CONTINUING YOUR GROUP TERM LIFE INSURANCE

Transcription

1 CONTINUING YOUR GROUP TERM LIFE INSURANCE Liberty Life Assurance Company of Boston (Instructions and Application) You may elect to continue your Optional Group Life Insurance, and that of your Dependent Spouse, without evidence of insurability if your insurance ends for any reason, other than retirement and you do not convert any part of the Optional Group Life Insurance which is scheduled to terminate. The effective date of the requested coverage (Portable Group Term Life Insurance) will be 12:01 am standard time on the day after coverage under the group plan ends, provided: you have submitted Liberty's Application for Portable Group Term Life Insurance (form PTL-APP.2) within 31 days of the date you are no longer eligible under your employer's group plan; and Liberty has received the required premium and application fee. SECTION ONE - YOU ARE ELIGIBLE FOR PORTABLE GROUP TERM LIFE INSURANCE IF: You elect Portable Group Term Life Insurance within 31 days of the date your Group Life Insurance terminates. You are under age 70. You are not a full time member of the armed forces of any country. You are a citizen or resident of the United States or Canada. No Group Life Insurance on you will continue with Liberty Life Assurance Company of Boston on a premium paying or premium waiver basis. You have not elected an individual Conversion Insurance policy. SECTION TWO - HOW TO APPLY: EMPLOYER: When you learn that an employee is terminating, complete the section captioned TO BE COMPLETED BY EMPLOYER on the back side of the application and give this form to the employee. EMPLOYEE: 1. Complete the attached application. 2. Be sure the application is signed and dated. Detach the application and attach to it your check made payable to Liberty Life Assurance Company of Boston for the required premium and application fee. 3. The application and check must be received no later than 31 days after termination of your group life insurance by: LIBERTY LIFE ASSURANCE COMPANY OF BOSTON c/o JHA Service Center P.O. Box 7146 Portland, ME PTL- INST.2 (General - Optional Life amount) 1

2 SECTION THREE - SUMMARY OF PORTABLE GROUP TERM LIFE INSURANCE BENEFITS: Employee and Dependent Spouse Amount of Insurance Benefits Maximum & Minimum Amounts Maximum amount of Portable Group Term Life Insurance available to you is equal to the lesser of the amount of Optional Group Life Insurance that terminates, or $500,000. Minimum amount of Portable Group Term Life Insurance is $10,000. The amount of insurance available for your Dependent Spouse is the amount that terminated under the group life insurance plan. Increasing & Decreasing Amounts The amount of Portable Group Term Life Insurance can be decreased at any time. However, once elected, the amount of Portable Group Term Life Insurance on you or your Dependent Spouse can not be increased. Employee and Spouse insurance benefits will reduce to 65% of the inforce amount at age 65. Termination Provisions The Participant (You) will cease to be insured on the earliest of the following dates: the date you fail to pay the required premiums. the date you attain age 70. five (5) years from the effective date of your Portable Group Term Life Insurance the date you are approved for Premium Waiver under the former plan with Liberty. the date you elect an individual Life Insurance Conversion Policy on the amount of insurance that terminated. the date you become a full time member of the armed forces of any country. Your Dependent Spouse will cease to be insured on the earliest of the following dates: the date your Spouse attains age 70. the date the Spouse goes on active duty in the armed forces of any country. the date Group Portable Term Life Insurance coverage ends for you, the Employee. SECTION FOUR - CALCULATING THE PREMIUM DUE: Premium rates per $1,000 Age at Birthday closest to application date Quarterly Mode Annually Mode Less than $.279 $.300 $.330 $.435 $.660 $1.170 $1.833 $2.889 $4.170 $6.954 $1.116 $1.200 $1.320 $1.740 $2.640 $4.680 $7.332 $ $ $ PTL- INST.2 (General - Optional Life amount) 2

3 SECTION FOUR - CALCULATING THE PREMIUM DUE: (Continued) How to calculate your premium EXAMPLE: Quarterly premium for an individual whose birthday is 10/22 and application date is 1/1/99 requesting $50,000 of Portable Group Term Life Insurance coverage. The closest birthday to the application date would be 10/22/98. The applicant uses his/her age on that date. We will use age 35. Premium rate per $1,000 is $.435 $50,000 requested amount divided by 1,000 = x 50 = $21.75; Rates are not guaranteed and may be changed at any time with a 31-day notice. Age banded rates are reviewed and communicated to you on each policy anniversary. Employee Premium Worksheet 1. Determine age at birthday closest to the application date 2. $ Premium rate per $1,000 (from premium rate table stated on page 2, based on your age at time of application and selected payment frequency) 3. $ Amount of insurance requested (item 12 in the Employee section on the application) 4. Divide the amount in item 3 by 1,000 (Example; 10,000 in requested insurance would equal 10) 5. $ Multiply the amount of item 4 by the amount in item 2. (This equals your premium amount for the payment frequency you selected.) If you selected Dependent Spouse coverage, you must do the same type of calculation using your Spouse's information. Dependent Spouse Premium Worksheet 6. Determine age of Dependent Spouse at birthday closest to the application date 7. $ Premium rate per $1,000 (from premium rate table stated on page 2, based on your dependent spouse's age at time of application and your selected payment frequency) 8. $ Amount of insurance requested (item 12 in the Employee section on the application) 9. Divide the amount in item 8 by 1,000 (Example; 10,000 in requested insurance would equal 10) 10. $ Multiply the amount of item 9 by the amount in item 7. Totaling the Premium Worksheet 11. $ Combine the amount in item 5 with the amount in item 10. (This is the premium due for the payment frequency you selected.) 12. $ Add the $25.00 non-refundable application fee to the amount in item $ Please remit this amount when submitting your application. If you have any questions, you may contact the JHA Service Center, Inc. at the following number: PTL- INST.2 (General - Optional Life amount) 3

