP ADMINISTRATION GUIDELINES 1. The Group Administrator must keep all necessary paperwork on file in his/her office including, but not limited to the policy, enrollment forms, change and adjustment forms, and beneficiary designation forms. (see Self-Administration Agreement) 2. The Group Administrator will be responsible for calculating, reporting and submitting premiums to Greater Georgia Life Insurance Company (GGLIC). 3. GGLIC will provide in a word document a Certificate of coverage to the Group Administrator to print for the insured employees, if needed an initial supply of printed Certificates can be furnished. GGLIC will also furnish a supply of Group Life Insurance Benefits booklets. When you need an additional supply of booklets for new hires, please contact your Personal Service Representative. 4. Annual Renewal Review - The Group Administrator must provide GGLIC with a complete list of all insured employees (employee census) within 120 days prior to each Policy Year renewal. This must include employee name, Social Security Number, date of birth, gender, basic annual earnings and job title. GGLIC will use this information to analyze the appropriateness of current rates. GGLIC will also notify the company of any change in premium rates no later than 60 days prior to renewal date. 4

5 ELIGIBILITY - General Information 1. New Enrollments (a) Who is eligible to enroll To obtain coverage under your group policy, an employee must meet the eligibility requirements as defined in your policy, reach an eligibility effective date as designated by the group policy probation period, and enroll by completing a member enrollment application. File the completed enrollment form with your office records. General eligibility requirements for coverage under your group policy include (actual eligibility provisions may vary - please refer to your group policy for details): Employees a. Must be full-time employees working 30 hours or more per week b. Must have completed the required probationary period. Dependents (Applicable to Life Only) a. Employee must complete the required probationary period b. Must be a dependent of a member employee who has elected dependent coverage. Dependents include: - Legal spouse (only one spouse may be enrolled at one time) AND not legally separated from the employee. - Unmarried children who are financially dependent upon the employee for support. Children are considered financially dependent if they qualify as dependents for Federal Income Tax purposes. - Unmarried children who meet all the other unmarried children criteria AND who are enrolled as fulltime students at an accredited secondary school, college or university. Please refer to your group policy for specifics pertaining to your group. - Age restrictions apply. Please see your policy for details. Notes: 1) An unmarried child may include the employee s natural child, stepchild, legally adopted child, and a child under custody pursuant to a court order or legal guardianship. (Note: Copies of the court documents are required.) 2) The term dependent does NOT include any person who: - is eligible as an employee - is a member of the armed forces of any country - is residing outside the United States and Canada 3) Exceptions to the age limits above may apply for disabled children or special groups. (b) Employees who do not wish to enroll For groups where an employee must share cost of coverage with the employer, an employee may decline coverage. If an employee declines coverage, the "Life/Disability Coverage Waiver Authorization Form" needs to be completed. This is necessary to document that the employee was given an opportunity to enroll through the group plan, but elected not to do so at that time. An employee who declines coverage when first eligible or who does not elect coverage for his eligible family members during the initial eligibility period may apply at a later date, but will be subject to medical underwriting. Refer to the Late Enrollees section for more information. Employees may not decline coverage where the employer pays 100% of cost of insurance. 5

6 ELIGIBILITY (continued) (c) (d) When may employees enroll Eligible employees may apply for coverage as a new hire within 31 days of employment or within 31 days of any group's specific employee probationary period. If an employee does not enroll for coverage by completing a member enrollment application within 31 days from his or her eligibility date, the employee and dependents become late enrollees and are subject to medical underwriting. Refer to the Late Enrollees section for more information. How to enroll new employees Eligible employees may enroll by completing the Group Insurance Application and Enrollment Form. These forms are created to clearly convey information between you and GGLIC and its parent and affiliates. Groups that are selfadministered must maintain these forms at their location. Please take a moment to review and verify that all items have been completed accurately. Important points to help your employees enroll: New employees should complete enrollment forms when hired. Applications must be submitted within 31 days from an employee s eligibility date, or the employee will be required to apply for coverage as a late enrollee. Having the form completed when the employee is hired will help in meeting the 31-day timeliness requirement in the event that you or the applicant are away from the office when eligibility occurs. Be sure that each employee indicates the exact coverage(s) desired. This is especially important when dependent term life insurance is desired. If the employee pays any portion of the premium for dependent term life insurance, the box for dependent term life insurance must be checked. If the box is not checked, the dependent life coverage will not be effective. Each member must name a primary beneficiary. (1) A primary beneficiary is the person(s) who will receive the death benefit upon the death of the member. If more than one primary beneficiary is named, be sure to indicate the percent each person is to receive. If percentages are not indicated, the proceeds will be divided equally. (2) If no beneficiary is named or surviving at the member s death, benefits will be paid to the member s estate. (3) In designating children as beneficiaries, note that we cannot make payment to children under the age of 18. If the beneficiary is under 18, we will only be able to pay benefits to a court appointed guardian of property (conservator). (4) Use the full first and last name of the beneficiary; do not use only initials for the first name. (5) A member cannot name his/her employer as their beneficiary. (6) A member cannot name himself as beneficiary. However, a member can name his estate or a trust. When naming a trust as beneficiary, we will need both the name and date of the trust. (7) The employee is always the primary beneficiary in a Dependent Life claim. 6

