The D.C. Long Term Disability Insurance Plan Exclusively for NBAC members Issued by The Prudential Insurance Company of America (Prudential)

Transcription

1 Plan Basis The D.C. Long Term Disability Insurane Plan Exlusively for NBAC members Issued by The Prudential Insurane Company of Ameria (Prudential) What does it over? The D.C. Long Term Disability Insurane Plan pays you a ash benefit eah month for a overed disability. You an use your benefits to help pay day-to-day living expenses and bills while you are unable to pratie. While disability insurane is important for all working adults, it may be more so for you, due to the physial nature of hiroprati. Who is eligible? This plan was speifially designed for members of the National Business Assoiation for Chiroprators (NBAC). (If you re not urrently a member, you may sign up for membership on the Payment Information Form.) As a member, you are eligible to apply if you are under age 60, working at least 30 hours per week and reside in the U.S. What benefit amount an I reeive eah month? The D.C. Long Term Disability Insurane Plan offers monthly benefit amounts from $500 to $7,500. Your benefit payable will be adjusted by other disability benefits you reeive inluding Soial Seurity, other group plans and individual insurane. The enlosed hart makes it easy to see what total amount you an apply for, based on your inome. On the first renewal date after you reah age 60, the maximum monthly benefit amount will be dereased to $2,000. (Your premium will be adjusted aordingly.) Please note that benefits reeived under this plan may be taxable. Consult your personal finanial planner or tax advisor for more information. How long will I reeive benefits? While some disabilities may last only a few weeks, others may last months, or even years. For a disability ourring prior to age 63, your D.C. Long Term Disability Insurane Plan benefits are payable up to age 65. For a disability ourring at ages 63 or 64, benefits are payable up to 24 months. Do I have to be unable to work in any oupation to reeive disability benefits? The D.C. Long Term Disability Insurane Plan supports your hosen profession as a D.C. You will reeive benefits for two years if you are unable to pratie hiroprati due to your disability. If you remain disabled after two years, you will reeive benefits if you annot perform the duties of any oupation for whih you are qualified. How does this plan meet the unique needs of D.C.s? It s inreasingly diffiult for D.C.s to find a disability program that overs hiroprators, not to mention one reated speifially for the profession like this one. Here s why you should onsider the D.C. Long Term Disability Insurane Plan: b NBAC and NCMIC Insurane Servies fully support hiroprati. b Some disability poliies treat eletive are suh as hiroprati are as evidene of a pre-existing ondition, and will exlude overage for related issues for a ertain length of time. With the D.C. Long Term Disability Insurane Plan, routine preventative/wellness are by a liensed D.C. IS NOT onsidered a pre-existing ondition, as long as that are was not intended to treat an existing ondition. This is a signifiant item we fought for beause we understand the importane of regular hiroprati are. b When you all with questions about your plan, NCMIC Insurane Servies will be here to help, as the exlusive agent for this NBAC plan. The NCMIC family of ompanies has proudly served D.C.s sine We know hiroprati and will give you the personalized servie you deserve

