The Prudential Insurance Company of America

Transcription

1 The Prudential Insurance Company of America Record Keeping Services PO Box Philadelphia, PA Dear New Uniformed Firefighter: The City of Chicago is committed to offering a benefits package that continues to meet its employees changing benefits needs. Life insurance is a valuable and important component of the benefits package. This insurance coverage is issued by The Prudential Insurance Company of America (Prudential). For over 95 years, Prudential has provided group life insurance plans that help protect families financial security and peace of mind. As a Uniformed Firefighter of the City of Chicago, you are automatically enrolled for $75,000 of City-paid Term Life Insurance and $5,000 of City-paid Accidental Death & Dismemberment (AD&D) Insurance coverage. These benefits become effective on the first day of the month following your date of hire. You may purchase additional Optional Term Life Insurance coverage up to 10 times your covered annual earnings, to a maximum of $1,500,000, subject to Prudential s underwriting requirements. Coverage may also be available for your spouse and eligible children. As a newly hired employee you are eligible to get the lesser of three times your covered annual earnings, not to exceed $1,000,000 with no medical questions asked when enrolling within 31 days following your date of hire. Any amounts over three times your covered annual earnings, not to exceed $1,000,000, will require proof of good health satisfactory to Prudential. These benefits also become effective on the first day of the month following your date of hire. You may also purchase Long Term Disability Insurance. Your monthly Long Term Disability benefit will be 60% of your monthly pre-disability earnings, up to the maximum of $10,000. Please note: If you decide to enroll in the Optional Term Life and Long Term Disability plans beyond the 31 days of your date of hire, you will be required to provide proof of good health satisfactory to Prudential. We appreciate the opportunity to serve you. If you have any questions or would like more information, please contact our Customer Service Office at We are available Monday through Friday, from 7:00 a.m. to 5:00 p.m., Central time. If you are using a telecommunications device for the hearing impaired (TDD), please call , Monday through Friday, from 7:00 a.m. to 5:00 p.m., Central time. One of our customer service representatives will be glad to help you. Sincerely, Record Keeping Services Group Term Life, Optional Term Life, Accidental Death & Dismemberment, and Long Term Disability Insurance coverages are issued by The Prudential Insurance Company of America, a Prudential Financial company, 751 Broad Street, Newark, NJ The Booklet-Certificate contains all details, including any policy exclusions, limitations, and restrictions, which may apply. Contract Series: Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide

2 City Of Chicago All Employees who are classified as Uniformed Fire Employees All coverages are issued by The Prudential Insurance Company of America. Basic Term Life, Basic Accidental Death & Dismemberment, Optional Term Life, Optional Dependent Term Life and Long Term Disability Coverage Options n Basic Term Life: You are automatically enrolled for $75,000. Basic Term Life - 100% Employer Paid n If you are terminally ill, you can get a partial payment of your group life insurance benefit. You can use this payment as you see fit. The payment to your beneficiary will be reduced by the amount you receive with the Accelerated Benefit Option. Refer to the plan booklet for details. n Coverage will end on your termination of employment or as specified in the plan booklet. You may convert your insurance to an individual life insurance policy issued by the Prudential Insurance Company of America. Basic Accidental Death & Dismemberment - 100% Employer Paid n Basic AD&D pays you and your beneficiary a benefit for the loss of life or other injuries resulting from a covered accident % for loss of life and a lesser percentage for other injuries. Injuries covered may include loss of sight or speech, paralysis, and dismemberment of hands or feet. Basic AD&D benefits are paid regardless of other coverages you may have. n Basic AD&D: You are automatically enrolled for $5,000. n Purchase coverage for 1.0 to 10.0 times your covered annual earnings to a maximum of $1,500,000. Optional Term Life - 100% Employee Paid n n n New Hires: Get the lesser of 3.0 times your covered annual earnings not to exceed $1,000,000 - no medical questions asked - when enrolling within 31 days following your date of hire to be eligible in Optional Group Term Life. Any amounts over 3.0 times your covered annual earnings not to exceed $1,000,000 require proof of good health. Current Participants: Your current coverage amount will be continued. Proof of good health satisfactory to The Prudential Insurance Company of America is required for all increases in coverage amounts. Current Employees who were denied coverage in the past, Current Employees who waived coverage in the past or Late Entrants (did not enroll when first eligible): Evidence of insurability satisfactory to The Prudential Insurance Company of America is required for all coverage amounts. n If terminally ill, you can get a partial payment of your group term life insurance benefit. You can use this payment as you see fit. In the event of your death, your beneficiary will receive a benefit payout which has been reduced by the amount you receive. n Upon termination of employment, you may continue at a certain level of your coverage, without having to provide evidence of good health. n Purchase coverage for your spouse for $10,000, $25,000 or $50,000, not to exceed 100% of your combined Basic Term Life and Optional Term Life coverage amount. n New Hires: Get up to $25,000 for your spouse- no medical questions asked - when enrolling within 31 days following your date of hire to be eligible in Optional Dependent Group Term Life. Spouse / Domestic Partner - Optional Dependent Term Life - 100% Employee Paid n n Current Spouse Participants: Your spouse's current coverage amount will be continued. Proof of good health satisfactory to The Prudential Insurance Company of America is required for all increases in coverage amounts. Current Employees whose spouse has been denied coverage in the past, Current Employees who waived spouse coverage in the past or Late Entrants (did not enroll when first eligible): Evidence of insurability satisfactory to The Prudential Insurance Company of America is required for all coverage amounts. n Upon termination of employment, your spouse (if eligible to port) may choose to continue a coverage amount equal to or lower than your current benefit amount. Coverage amounts for you and your spouse will be subject to a maximum of five times your annual earnings or $1 million, whichever is less. ECEd EXP