7 ELIGIBILITY (continued) (e) Effective date of coverage If an employee applies for coverage when first eligible, the effective date of coverage will be as stipulated in accordance with the Eligibility section of the Group Master Application. Example 1: Assume that your group master application provides that employees and their dependents become eligible for coverage on the first of the month following 30 days of employment. Here is how coverage would begin for a new employee hired on August 15: 1. Date of hire 08/15 2. Date probationary period is completed (Hire date plus 09/14 term of probationary period as shown in the Group Policy) 3. Date coverage begins (as specified in your Group 10/01 Policy) 4. First billing period for which premiums must be paid 10/01-10/31 Example 2: Now let us see how coverage and the first premium payment would differ if the employee is hired on August 1 (rather than August 15): 1. Date of hire 08/01 2. Date probationary period is completed 08/31 3. Date coverage begins 09/01 4. First billing period for which premiums must be paid 09/01-09/30 7

8 ELIGIBILITY (continued) 2. Late Enrollees (a) Who is a late enrollee? Contributory Products (Employee Paid) Late enrollment rules apply to employees who elected not to apply when first eligible or who inadvertently missed the date and later wish to change their status. Also, if an employee has an existing policy with GGLIC but chooses to decline dependent life coverage for dependents and later elects to provide coverage for those dependents, a Request for Change Form (change form) and a Medical Questionnaire are required. Non-Contributory Products (Employer Paid) Late enrollment rules do not apply. All employees should be enrolled during their initial eligibility period. (b) How to enroll late enrollees Late enrollees may apply for coverage by completing the Group Insurance Application form and a Medical Questionnaire. The Medical Questionnaire form is self-explanatory with clear instructions. A copy has been enclosed in this manual. Information on the form should be verified by the employee and the group administrator for completion and accuracy to prevent a delay in processing. The GGLIC underwriting department will review the Medical Questionnaire for approval. For legal and audit purposes, please be sure the original forms are filled out in ink, signed by the employee and spouse (if applying). The forms should be mailed immediately to the address indicated on the form -- group underwriting will not accept applications with signatures more than 60 days old. In some instances, additional medical information may be required. The originals of all questionnaires are to be submitted to GGLIC; duplicates or facsimiles cannot be accepted. If such health evidence is required, GGLIC will not be liable for any of the costs related to acquiring the additional documents. It will take approximately 30 days to process your forms. If approved, the effective date of coverage will be the first service date following group underwriting s approval. 3. Changes The change form provides documentation that a member has made a change in beneficiary, dependent status (adding or deleting dependent life coverage) or a change in name. All of the appropriate sections of the form must be completed, signed and dated by the employee and must include the employee s certificate number and group number(s). File the completed form with your office records and be sure to note the change in your billing records. Events that might occur after an employee is originally enrolled include the following: - Primary beneficiary dies Complete change form to specify a new primary beneficiary; otherwise, benefits will be paid to the contingent beneficiary, if one was named; if no contingent beneficiary was designated, benefits will be paid to the member s estate. 8

9 ELIGIBILITY (continued) - Spouse or dependent loses eligibility (divorce, spouse or dependent s death, dependent s attainment of policy s maximum age, dependent s marriage, etc.) Employee submits Group Insurance Request for Change Form within 31 days of the event for consideration. The effective date of the change will be the date of the event unless otherwise specified in your Policy. Note that the loss of eligibility may also qualify the individual for a conversion policy. - Employee wishes to add a new spouse or child(ren) A change form must be completed and returned to the Group Administrator within 31 days of the event; the coverage effective date will be the first of the month following the event. For life events (i.e. marriage) we make the coverage effective the date of event. If not submitted to the Group Administrator within 31 days of the event, a Medical Questionnaire for the spouse and child(ren) will also be required and forwarded to GGLIC for review. The effective date of coverage will be the first service date following medical underwriting approval. - Employee wishes to assign benefits An employee may request an assignment of benefits by submitting an Absolute Assignment Of Group Life Insurance form to GGLIC (form available from Atlanta, GA claims office). The request must be approved by GGLIC to be a valid assignment under the Policy. To be valid, an assignment must also be absolute and irrevocable. GGLIC assumes no liability for its sufficiency. 4. Retroactivity Retroactivity is generally defined as any change affecting additions or terminations of a member or members with an effective date prior to forwarding on GGL's monthly premium statement. The approving of all retroactive changes is solely at the discretion of GGL, and the following guidelines are in place: Non-Contributory Products: Retroactive terminations and changes will be processed for effective dates up to six months prior to most current monthly premium billing statement received by GGL. Retroactive additions will be added back to the date first eligible. Contributory Products: Retroactive terminations and changes that reduce benefits will be processed for effective dates up to 90 days prior to billing purposes. Additions and changes that increase benefits must be applied for within 31 days of becoming eligible. Premium will be billed from the date first eligible. Additions and changes that increase benefits that are not applied for within 31 days of becoming eligible will require the submission of a medical questionnaire and will not be effective until the first of the month following underwriting approval. Requests for effective dates other than what would be provided using the above guidelines must be approved by our underwriting department. 9