4 APPLICATION FOR PORTABLE GROUP TERM LIFE INSURANCE Liberty Life Assurance Company of Boston How to Apply: This form completed by the applicant, together with a check made payable to Liberty Life Assurance company of Boston for the first premium must be received within 31 days after termination of group coverage at: LIBERTY LIFE ASSURANCE COMPANY OF BOSTON, c/o JHA Service Center, P.O. Box 7146, Portland, ME TO BE COMPLETED BY APPLICANT I have the right to apply for a Portable Group Life Insurance Certificate under the terms of Group Life Insurance Policy Number: 1. Name (Last, First, Middle Initial) 2. Sex 3. Social Security Number [ ] Male [ ] Female 4. Home Address (Street, City, Street, Zip) 5. Date of Birth [6. Dependent Spouse Name [7. Dependent Spouse Sex [8. SS# and Date of Birth] (Last, First, Middle Initial)] [ ] Male [ ] Female] 9. Date you were no longer eligible for the group life insurance: 10. What was your job with the above Employer? 12. Amount of insurance requested? (Must be less than or equal to the optional coverage terminated under the Group Life plan) Applicant Amount $ [Dependent Amount $ ] 14. Amount of premium submitted with the application? $ (See Instructions, page 3, line 13) 17. Additional Instructions: 15. Primary Beneficiary of the Applicant (See the reverse side of this form) 11. Plan of Insurance PORTABLE GROUP TERM LIFE 13. How will premiums be paid? [ ] Annually [ ] Quarterly 16. Contingent Beneficiary of the Applicant THE STATEMENTS ABOVE ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND I AGREE THAT THEY SHALL FORM A PART OF THE CONTRACT OF INSURANCE APPLIED FOR. I UNDERSTAND THAT ANY PERSON WHO KNOWINGLY OR WITH INTNENT TO INJURE, DEFRAUD OR DECEIVE AN INSURANCE COMPANY, FILES A STATEMENT CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION MAY BE GUILTY OF A CRIMINAL ACT PUNISHABLE UNDER LAW. Signature of Applicant Date Upon approval of this application, a certificate of coverage will be sent directly to you at the address provided. NOTE: Employer MUST complete information required on reverse side. PTL - APP. 2 (General - Optional Life amount)

5 TO BE COMPLETED BY EMPLOYER 1. Employer (Firm Name and Division) 2. Employer s Address (Street, City, Street, Zip) 3. Group Life Policy Number 4. Name of Person Eligible for Portable Group Term Life Insurance 5. Date of Birth (mm/dd/yy) 6. Sex [ ] Male [ ] Female 7. Date Eligibility for Group Life Insurance Ceased* 8. Amount of Optional Group Life Insurance which is terminated 9. Date this Person was first Insured under the Group Life Insurance Policy Applicant Amount $ [Dependent Amount $ ] 10. Reason for Termination of Person s Group Life Insurance [ ] Employment terminated or membership in an eligible class terminated [ ] Class of eligible persons terminated 11. Employer Representative Signature Date: INFORMATION ABOUT BENEFICIARIES The person(s) designated as Beneficiary on the application will receive the amount of insurance upon the death of the Applicant. The Beneficiary for Dependent Spouse coverage is the applicant listed on the reverse side of this form. You may name more than one Primary Beneficiary if you wish. All Primary Beneficiaries who survive the applicant, will share equally in the insurance benefits. You may name more than one Contingent Beneficiary who will receive the benefits if the Primary Beneficiary should die before you. If more than one contingent Beneficiary is named, all Contingent Beneficiaries who survive the Applicant will share equally. When naming Beneficiaries, please follow this example: a. PRIMARY BENEFICIARY: Mary J. Doe, Wife b. CONTINGENT BENEFICIARY: John P. Doe, Son NOTE: If a Beneficiary is a married woman, use her given name, for example Mary J. Doe and not Mrs. John Doe. If a beneficiary is not related to you, use the term no relation and enter the Beneficiary s address in Question 17. NOTE: BOTH SIDES OF THIS APPLICATION MUST BE COMPLETED. PTL - APP. 2 (General - Optional Life amount)