3 Child Optional Dependent Term Life - 100% Employee Paid Coverage Options n Purchase coverage for $5,000 or $10,000. There are no health requirements for this coverage. n Coverage begins from live birth, and continues to age 25. n Upon termination of employment, you (if eligible to port) may choose to continue a dependent child coverage amount equal to or lower than your current benefit amount. n Your monthly Long Term Disability benefit will be 60% of your monthly pre-disability earnings, up to the maximum of $10,000, less deductible sources of income. No medical questions asked - if enrolling when first eligible. The minimum monthly benefit is $100. Deductible sources of income may include benefits from statutory plans, Social Security to you and your dependents, workers compensation, unemployment income and other income. n If you meet the definition of disability, your benefits will begin 180 days following an accidental injury or sickness. The benefit duration is up to age 65. However, if you become disabled at or after age 65 benefits are payable according to an age-based schedule. Refer to the Booklet-Certificate for details. n You are considered disabled when, because of injury or sickness, you are under the regular care of a doctor, you are unable to perform the material and substantial duties of your regular occupation and your disability results in a loss of income of at least 20%. After receiving benefits for 24 months, you are considered disabled when, due to the same sickness or injury, you are unable to perform the material and substantial duties of any gainful occupation for which you are reasonably fitted by education, training or experience, and disability results in a loss of income of a specified percentage determined by your plan. Long Term Disability - 100% Employee Paid n Disabilities due to mental illness are limited to 24 months of benefits during your lifetime. Examples of mental illness include schizophrenia, depression, manic depressive or bipolar illness, anxiety, somatization, substance related disorders (including drug and alcohol abuse), and/or adjustment disorders. Disabilities which are primarily based on self-reported symptoms are limited to 36 months of benefits during your lifetime. Examples of self-reported symptoms include headache, pain, fatigue, stiffness, soreness, ringing in the ears, dizziness, numbness and loss of energy. Disabilities due to mental illness and disabilities which are primarily based on self-reported symptoms have a combined limited pay period during your lifetime. n LTD benefits will not be paid for a disability that begins during the first 12 months of coverage and due to a pre-existing condition. A pre-existing condition is an injury or sickness for which you received medical treatment, consultation, diagnostic measures, prescribed drugs or medicines, or for which you followed treatment recommendations during the 90 days prior to your effective date of coverage. n During the first 12 months of part-time work while disabled, you can receive full benefits as long as your combined income and disability benefits do not exceed your monthly pre-disability earnings. n If you die while collecting disability benefits, a lump sum payment may be paid to your eligible survivors. n You are not covered for a disability caused by war or any act of war, declared or undeclared, an intentionally self-inflicted injury, active participation in a riot, and commission of a crime for which you have been convicted. Benefits are not payable for any period of incarceration as a result of a conviction. Benefits, exclusions and provisions may vary by state. Refer to the plan booklet for details. For your coverage to become effective, you must be actively at work on the effective date of the plan. If you apply for an amount that requires satisfactory evidence of insurability to The Prudential Insurance Company of America, you must be actively at work on the date of approval for the amount requiring satisfactory evidence of insurability.