10 ELIGIBILITY (continued) 5. Employee Terminations Upon the effective date of any employee's termination date, the Group Administrator must include this change on the monthly Group Insurance Premium Statement as an Adjustment per contract provisions. 6. Conversions Eligible employees or spouses may apply, without evidence of insurability, for an individual policy of life insurance when they have lost their eligibility to be covered under the group policy for the following reasons: a. termination of the employee s employment b. death of the employee c. loss of eligibility in a class under this policy Consult your group policy for additional reasons that may allow an eligible employee or spouse to apply for an individual policy. The steps to follow if an eligible employee or eligible dependent wishes to exercise his or her conversion option: a. The employer must complete Section I of the Request for Group Life Conversion Form. (refer to "Forms" section for copy of conversion form) b. The employer forwards the request to the employee to complete Section II of the form and mail to the address at the bottom of the form. c. The employee will then be sent an application for life conversion, along with the rates for a conversion policy. The employee completes the application and returns it, along with appropriate premium, to the address designated on the form. NOTE - IN ORDER TO MEET THE CONVERSION REQUIREMENTS SET FORTH IN THE POLICY, IT IS CRITICAL THAT THESE STEPS BE COMPLETED WITHIN 31 DAYS FOLLOWING TERMINATION OF EMPLOYMENT OR LOSS OF COVERAGE. 10

11 BILLING General Information 1. How does Group Administrator submit monthly premium due for all lines of coverage.? The Group Insurance Premium Statement will provide total amount of premium due for all GGL coverages included in your policy. A supply of self-addressed envelopes will be furnished for the Group Administrator to mail monthly Premium Statement to GGL. 2. When will I receive the bill? Due to the self-administered nature of your account, a self-administered "Group Insurance Premium Statement" will be provided in the form of an Excel file to the Group Administrator when the group sale is finalized. Use the Group Insurance Premium Statement to pay your monthly premium (see page 13 for sample of the Monthly Premium Statement). If you do not have access to Excel software, then a supply will be provided by GGL. 3. When is payment due? Payment is due on the first day of the billing period. For example, the premium for March 1 to April 1 billing period is due on March 1. If premium is not received prior to the expiration of your grace period (31 days), your policy will lapse. 4. What do I return with the payment? Along with your remittance check made payable to GGL, you should include a copy of the group self-administered billing statement. Please ensure that the amount of your check equals the Total Premium Due on the billing statement. Please write your group policy number on the check before mailing to Greater Georgia Life Insurance Company. 5. How are new enrollments and changes reflected on the bill? The total of all terminations and additions of new hires completed during the prior month(s) should be included in the "Adjustments" on your billing statement. 6. What is the Total Premium Due? You are responsible for reporting LIVES, VOLUME and PREMIUM for each line of coverage every month. Your monthly premium payment should always equal the Total Premium Due as shown on your Group Insurance Premium Statement. (see "Calculating Premium" example) 7. Whom do I call for help? You should contact your Service Representative to answer questions you may have regarding the status of your account. For specific claim related questions, please contact either the Life or the Disability Claims Service Center by using the numbers provided in section for Claims information. 11

12 CALCULATING PREMIUM To calculate the premium due for a particular coverage, please follow the formulas provided below. Please refer to your insurance contract to determine the coverage amounts for your employees. LIFE/AD&D INSURANCE (BASIC AND VOLUNTARY) Life and AD&D rates are per $1,000 of coverage, so premium should be calculated based on the actual benefit amounts provided to each employee. Use the formula listed below to calculate the cost: EXAMPLE: (Life insurance for John Smith) 25,000 = x.55 = $ ,000 BENEFIT AMOUNT X RATE = PREMIUM $1,000 EXAMPLE: (Life insurance for all employees of ABC Corp) 610,000 = x.55 = $ ,000 EXAMPLE: (AD&D insurance for John Smith) 25,000 = x.05 = $1.25 1,000 EXAMPLE: (AD&D for all employees of ABC Corp.) 610,000 = x.05 = $ ,000 LONG TERM DISABILITY INSURANCE Traditional LTD rates are based on a per $100 of monthly covered payroll. However, the payroll rate must be converted to a monthly covered benefit rate. Payroll rate.38 =.633 Benefit Rate Benefit Percentage.60 Use this formula to calculate the cost of LTD coverage: MONTHLY BENEFIT X RATE = PREMIUM $100 EXAMPLE: (LTD insurance for Julie Johnson) According to the group contract, this plan will cover a EXAMPLE: (LTD covered benefits for all employees of ABC Corp.) 60% of maximum per member's monthly benefit of $5,000. Julie's monthly earnings: $3,012 x.60 = 1, (Julie's benefits) 50,264 = X.633 = $ Cost of Julie's coverage: 1, = x.633 = $ DEPENDENT LIFE INSURANCE Dependent life insurance rates are per family unit. The same rate is charged per family regardless of the actual number of dependents covered. Use the formula below to calculate the cost of dependent life insurance: FAMILY UNIT X RATE = PREMIUM EXAMPLE: (Dependent life insurance for John and Sarah Smith and children) 1 Family unit X 1.20 = $1.20 EXAMPLE: (Coverage for all employee families at ABC Corp.) 20 Family Units X 1.20 = $24.00 SHORT TERM DISABILITY The cost of weekly income (or short term disability) insurance is calculated based on the actual benefit provided to the employee if that employee becomes disabled. Rates are per $10 of benefit. Use the formula below to calculate the cost of WI/STD coverage: BENEFIT AMOUNT X RATE = PREMIUM $10 EXAMPLE: (STD coverage for John Smith) According to the contract under which he is covered, John's benefit amount will be 60% of his weekly earnings. The maximum benefit allowed under this group plan is $ % of John's weekly earnings: $ Maximum Benefit Amount: $250 Cost of John's coverage: 250 = 25 X.44 = $

