Life & Short Term Disability Group Insurance Plans

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1 Life & Short Term Disability Group Insurance Plans for the Trustees of the Pennsylvania Municipal Authorities Association Insurance Fund

2 GROUP INSURANCE PLANS Dear Authority Member: In response to your request for information, it is with a great deal of pleasure that your Association announces through this letter to you, the Group Insurance plans now available because of your membership in the Association. What plans do you have to offer? PLAN I Group Life Insurance Accidental Death, Dismemberment & Loss of Sight Insurance PLAN II PLAN III Group Weekly Disability Income Insurance Group Hospital Indemnity Insurance Your authority may choose from Plan I, Plan II and Plan Ill or any combination of these, and: within Plan I, select any combination of two of the schedules shown within Plan II, select any schedule from the alternatives offered Who is eligible? If you have at least one employee (including board members and solicitors) who customarily work at least 30 hours weekly and have completed three months of service (board members and solicitors do not have to have completed the three months of service), you are eligible to participate in the plan by completing the enclosed Notice of Participation form and paying the employee's cost. If you decide not to include your board members and solicitors (which is your option), you may include them at a later date by furnishing evidence of their insurability satisfactory to the life insurance company. What is the effective date of the insurance? When your Notice of Participation has been approved, your insurance plan will become effective on the first day of the month coincident with or next following the date of acceptance. Your eligible employees will become insured on the same day if they are actually at work or are available for and physically able to perform every duty of their job on that date. s hired after the effective date of your plans will become insured on the 1 st day of the month coincident with or next following the date they complete three months of service, provided that during the pre-eligibility period and thereafter they work at least 30 hours weekly, and are actually at work or are available for and physically able to perform every duty of their job on that date. Under what conditions is an employee's or board member's insurance terminated? If an employee terminated his or her employment, or if a Board Member or Solicitor ceases to be affiliated with an Authority, his or her insurance terminates immediately. Why do the Trustees heartily endorse this plan? Because insurance under this plan: provides insurance coverage at group rates provides needed protection for authority employees, members, solicitors and their families promotes good will among the authority's workforce and reduces labor turnover it improves morale and loyalty there is no age limit for participation

3 Plan I Group Life and Accidental Death, Dismemberment and Loss of Sight Insurance Classification A Amount of Coverage B Amount of Coverage C Amount of Coverage Class Occupation or Position Under thru 74 Age 75 & over Under thru 74 Age 75 & over Under thru 74 Age 75 & Over 1 2 All Occupations or Positions not included in Classes 2, 3 or 4 Asst. Executive Director Asst. Comptroller/ Controller Plant Maintenance Foreman Field Foreman/ Supervisor Superintendent of Plant Plant Operator Asst. Manager Foreman or Supervisory $6,000 $3,900 $3,000 $10,000 $6,500 $5,000 $13,000 $8,450 $6,500 $10,000 $6,500 $5,000 $12,000 $7,800 $6,000 $20,000 $13,000 $10,000 Comptroller/ 3 Controller Office/Business Manager 4 Board Member or Solicitor $12,000 $7,800 $6,000 $18,000 $11,700 $9,000 $25,000 $16,250 $12,500 $5,000 $3,250 $2,500 $5,000 $3,250 $2,500 $6,000 $3,900 $3,000 Reduction in Amounts of Insurance at and 75 shall take place on January 1 st coincident with or next following the s' 70 th and 75 th birthdays. Each Authority may choose either one or a combination of two of the above s. Evidence of Insurability to shall be required for any amounts in excess of $30,000.