4 R A T E S H E E T City of Chicago Issued by The Prudential Insurance Company of America Rates Effective: January 1, 2015 Optional Term Life* (Employee) Age (Initial rates based on age as of effective date of your coverage. Rates will change based on the following age schedule.) Monthly Cost of Insurance (Rates per $1,000 of Coverage) For Employee Under 25 $ $ $ $ $ $ $ $ $ $ $ Follow this worksheet to determine your semi-monthly cost of insurance. Refer to the attached Rate Sheet to find the monthly rate per $1,000 of coverage based on your age. Steps to Determine Cost of Insurance 1. Select desired amount of coverage. (Coverage is available for one, two, three, four, five, six, seven, eight, nine or ten times your covered annual earnings, not to exceed $1,500,000. Refer to the Optional Term Life section for evidence of insurability details.) 2. Locate your age on the Rate Sheet and note the corresponding monthly rate. 3. Divide your selected amount of coverage by $1,000. Then multiply the result by the monthly rate for your age. The answer is your monthly cost of insurance. Worksheet $ The monthly rate per $1,000 is $ $ divided by $1,000 = $ $ multiplied by $ = $ Total Monthly Cost of Insurance = $ Cost of insurance for all coverages, which are deducted from your paycheck, may increase or decrease in the future based upon the claims experience of participants. All provisions that apply to these coverages are governed by the Certificate. Rates may be subject to change.

5 R A T E S H E E T City of Chicago Issued by The Prudential Insurance Company of America Rates Effective: January 1, 2015 Optional Dependent Term Life* (Spouse/Domestic Partner)* $10,000 $25,000 $50,000 Age < 24 $0.42 $1.05 $ $0.51 $1.28 $ $0.68 $1.70 $ $0.76 $1.90 $ $0.85 $2.13 $ $1.27 $3.18 $ $1.95 $4.88 $ $3.64 $9.10 $ $5.58 $13.95 $ $10.74 $26.85 $ $17.43 $43.58 $87.15 Spouse/Domestic Partner Rate is based on Employee s Age Optional Dependent Term Life* (Child(ren) - Regardless of the number of children) Coverage Amount Monthly Cost of Insurance $ 5,000 $ 0.29 $10,000 $ 0.57 *This is optional coverage and the entire cost of coverage is employee paid. Cost of insurance for all coverages, which are deducted from your paycheck, may increase or decrease in the future based upon the claims experience of participants. All provisions that apply to these coverages are governed by the Certificate. Rates may be subject to change.

6 R A T E S H E E T City of Chicago Issued by The Prudential Insurance Company of America Rates Effective: January 1, 2015 Voluntary Long Term Disability Employee s Age (Initial rates based on age as of effective date of your coverage. Rates will change based on the following age schedule.) Employee s Rate < 29 $ $ $ $ $ $ $ $ $ $ 1.51 Voluntary Long Term Disability 1. Indicate your monthly earnings. = $ 2. If your monthly earnings are greater than the maximum monthly covered earnings of $16.667, indicate $16,667. Otherwise, indicate the amount from Step Multiply the amount in Step 2 by the rate for your age from the chart above and divide by 100 to obtain your Total LTD Monthly Cost. = $ = $ *This is optional coverage and the entire cost of coverage is employee paid. Cost of insurance for all coverages, which are deducted from your paycheck, may increase or decrease in the future based upon the claims experience of participants. All provisions that apply to this coverage are governed by the Certificate. Rates may be subject to change.