13 Below is a sample of the monthly Group Insurance Premium Statement that you will receive from GGL. The bill illustrates a combination of group coverages. See below for information (1-10) to complete your billing statement. Include this statement with your monthly payment. SAMPLE: MONTHLY PREMIUM STATEMENT GREATER GEORGIA LIFE INSURANCE COMPANY Phone: (678) Fax: (678) Group Insurance Premium Statement (1) Premium Due Date: ABC Company Group #: (2) Date Prepared: 03/11/2003 (3) (4) (5) (6) (7) # of Product/Coverage Covered Volume Monthly Premium Employees /Unit RATE (Vol x Mo Cost) Basic LIFE $ 0.27/1000 $ 0.00 Basic AD&D $ 0.05/1000 $ 0.00 Dependent Life $ 2.00/unit $ 0.00 Short Term Disability $ 0.33/10 $ 0.00 Long Term Disability $ 0.35/100 $ 0.00 Voluntary Ee Life $ Step Rates $ 0.00 Voluntary Sp Life $ Step Rates $ 0.00 Voluntary Child Life $.90 $ 0.00 Voluntary STD $ Step Rates $ 0.00 Voluntary LTD $ Step Rates $ 0.00 (8) Premium Due 0.00 (9) Adjustments (10) Total Premium Due $ 0.00 COMPLETE FOR EACH LINE OF COVERAGE (1) Premium Due Date - Fill in Premium Due Date (2) Date Prepared - Fill in Date Prepared (3) Product Coverage - Represents Product Coverage you have inforce (4) Number of Covered Employees - Represents number of employees enrolled for each coverage (5) Volume/Unit - Indicate volume or units for each coverage (6) Rate - Represents billed rate for each coverage (7) Monthly Premium - Input monthly premium amount due for each coverage (8) Premium Due - Total of all monthly premium for each line of coverage (9) Adjustments - Indicate premium adjustments due to total terminations of employees for the billing month and/or adjustments from prior months (10) Total Premium Due - Indicate sum of premium due after the adjustments are input 13

14 VOLUNTARY BENEFITS General Information Voluntary Group Term Life Voluntary Group Term Life is available for all full-time, active employees and is paid completely by employees through payroll deduction. Benefit amount options up to the maximum amounts offered are based on the size of the group subject to five times earnings maximum. Annual earnings means regular salary or wages, but does not include bonuses or overtime pay. Coverage for spouses are available in $5,000 increments not to exceed 50% of the employee amount. The benefit allowable for child(ren) is usually $5,000 or $10,000. Enrollment for Voluntary Employee, Spouse and Child(ren) Life will be done by completing the appropriate sections of the Voluntary Group Term Life Insurance Benefits Voluntary Group Term Life Enrollment Brochure (Form No. VGTL 98-B (Rev. 6/1/1999). Complete all sections on Part A of Enrollment Application (Section 1 16) and indicate amount of selected employee, spouse and child(ren) coverage (Section 12). Please refer to separate Voluntary Life Q&A and Rate Grid to determine levels of voluntary life coverage available and applicable premium costs based on age and level of coverage. If an employee or spouse selects a level of life coverage over the Guaranteed Issue Limits (G.I.), then Part B Insurability Questionnaire of the application must be completed (Section 1 thru 10). The application should be mailed to GGL to be reviewed by GGL Underwriting Department. The group administrator will be notified of approval or denial of life coverage over the G. I. limits. Approved level will become effective the first of the month following GGL approval. Premium costs for employee and spouse coverage is based on appropriate 5 year age bracket at time of enrollment. When an employee moves into another age bracket at a later date, new age bracket rates will apply. Please note Spouse rates based on employee age. Portability of Coverage Under Voluntary Group Term Life an employee and his/her spouse can continue insurance coverage if employment terminates. Insurance cannot be continued under this provision if employee's insurance terminates because the group policy terminates. Refer to Portability Provisions in your group Policy for details. Employee and spouse (if applicable) should complete the Request For Portability Provision Life Insurance Benefits Form and return to Greater Georgia Life no later than 31 days after the date the insurance would terminate. Voluntary Long Term Disability Voluntary Long Term Disability (LTD) is available for all full-time, active employees and is paid completely by employees through payroll deduction. Benefit amounts are available in $100 increments up to $5,000 per month maximum not to exceed 60% of monthly Basic Earnings. Basic Earnings means regular salary or wages, but does not include bonuses or overtime pay. Enrollment for Voluntary LTD will be done by completing the appropriate sections of the Voluntary LTD Enrollment Brochure (Form No. GLTD 98-B (10-98). Complete all Sections of enrollment application including employees basic earnings and benefit selection. Please refer to separate voluntary LTD Q&A and Rate Grid to determine level of voluntary LTD coverage available and applicable premium costs based on age and level of coverage. Selected amounts of voluntary LTD are guaranteed issue if within 60% of monthly pay and monthly maximum benefit of $5,000. Premium cost is based on appropriate age bracket at time of enrollment and if employee moves into another age bracket at a later date, new age bracket rates will apply. Voluntary Short Term Disability To enroll for Voluntary STD the employee will complete the Voluntary STD Enrollment Brochure (Form No. VGSTD98-B (Rev. 9/1999). All full-time, active employees are eligible between ages Benefits amounts in $25 increments up to $500 per week not to exceed 60% of weekly Basic Earnings. Please refer to separate Voluntary STD Q&A and Rate Grid to determine level of Voluntary STD coverage available and applicable premium costs based on age and level of coverage. 14