4 Plan II Group Weekly Disability Income Insurance Classification B Amount of Weekly Indemnity D Amount of Weekly Indemnity E Amount of Weekly Indemnity Life Classes 1, 2 and 3 (All Occupations or Positions except Board Member or Solicitor) 50% of Basic Weekly Earnings. The Maximum Amount of Weekly Indemnity is $ % of Basic Weekly Earnings. The Maximum Amount of Weekly Indemnity is $ % of Basic Weekly Earnings. The Maximum Amount of Weekly Indemnity is $ Life Class 4 $40.00 $40.00 $40.00 Day Disability Benefits commence when disability results from: Accidental Bodily Injury 1 st 1 st 1 st Sickness or Pregnancy 8 th 8 th 8 th Benefit Weeks No benefits are payable for sickness or injury where Workers' Compensation benefits are payable. "Basic Weekly Earnings" means rate of basic weekly compensation exclusive of bonuses, commissions, overtime or other additional remuneration. APPLICABLE TO SCHEDULE D AND E - CLASSES 1, 2 and 3 In no event will the amount of Weekly Indemnity payable exceed the amount, if any, which when added to the 7/31 π of your primary disability or retirement benefits under the Social Security Act, equals the amount of benefits determined by the applicable formula above. "Social Security Act" means the U.S. Social Security Act of 1935 as in effect on the date of commencement of disability. Plan III Group Hospital Indemnity Insurance Classification Amount of Hospital Indemnity Weekly Benefit Each Insured $ Benefits begin with the 1 st day of hospital confinement due to accident or sickness, and are payable for a maximum of 26 weeks for each disability. (No Benefits are payable for sickness commencing or injury sustained prior to becoming insured for this benefit, or for disabilities for which benefits are payable under Workers' Compensation or similar legislation.)

5 PLAN I LIFE INSURANCE In the event of the employee's death from any cause, the amount of Life Insurance shown in the schedule is payable to the beneficiary the employee selects. This amount will be paid in a lump sun unless the employee elects any of the other settlement options available. If the employee becomes permanently and totally disabled prior to his/her 60 th birthday, his/her insurance will be continued without further cost provided he/she submits satisfactory evidence of such disability. ACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF SIGHT BENEFITS The amount of insurance show in the schedule is payable to the beneficiary if the employee loses his/her life; or to the employee is he/she loses both hands, both feet, sign of both eyes, one hand or one foot and sign of one eye, or one hand and one foot within 90 days after the accident. One-half of the amount of insurance is payable to the employee for loss of one hand, one foot, or sight of one eye. The maximum amount payable for all losses resulting from one accident is shown in the schedule. Benefits are not payable for losses resulting from: a. injuries intentionally self-inflicted while sane, war, bodily or mental infirmity, ptomaines and any kind of poisoning while sane, or bacterial infections; b. flight or travel in any type of aircraft, if i. the employee is the pilot, an officer or member of the crew of the aircraft, or ii. the aircraft is being used for any training purpose, or iii. the aircraft is a military, naval or air force aircraft PLAN II WEEKLY DISABILITY INCOME BENEFITS The amount of Weekly Indemnity benefit show in the schedule is payable if the employee is unable to work because of an accident or a sickness for which benefits are not payable under Workers' Compensation or similar legislation. The employee must be under the care of a licensed medical doctor. The maximum period for which the benefit is payable is also shown in the of Benefits. There is no limit to the number of separate periods of disability for which benefits are payable. However, successive terms of disability due to the same or a related cause and separated by less than two week of full-time work will be considered one period of disability. Benefits are not payable for injuries self-inflicted while sane, or for any disability for which Workers' Compensation is payable. Benefits are payable for certain dismemberment and loss of sight accidents as described in the certificated after he/she becomes insured.

6 PLAN III HOSPITALIZATION INDEMNITY BENEFIT The amount of Weekly Indemnity benefit show in the schedule is payable if the employee is necessarily confined in a hospital as a result of an accident or sickness. The employee must be under the care of a licensed medical doctor. Benefits are not payable for injuries self-inflicted while sane, or for any disability for which Workers' Compensation is payable, or for any disability resulting from an accident or sickness incurred prior to the effective date of the employee's insurance until the employee has gone three months (ending after the effective date of his/her insurance) without treatment for such condition, or until he/she has been continuously insured for this coverage for 12 months. "Hospital" means an institution operating pursuant to law which is engaged in providing organized facilities for the treatment and confinement beyond 24 hours of sick and injured persons, including facilities for diagnosis and which is under the supervision of a staff of physicians and with 24 hour a day nursing service by Registered Nurses. In no other event shall the term include an institution which is primarily a rest home, nursing or convalescent home, or a home for the aged, or which is primarily engaged in the care and treatment of drug addicts or alcoholics. "Confined" means being a resident patient using the room and board facilities of a Hospital but the period of confinement shall not include any part for the last clay of such hospital confinement. FRAUD NOTICE Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