7 Enrollment Form - City Of Chicago Page 1 of 3 The Prudential Insurance Company of America 751 Broad Street, Newark, New Jersey General Information (Employee) Effective Date of Coverage (for office use only) / / Last Name First Name Middle Initial Phone Address City State Zip Code Social Security No. Date Employed Month Day Year Single Divorced Marital Status Married Widowed Your Annual Earnings Date of Birth Month Day Year / / (For Prudential Use Only) / / $ Control # Basic Term Life and Accidental Death & Dismemberment (AD&D) City Of Chicago offers you Basic Term Life and AD&D Insurance coverages at no cost to you. You will automatically be enrolled in these plans. Optional Term Life If you are a new hire, you can elect the lesser of 3.0 times your covered annual earnings to a maximum of $1,000,000 without evidence of insurability. If you are a current employee, refer to plan details above to determine the amount of coverage you can enroll in without evidence of insurability. 1 Times your cover annual earnings: $ Payroll deduction: $ 2 Times your cover annual earnings: $ 3 Times your cover annual earnings: $ 4 Times your cover annual earnings: $ 5 Times your cover annual earnings: $ 6 Times your cover annual earnings: $ 7 Times your cover annual earnings: $ 8 Times your cover annual earnings: $ 9 Times your cover annual earnings: $ 10 Times your cover annual earnings: $ No coverage chosen Optional Dependent Term Life You must be enrolled for Optional Term Life to elect coverage for your dependents. Spouse coverage cannot exceed 100% of your Optional Term Life coverage amount. Spouse/Same and Opposite Sex Domestic Partner Children Coverage amount chosen: $ 10,000 Coverage amount chosen: $ 5,000 Coverage amount chosen: $ 25,000 Coverage amount chosen: $ 10,000 Coverage amount chosen: $ 50,000 Payroll deduction: $ Payroll deduction: $ No coverage chosen No coverage chosen Long Term Disability I wish to enroll for the Long Term Disability insurance coverage. Payroll deduction: $ I authorize my employer to deduct contributions for the cost of the plan from my earnings. No Long Term Disability insurance coverage chosen. I understand that in the event I desire such insurance at a later date, I will be required to furnish medical evidence of insurability at my own expense, and the insurance company will have the right to refuse my request. GL

8 Enrollment Form - City Of Chicago Page 2 of 3 Employee General Information Last Name First Name Middle Initial Social Security No. Acceptance or Waiver of Coverage I am enrolling for coverage and I authorize City of Chicago to deduct from my earnings until further notice my contributions for insurance under a contract issued by The Prudential Insurance Company of America. I understand that if I desire to increase the amount of my insurance or add dependent coverage hereafter, I may be required to furnish evidence of insurability for myself and/or my dependents. To the best of my knowledge and belief, I declare the statement above is true and understand it is the basis for determining the contribution for coverage. I also understand that for coverage to become effective, I must be actively at work during the enrollment period and on the effective date of the plan. If I apply for an amount that requires evidence of insurability satisfactory to The Prudential Insurance Company of America, I must be actively at work on the date of approval for the amount requiring satisfactory evidence of insurability. I do not wish to enroll for any of the above optional coverages. I certify that I have been given the opportunity by my above named employer to enroll for coverage. I understand that if I desire to enroll hereafter, I may be required to furnish satisfactory evidence of insurability to The Prudential Insurance Company of America for myself and/or my dependents. FOR RESIDENTS OF ALL STATES EXCEPT ALABAMA, DISTRICT OF COLUMBIA, FLORIDA, KENTUCKY, MARYLAND, NEW JERSEY, NEW YORK, PENNSYLVANIA, PUERTO RICO, RHODE ISLAND, UTAH, VERMONT, VIRGINIA AND WASHINGTON; WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided b y the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. ALABAMA RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. DISTRICT OF COLUMBIA and RHODE ISLAND RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. KENTUCKY RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. MARYLAND RESIDENTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW JERSEY RESIDENTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. PENNSYLVANIA AND UTAH RESIDENTS: 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 material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. PUERTO RICO RESIDENTS: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. VERMONT RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. VIRGINIA RESIDENTS: Any person, who with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law. WASHINGTON RESIDENTS: Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits. GL