15 TERMINATING THE GROUP POLICY A group can cancel their GGL coverage. To do so, the group must submit a written letter requesting cancellation to GGLIC within 30 days prior to the next premium due date. If GGLIC terminates coverage, GGLIC will send the group written notice at least 30 days prior to the group's next premium due date. Example: Next premium due date Group's termination letter must be received by GGL or the group must receive GGL's notice of termination no later than Cancellation of the group occurs on If no written notice is given, the policy renews under the same terms and conditions. In the event that group premium is delinquent, a group s policy with GGLIC will be cancelled as of the Policy's paid-to-date if premiums are not paid by the end of the grace period. Upon termination, it is the group s responsibility to notify its employees when GGLIC coverage is cancelled. 15

16 LIFE CLAIMS - General Information Life claims are processed by a claims unit that specializes in the administration and payment of life related claims. For claim forms or questions related to life claims, contact the Life Claims Service Center at , Monday through Friday, 8:30 a.m. to 5 p.m. EST. For specific details regarding the benefits provided by your policy, please refer to the benefit provisions of your policy. Claims Information Who To Contact Topic: Phone: Fax: Claims - Customer Service (800) (770) Mailing Address: Life Claims Service Center, P.O. Box , Atlanta, GA Claims Submissions Please submit all Life, AD&D, Waiver of Premium, and Accelerated Death claims to the Life Claims Service Center in Atlanta, Georgia. Our goal is to process all life claims with complete information within 5-7 days of receipt. Life and Dependent Claims require the following: Beneficiary Claim Form Certified Copy of death certificate Enrollment Form Any change of beneficiary designation is applicable Employer provides payroll records for last period worked Beneficiary Designations In the event of a claim, the GROUP ADMINISTRATOR is responsible for providing copies of the enrollment form (with beneficiary information) plus any other beneficiary designation forms that the insured completed. Valid beneficiary designations must include name and must include either Social Security number, relationship to insured, or birth date. In addition, the form must be signed and dated by the insured. Multiple beneficiaries may be named on the same form. If percentages are not filled in, equal shares will be assumed. Primary and secondary beneficiaries may also be named on the form. If the Primary beneficiary is not living at the time of the insured's death, the secondary beneficiary will receive the benefit. 16

17 LIFE CLAIMS (continued) If no beneficiary is living at time of death, or none is named, the benefit will be paid as shown in the certificate booklet. Standard wording would be "Benefits are payable to the executor or administrator of the estate. If there is no executor or administrator, we may at our option: (a) pay benefit to the spouse if living; or (b) if there is no living spouse, pay equal shares of the benefit to your children if living; or (c) if there are no living children, pay the benefit in equal shares to the direct parents if living." It is important to review the wording in the certificate booklet, since this wording may vary. ABSOLUTE ASSIGNMENT BENEFICIARY DESIGNATIONS are a special type of beneficiary designation that can ONLY be changed if the new owner agrees to the change. They change the ownership of the group life benefit. They are often done for estate planning, taxation issues, and for viatical arrangements. Forms are available from the Atlanta, GA claims office. Accidental Death & Dismemberment Claims (a) Accidental Death Claims require the following: Beneficiary Claim Form Certified copy of death certificate Enrollment form Any change of beneficiary designation is applicable Newspaper clipping and/or police report Employer provides payroll records for last period worked AD&D includes the following benefits in addition to life insurance: Accidental Death - Benefit paid if death is by accidental means. Usually, the benefit equals the life benefit. Dismemberment - Benefit paid due to loss of limbs or vision in the event of an accident. Seatbelt - Additional benefit of 10% of face amount or $25,000 (whichever is less), if accidental death was caused while using an unaltered seat belt. Repatriation - Pays up to an additional $5,000 to return remains of member to a mortuary, if accidental death occurred more than 100 miles from primary residence. Education Benefit - Pays an additional benefit in four equal installments of $3,000 to a maximum of $12,000 for the education of the child of the deceased. AD&D has some exclusions; see the Exclusions section of the Certificate booklet for more information. 17