7 Cost Estimate Sheet If two schedules have been selected, add the cost for the appropriate s and put the total under the column headed "Combination s, then multiply by the number of employees shown. Age of PLAN I Group Life and Accidental Death & Dismemberment Insurance (Use rates in each Class applicable to selected) Class 1 employees multiplied by: A B C Under 40 x $ $ $ to 50 x to 55 x to 60 x to 65 x to 70 x to 75 x & over x Age of Total Cost $ Combination s PLAN I Group Life and Accidental Death & Dismemberment Insurance (Use rates in each Class applicable to selected) Class 2 employees multiplied by: A B C Under 40 x $ $ $ to 50 x to 55 x to 60 x to 65 x to 70 x to 75 x & over x Total Cost $ Combination s Total Cost Class 1 Total Cost Class 2

8 Age of PLAN I Group Life and Accidental Death & Dismemberment Insurance (Use rates in each Class applicable to selected) Class 3 employees multiplied by: A B C Under 40 x $ $ $ to 50 x to 55 x to 60 x to 65 x to 70 x to 75 x & over x Age of Total Cost $ Combination s PLAN I Group Life and Accidental Death & Dismemberment Insurance (Use rates in each Class applicable to selected) Class 4 employees multiplied by: A B C Under 40 x $ $ $ to 50 x to 55 x to 60 x to 65 x to 70 x to 75 x & over x Total Cost $ Combination s Total Cost Class 3 Total Cost Class 4 ESTIMATED TOTAL ANNUAL COST FOR PLAN I (Classes ): $

9 PLAN II Group Weekly Disability Income Insurance Class Annual Cost per Multiplied by: s B Classes 1, 2 & 3 x $ Class 4 x $58.85 Annual Cost D Classes 1, 2 & 3 x $ Class 4 x $63.15 E Classes 1, 2 & 3 x $ Class 4 x $63.15 Total Annual Cost $ s PLAN III GROUP HOSPITAL INDEMNITY INSURANCE Multiplied by: Annual Cost per Annual Cost x $29.00 TOTAL COST OF PLAN III ESTIMATED TOTAL ANNUAL COST FOR PLANS I, II & III: $

10 APPLICATION FOR PARTICIPATION Detach and return to: Trustees of the Pennsylvania Municipal Authorities Association Insurance Fund 1000 North Front Street, Suite 401 Wormleysburg, PA We hereby elect to participate in the following Pennsylvania Municipal Authorities Association Insurance plan or plans subject to the terns of the Group Insurance policies issued by the Insurance Company to the Trustees of the Pennsylvania Municipal Authorities Association Insu r ance Fund. PLAN I Group Life and Accidental Death and Dismemberment (Check up to 2 schedules) A B C Each Authority may choose any one or combination of two of the above schedules. PLAN II Group Weekly Disability Income B D E PLAN III Group Hospital Indemnity Income CHOICE OF PLANS - An Authority may choose either Plan I, Plan II or Plan III or any combination of these. Within Plan I, you may select any combination of two of the schedules shown, and within Plan II, select any of the d from the alternates shown. Eligibility The undersigned authority hereby certifies the following: 1. The authority is incorporated in the Commonwealth of Pennsylvania. 2. The authority has at least one eligible employee. 3. The authority shall fund the cost of insurance here applied for. 4. Participation shall include all eligible employees and shall include the following individuals, if checks: Board Member Solicitors Please send enrollment cards (one for each individual to be covered). Any insurance provided under a group policy is governed by the terms of the policy as to the effective date of coverage and the terns of coverage. Existing coverage should be kept in force, until the Authority is accepted for participation. If the Authority is not accepted for the participation requested, any payment made by it will be returned and there will be no further obligation whatsoever to the undersigned in connection therewith. Name Title Date Authority Name Address OTHER INFORMATION It is hereby certified that all of the formalities and requirements prescribed by the Authority Cove or any statute applicable thereto for authorizing the Authority to contract and pay for insurance on its employees (including elected officials) have been duly complied with. Name and Title

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