9 Enrollment Form - City Of Chicago Page 3 of 3 Employee General Information Last Name First Name Middle Initial Social Security No. FLORIDA RESIDENTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony of the third degree. NEW YORK RESIDENTS: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. This warning ONLY applies to accident and disability coverage. Employee Signature Date (Month/Day/Year) / _/_ FOR INSUREDS WHO RESIDE IN MICHIGAN OR MINNESOTA ONLY If you wish to enroll your spouse, domestic partner, and/or eligible child 18 years of age or older for Dependent Life and/or Accidental Death and Dismemberment Insurance coverage, your spouse, domestic partner, and/or each of your eligible children age 18 years or older must consent to such coverage by signing and dating this consent in the appropriate space(s) below. Spouse or Domestic Partner Signature Date (Month/Day/Year) / / Child Signature Date (Month/Day/Year) / / Child Signature Date (Month/Day/Year) / / You must also complete a separate beneficiary designation form. A Receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. Please contact your personal tax advisor for further information. There is no administrative fee to accelerate death benefits. The accelerated amount is not discounted. Important: Mail completed Enrollment Form, including the Beneficiary Designation Form to: Prudential, P.O. Box Philadelphia, PA Group Life, Accidental Death and Dismemberment and Disability coverages are issued by The Prudential Insurance Company of America, a New Jersey company, 751 Broad Street, Newark, NJ Life Claims: and Disability Support Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet- Certificate/Group Contract issued by Prudential, the terms of the certificate will govern. Contract provisions may vary by state. California COA #1179, NAIC# Contract Series: Prudential Financial, Inc., and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. GL

10 IMPORTANT INFORMATION ABOUT BENEFICIARY DESIGNATIONS Use this form to designate or make changes to the beneficiary(ies) of your Group Insurance death proceeds. The information on this form will replace any prior beneficiary designation. You may name anyone or any entity as your beneficiary and you may change your beneficiary at any time by completing a new Group Insurance Beneficiary Designation/Change form. Common designations include individuals, estates, corporation/organizations and trusts. Payment will be made to the named beneficiary. If there is no named beneficiary, or the named beneficiary predeceased the insured, settlement will be made in accordance with the terms of your Group Contract. DEFINITIONS You may find the following definitions helpful in completing this form: Primary Beneficiary(ies) - the person(s) or entity you choose to receive your life insurance proceeds. Payment will be made in equal shares unless otherwise specified. In the event that a designated primary beneficiary predeceases the insured, the proceeds will be paid to the remaining primary beneficiaries in equal shares or all to the sole remaining primary beneficiary. Contingent Beneficiary(ies) - the person(s) or entity you choose to receive your life insurance proceeds if the primary beneficiary(ies) die (or the entity dissolves) before you die. Payment will be made in equal shares unless oth erwise specified. In the event that a designated contingent beneficiary predeceases the insured, the proceeds will be paid to the remaining contingent beneficiaries in equal shares or all to the sole remaining contingent beneficiary. INSTRUCTIONS FOR DESIGNATING A PRIMARY OR CONTINGENT BENEFICIARY 1. EMPLOYEE INFORMATION All information in this section is required. Unless otherwise indicated in Section 1, the information supplied on the form will apply to ALL coverages offered under the employer s group plan. Unless otherwise indicated in Section 2, the information supplied on the form will apply to all the Group Life coverage(s) issued by The Prudential Insurance Company of America to the group contract holder. 2. BENEFICIARY DESIGNATION You may name more than one primary and more than one contingent beneficiary. This form allows you to name up to four primary and four contingent beneficiaries. If you need additional space, please attach a separate sheet of paper. Please indicate the percentage share designated to each primary beneficiary. The total for all primary beneficiaries must equal 100%. If no percentages are specified, the proceeds will be split evenly among those named. Payment will be made to the named beneficiary. If there is no named beneficiary, or the named beneficiary predeceased the insured, settlement will be made in accordance with the terms of your Group Contract. If designating percentages for contingent beneficiaries, the percentage for all contingent beneficiaries must also equal 100%. You can name an individual, corporation/organization, trust, or an estate as a beneficiary. The following examples may be helpful in designating beneficiaries: Individual: Mary A. Doe Each name should be listed as first name, middle initial, last name ( Mary A. Doe, not Mrs. M. Doe ) Include the address, relationship and Date of Birth for each individual listed. Indicate the percentage to be assigned to each individual. Estate: Estate of the Insured Select Other as the Beneficiary Description and write Estate in the blank space provided. Indicate the percentage to be assigned to the Estate of the Insured. Corporation/Organization: ABC Charitable Organization Select Corporation/Organization as the Beneficiary Description. Write the legal name of the corporation or organization in the space for the Beneficiary s First Name. You must provide the address, city and state of operation for each organization or corporation listed. Indicate the percentage to be assigned to the corporation or organization. Trust: The John Doe Trust. A Trust with a trust agreement dated 1/1/99 whose Trustee is Jane Smith. Select Trust as the Beneficiary Description. Indicate the percentage to be assigned to the trust. Complete Section 3, Trust Designation. 3. TRUST DESIGNATION Complete this section if you have named a trust as a primary or contingent beneficiary in Section 2. Fill in the name and address for each trustee. Fill in the title and date of the Trust Agreement in the space provided. 4. AUTHORIZATION/SIGNATURE The employee must read, sign and date the authorization. Submit the completed form to your Benefits Administrator or Human Resources (as directed by your employer) and keep a copy for your records. GL Ed. 11/2014 Page 1 of 3