18 LIFE CLAIMS (continued) Accelerated Death Benefit (ADB) Claims ADB may be included with the Basic Life. It is not available for AD&D or Dependent Life coverages. This benefit is also referred to as Living Life Benefit (LLB). This provision offers a 50% of the life benefit when an active member becomes terminally ill* and life expectancy is 12 months or less. Employees can opt for less than the maximum, but only one payment will be made during the member's lifetime. Unlike some Life carriers, GGL does NOT charge an administration fee for this provision. GGL also does not discount the present-day value. *Refer to contract wording for specfic definition. (a) Typical steps for an ADB claim: 1. Claim forms completed by group, subscriber and physician 1. "Claim for Personal Accelerated Death Benefit" 2. "Accelerated Death Benefit Attending Physician's Statement" 2. Employer provides payroll records for last period worked 3. Submit claim forms to Life Claims Operations office 4. Life Claims Operations reviews 5. If approved, Life Claims Operations pays ADB benefit to member 6. Employer should reduce the life benefit by the ADB amount paid (reducing monthly cost to employer) 7. Member may file for waiver of premium benefit on remaining benefit, if not already completed. Refer to "Waiver of Premium " section for more information. (b) Death claim: 1. Upon death of member, group files death claim 2. Employer provides payroll records for last period worked 3. Life Claims Operations pays remaining amount to beneficiary 4. Employer terminates member from billing system Refer to "Forms" Section for copies of claim forms. 18

19 LIFE CLAIMS (continued) Waiver of Premium Claims Waiver of Premium (also referred to as "W of P", "Total and Permanent Disability" or "TPD") (WAIVER) is a standard provision of group basic and supplemental life policies throughout the industry. It is not available for AD&D or for dependent life. A member may qualify for WAIVER if he/she becomes totally disabled* before age 60 (65 in certain contracts), and is continuously totally disabled for 6 months. If WAIVER is approved, life coverage remains in force, without premium payments, assuming continuous total disability. Approvals are usually for one year with re-certification required annually. * If a member was totally disabled and under age 60 when coverage terminated, and dies within the first 12 months of continuous total disability, a death benefit may be payable even if premium payments ended. Proof of total disability would be required with the death claim. (a) Waiver of Premium Claims require the following: "Disability Claim" form "Application for Group Life Insurance Disability Benefits" form "Attending Physician's Statement" form Employer provides payroll records for last period worked (b) How to apply for waiver: To apply for WAIVER, the group and member must complete the "Disability Claim" form. The doctor must complete the "Application for Group Life Insurance Disability Benefits" and the "Attending Physician's Statement" form. These forms should be completed no earlier than three months before the end of the WAIVER waiting period. Assuming a nine-month waiting period, proof can be submitted when the member has been continuously totally disabled six months but must be submitted prior to 12 months from the date disability commenced. (c) When waiver is approved: The member and group are notified of approval by letter. The "Re-certification for Waiver of Premium" form is sent with the member's letter that indicates the time frame in which to submit the re-certification assuming continuous total disability. We may request a copy of the Notice of Award for Social Security Disability benefits. Under certain conditions, we may also require an examination by our physician, at our expense, at reasonable intervals. A member cannot be covered under WAIVER and a conversion policy simultaneously. If a member converted when group coverage terminated, the conversion policy must be returned when WAIVER is approved. Conversion premiums are then refunded. (d) When waiver ends: WAIVER ceases when any of the following occur: The member is no longer totally disabled. Written proof of continuous disability is not provided when required. The member refuses an examination by our physician when required. The benefit schedule provides for a termination or reduction of benefits at a specific age or retirement. When WAIVER ceases, or coverage is reduced, the conversion privilege is applicable. 19

20 STD CLAIMS - General Information Short Term Disability claims are processed by a claims unit that specializes in disability benefits. For disability claim forms or questions related to disability claims, please contact the Disability Service Center by calling , Monday through Friday, 8:00 a.m. to 5:00 p.m. EST. Short-Term Disability (STD) Claims Claims for weekly disability benefits should be filed using the "Short Term Disability Claim Form". You, as the employer, complete Section II. The employee should complete Section I and the attending doctor completes Section III. Mail or fax the completed claim form along with a copy of the claimant's signed enrollment application to the address below. All disability checks will be mailed directly to your member employee. Please contact the Disability Service Center to report the employee s return to work date. Claims Information Who To Contact Topic: Phone: Fax: (770) Claims - Customer Service (800) (800) Mailing Address: Greater Georgia Life Insurance Company, Disability Service Center P.O. Box , Atlanta, GA STD INSURED CLAIM PROCESS OVERVIEW The administration of Short Term Disability (STD) claims involves a comprehensive review of eligibility, medical information, job requirements and any corresponding functional limitations to determine whether or not a claimant is totally disabled under the provisions of the disability policy. The claim process begins with the completion of a three part STD Claim Form, including data from the employee, the employer and the attending physician. Eligibility for benefits is confirmed by the policyholder's Benefits Representative who completes the employer's portion of the form. The claim should be submitted as soon as it becomes evident that the employee will be out of work in excess of the plan's initial elimination period. The Claim Form may be either faxed or mailed to the Disability Service Center. Upon receipt of all three parts of the completed Claim Form and any clinical information (if requested), the Disability Case Manager (DCM) is in a position to evaluate the claim. The DCM works closely with policyholder's Benefit Representative to obtain physical job descriptions and evaluate any opportunities for modified or light duty work. A claim decision is made within three days of receipt of all required information. The Claim Form with clinical documentation and occupational requirements are taken into consideration when a claim is reviewed. Once a claim is approved, STD benefits are issued to the claimant on a weekly basis. Periodic clinical updates are requested as needed. 20

21 LTD CLAIMS - General Information Long Term Disability claims are processed by a claims unit that specializes in disability benefits. For disability claim forms or questions related to disability claims, please contact the Disability Service Center by calling , Monday through Friday, 8:00 a.m. to 5:00 p.m. EST. Submit the following Long Term Disability forms approximately 30 days before the end of the benefit waiting period: 1. "Long Term Disability Employee's Disability Benefits Application" The claimant must complete the Long Term Disability Employee's Disability Benefits application and have his/her physician(s) complete the "Long Term Disability Attending Physicians Statement Form". Send completed forms and items listed below to the Disability Service Center: Copy of awards from other sources of benefits: Social Security, Worker's Compensation, retirement, state disability, no-fault auto insurance and any other disability income. Proof of claimant's age. (Certified copy of the claimant's birth certificate) Give claimant additional "Attending Physician's Statement" forms for completion if claimant has more than one treating physician. Copy of the claimant's signed enrollment application. 2. "Long Term Disability Employee Authorization For Release of Information" The claimant must complete the Long Term Disability Employee Authorization Release of Information form. 3. "Long Term Disability Employer's Report of Claim" The Employer should complete the Employer's Report of Claim in full and include the following: Job description (detailed duties, including physical requirements) Documentation of earnings in accordance with your plan description Workers Compensation information (copy of first report of accident and the decision, if any has been determined at this time). 4. "Long Term Disability Attending Physician's Statement" The claimant must complete the Long Term Disability Employee's Disability Benefits application and have his/her physician(s) complete the "Long Term Disability Attending Physicians Statement Form". Send completed forms and items listed below to the Disability Service Center. All forms must be completed to avoid undue delays in processing the claimant's request for benefits. 21

22 LTD CLAIMS (continued) Any questions about LTD claim filing procedures should be referred to: Claims Information Who To Contact Topic: Phone: Fax: (770) Claims - Customer Service (800) (800) Mailing Address: Disability Service Center P.O. Box , Atlanta, GA LTD MEMBER CLAIM PROCESS OVERVIEW The administration of Long Term Disability (LTD) claims involves a comprehensive review of eligibility, medical information, job requirements and any corresponding functional limitations to determine whether or not a claimant is Totally Disabled under the provisions of the disability Policy. The claim process begins with the completion of the employee s, employer's and attending physician s portion of the LTD claim forms. The claim forms should be completed as soon as it becomes evident that the employee s illness or injury may exceed the Elimination Period under the LTD Policy. Each LTD claim undergoes an extensive review process by several individuals. The Disability Case Manager (DCM) is the primary person responsible for the assessment of the claim and making the appropriate determination. All LTD claims go through an initial screening to determine if Vocational Rehabilitation may be a possibility or if Social Security Disability benefits should be immediately pursued. If this initial review does not indicate either option at that time, the claim is reviewed again periodically. Furthermore, certain diagnoses are required to be immediately referred for Social Security assistance and certain other diagnoses require a mandatory review by an R.N. Additionally, all behavioral health claims are reviewed by our staff Psychologist. Once a claim is approved, LTD benefits are issued to the claimant on a monthly basis. The DCM continues to monitor each claim closely, requesting periodic updates as needed. 22

23 FORMS NOTE: IF YOUR GROUP HAS MEDICAL COVERAGE WITH BLUE CROSS BLUE SHIELD OF GEORGIA, COMBINED MEDICAL AND LIFE FORMS MAY BE USED FOR ENROLLMENT. ELIGIBILITY FORMS Request For Change Form [83-A-RC] Medical Questionnaire [0103 Mquest (1/03)] Life/Disability Coverage Waiver Authorization Form CLAIM FORMS Life and AD&D Beneficiary Claim Form [17568 Ed. 7/01] Group Policyholder's Statement Accidental Dismemberment or Loss of Sight Forms [GA84 (4/02)] Accidental Dismemberment or Loss of Sight Claim Form Proof of Accidental Dismemberment Attending Physician's Statement Accelerated Death Benefit Forms Claim for Personal Accelerated Death Benefit Form [GA6224 (12/00)] Accelerated Death Benefit Attending Physician's Statement [GA6223 (297)] Continuation of Life Insurance Forms Disability Claim Form [297G Ed. 7/00] Application for Group Life Insurance Disability Benefits [766G (GGL) (12/02)] Attending Physician's Statement Form Attending Physician's Statement Group Life Insurance Disability Benefits (Renewal purposes) Short Term Disability Short Term Disability Claim Form Long Term Disability Long Term Disability Employee Authorization For Release of Information Long Term Disability Employee's Disability Benefits Application Long Term Disability Attending Physician's Statement Long Term Disability Employer's Report of Claim Conversion Forms Request For Group Life Conversion Information Request For Portability Provision Life Insurance Benefits A sample of each of these forms is provided on the following pages. [767G (GGL)] 23