11 Group Insurance Beneficiary Designation/Change 1. EMPLOYEE INFORMATION (please print) Last Name First Name MI Employee ID # (if applicable) Marital Status (check one) Married Widowed Gender (check one) Has this insurance been assigned? Single Divorced Male Female Yes No Address City State ZIP Code Daytime Phone Home Phone Date of Birth Date of Hire Date of Retirement (if applicable) Name of Employer/Group Policyholder Group No This Beneficiary Designation/Change form applies to: Select all that applies City Of Chicago Basic Term Life Accidental Death & Dismemberment Optional Term Life 2. BENEFICIARY DESIGNATION: I hereby revoke any previous designations of primary beneficiary(ies) and contingent beneficiary(ies), if any, and in the event of my death, designate the following: A. Primary Beneficiaries Beneficiary Description (check one) First Name MI Last Name Address (include city, state, Relationship Date of Birth SSN/Tax ID Phone % Share ZIP) Number TOTAL: (must equal 100) B. Contingent Beneficiaries Beneficiary Description (check one) First Name MI Last Name Address (include city, state, ZIP) Relationship Date of Birth SSN/Tax ID Number Phone TOTAL: (must equal 100) % Share 3. TRUST DESIGNATION - COMPLETE IF A TRUST HAS BEEN NAMED AS A BENEFICIARY IN SECTION 2 Trustee s Name (First, MI, Last) Address (include city, state, ZIP) And successor(s) in trust, as Trustee(s) under dated as amended and executed by me and said Trustee. Title of Agreement Date of Agreement GL Ed. 11/2014 Page 2 of 3

12 Group Insurance Beneficiary Designation/Change 4. AUTHORIZATION/SIGNATURE I authorize my plan administrator to record and consider the individuals/institutions that I have named on this form as beneficiaries for benefits under the applicable employee benefit plans. If designating a trust as a beneficiary, I understand Prudential assumes no obligation as to the validity or sufficiency of any executed Trust Agreement and does not pass on its legality. In making payment to any Trustee(s), Prudential has the right to assume that the Trustee(s) is acting in a fiduciary capacity until notice to the contrary is received by Prudential at its Group Life Claim office. I agree that if Prudential makes any payment(s) to the Trustee(s) before notice is received, Prudential will not make payment(s) again. Employee s Signature X The employee must sign and date this form. The signature date must be the date the employee actually signed the form. Date Important Mail completed Beneficiary Designation Form to: Prudential Prudential, P.O. Box Philadelphia, PA Group Life and Accidental Death and Dismemberment coverages are issued by The Prudential Insurance Company of America, a New Jersey company, 751 Broad Street, Newark, NJ Life Claims: and Disability Support Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet- Certificate/Group Contract issued by Prudential, the terms of the certificate will govern. Contract provisions may vary by state. California COA #1179, NAIC# Contract Series: Prudential Financial, Inc., and its related entities.. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. GL Ed. 6/2014 Page 3 of 3