24

25

26 Life/Disability Coverage Waiver Authorization Form Greater Georgia Life Insurance Company Three Ravinia Drive, Ste. 1770, Atlanta, GA Please type or print all information. I understand that my employer offers a group life and/or disability insurance program which is underwritten by Greater Georgia Life Insurance Company and that, as an employee, I have a right to obtain such coverage for myself and my dependents. I also understand that some or all portions of this program may be available at no cost to me. However, after carefully considering the benefits and my rights, I have decided not to enroll in the following: Check appropriate box(es): (a) Basic Life and AD&D Insurance (b) Dependent Life Insurance (c) Short-Term Disability Insurance I understand that if I wish to participate in this program at some future date, my coverage or my dependents coverage will not be effective until after I submit evidence of insurability to Greater Georgia Life Insurance Company or its designee and I/we are approved for coverage. I understand that if a physical examination or further medical information is required for evidence of insurability, I will be responsible for any expenses associated with obtaining the physical examination or the medical information. Employee Name (please print): Social Security Number: Employee Signature: Date Signed (mo/day/yr): Group/Policy Number: Policyholder (Employer) Name: To the Employer:When this form is completed and signed by the employee, please make two copies. 1) Maintain one copy in the employee's personnel file and give one copy to the employee.

27 Life Claims Service Center P.O. Box Atlanta, GA Please accept our condolences on your recent loss. We realize there is not much we can say that will comfort you during this difficult time. However, we will do our best to assure that all your dealings with us are handled in a professional, caring and timely manner. To better meet your needs and speed the processing of your claim, lump sum proceeds of $5,000 and more are paid through our Control Plus Account SM program. Control Plus Account is a checkbook program paying competitive money market interest rates on the balances in your account and it is fully guaranteed by Greater Georgia Life (GGL). This improved method of payment is provided without cost to you as an additional benefit under a Group policy. As soon as your claim is approved, we will send your Control Plus Account kit containing your checkbook. Your funds will be immediately available to you simply by writing a check. You will have the opportunity to withdraw money as you need it, leaving the balance earning money market interest rates, or you may withdraw the total amount it s all based upon your needs. If you have questions, we encourage you to call our Beneficiary Service Center at our toll-free number, , Monday to Friday, 8:30 a.m. to 4:30 p.m. eastern time. We are pleased to be able to serve you and hope we have relieved you of one worry during this difficult time. Respectfully yours, Greater Georgia Life Registered Mark of Greater Georgia Life

28 How to Complete Your Beneficiary Claim Form Please read this page before you fill out the Beneficiary Claim Form. Greater Georgia Life begins gathering information for your claim as soon as it learns of the death.* To complete processing of your claim, we must have: 1. A fully completed Beneficiary Claim Form from each beneficiary. (You may use a photo copy of the attached form if there is more than one beneficiary.) 2. A certified copy of the death certificate. 3. A copy of the enrollment form or beneficiary designation form on which the insured named beneficiaries. Section 1: Claimant/Beneficiary Information This information enables us to speed payment to you. Your telephone number(s) help us contact you quickly if any required information has been omitted. Social Security Number In nearly all cases, life insurance benefits are NOT subject to income tax. However, because you will be earning taxable interest under the Control Plus Account program, the Federal government requires us, and all other financial institutions that pay interest, to ask for and obtain your Social Security Number or other Taxpayer Identification Number. If you fail to supply is with your Social Security Number or other Taxpayer Identification Number, the Federal government requires us to withhold a portion of any interest we would otherwise pay you as a deposit against the taxes that may be due. If you are applying for a tax number, please write applied for in the appropriate space. Some persons have been notified by the Internal Revenue Service that they are subject to backup withholding because in the past they did not report all their interest or dividends. If you have been so notified, and the Internal Revenue Service has not written to you stating that you are no longer subject to backup withholding, you must cross out the statement right below your Social Security Number or Taxpayer Identification Number. We may need to contact you for more information if you are not a citizen of the United States and/or you reside in a foreign country. Claims by an Estate or Assignee If this claim is being filed by an Executor or Administrator, he or she must sign the Beneficiary Claim Form and submit certified copies of the appointment papers. Be sure to use the Estate s taxpayer number. Assignment of Benefits If you have assigned all or any portion of the claim to a funeral home for final expenses, please include a copy of that assignment and the itemized bill. If the policy proceeds have been assigned to a bank or other financial institution, the Beneficiary Claim Form must be signed by an authorized representative of that institution. Section 2: Information about the Insured (the Deceased) This information is necessary for purposes of identification. If the insurance coverage was issued within two years of the insured s death, or the death was due to an accident and the Group Policy provided for accidental death benefits, we may ask you for additional information. Section 3: Signature and Certification Please sign the Beneficiary Claim Form in the same manner as you would sign checks. Your signature may be used to verify Control Plus Account checks you write or instructions you give us in the future. You will also be certifying, under penalties of perjury, that your Social Security Number or other Taxpayer Identification Number and backup withholding status are true. *This Claim Form may have been sent before GGL has determined whether any insurance was in force at the time of death, whether any proceeds are payable and to whom any proceeds are payable. GGL retains its rights to make these determinations.

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