2 Can I ollet benefits if I am disabled but still working? Yes. We understand that your disability may only allow you to work part-time. In that ase, you an still reeive a portion of your monthly benefit amount as long as your disability results in a monthly inome loss of at least 20%. How soon will I ollet monthly benefits? You hoose how soon you reeive monthly benefits after 90 or 180 days of ontinuous disability. (This is alled the Elimination Period.) Before deiding, onsider your personal finanes and how long you an over your bills without your inome. Will my premiums be waived? Yes. If you beome disabled, you shouldn t have to worry about paying another bill. While you are reeiving disability benefits, the premiums for your D.C. Long Term Disability Insurane Plan will be waived. When will my protetion start? Your overage under the D.C. Long Term Disability Insurane Plan will begin on the first day of the month after you have been approved and have paid the first premium, as long as you are working at least 30 hours a week. (If you are not working at least 30 hours a week, overage will start the first of the month after you resume working 30 hours a week.) How long will my overage ontinue? Your D.C. Long Term Disability Insurane Plan will ontinue as long as: the Group Contrat or plan is ative, you retain ative membership in NBAC, you ontinue to be eligible, you have not reahed your renewal after attainment of age 65, you ontinue working at least 30 hours per week, you have not retired, you pay the premiums and you do not begin ative duty in the armed fores of any ountry. Can I get this plan anywhere else? No. You annot get this plan from your loal agent. It is only available through NCMIC Insurane Servies, the exlusive agent. The ontrat holder is NBAC. What if the plan is not what I expeted? The D.C. Long Term Disability Insurane Plan omes with a satisfation guarantee. One you reeive your Certifiate of Coverage, read it over arefully. If the plan does not meet your expetations, return it within 30 days of reeipt. Any premiums paid will be refunded to you. How do I apply? It is easy to apply. Complete the Request for Coverage and Payment Information Form. Return both forms to NCMIC Insurane Servies by mail, fax or . Valuable Extras The D.C. Long Term Disability Insurane Plan also inludes the following benefits and features Survivor Benefit Your spouse will reeive a benefit equal to 6 months of disability payments if you die after you were disabled for at least 90 days and you were reeiving or eligible to reeive benefits under the plan. (If your spouse is no longer living, this Survivor Benefit will be paid to your hildren under the age of 25.) Continuous Disability Benefit If your disability stops for 30 onseutive days or less during your Elimination Period, you will not have to start the Elimination Period over if the disability starts again. (The days that you were not disabled do not ount toward your Elimination Period.) Reurrent Disability Benefit Too often, disabilities are reurring. If this happens to you, we want to make sure you reeive monthly benefits as soon as possible. You will not be required to satisfy another Elimination Period before reeiving benefits, as long as you were ontinuously insured under the plan and the reurring disability ours within 6 months of the end of your prior laim. Catastrophi Disability Benefit If you suffer a atastrophi disability, you may be eligible to reeive an additional 20% of your monthly benefit amount.* Extension of Benefits Feature You may qualify to reeive benefits for an additional 5 years in the event of a atastrophi disability.* Worksite Modifiation Benefits Changes to your workplae may be neessary to help you return to work. Prudential will work with your employer to failitate any hanges, and will reimburse them up to $1,000. Rehabilitation Servies You may qualify for a rehabilitation program paid for by Prudential. Program servies vary; eah one will be geared to your individual needs and designed to help you return to work.

3 Important Information * Catastrophi disability benefits are based on your inability to perform two of the six Ativities of Daily Living as defined in and aording to the terms of the Certifiate of Coverage. Pre-Existing Condition Any disability for whih you reeived medial treatment, onsultation, are or servies, inluding diagnosti measures, or took presribed drugs or mediines, or followed treatment reommendation in the 12 months just prior to your effetive date of overage would not be overed for the first 24 months of overage. Disabilities not overed The D.C. Long Term Disability Insurane Plan does not over any disabilities aused by, ontributed to by, or resulting from your: Intentionally self-inflited injuries; ative partiipation in a riot; or ommission of a rime for whih you have been onvited under state, provinial or federal law; or pre-existing ondition or a Speified Condition. This plan does not over disabilities due to war, delared or undelared, or any at of war; or your pregnany. (This does not inlude a ompliation of pregnany.) Limitations Disabilities due to a sikness or injury whih are primarily based on self-reported symptoms and disabilities due in whole or in part to mental illness have a limited pay period, as desribed in the Certifiate of Coverage. All overage is subjet to Prudential s approval of satisfatory evidene of insurability. Group Life and Disability Inome Medial Underwriting Notie Thank you for hoosing The Prudential Insurane Company of Ameria (Prudential) for your insurane needs. Before we an issue overage we must review your appliation/ enrollment form. To do this, we need to ollet and evaluate personal information about you. This notie is being provided to inform you of ertain praties Prudential engages in, and your rights, with regard to your personal information. We would like you to know that: personal information may be olleted from persons other than yourself or other individuals, if appliable, proposed for overage; this personal information as well as other personal or privileged information subsequently olleted by us may, in ertain irumstanes, be dislosed to third parties without authorization; you have a right of aess and orretion with respet to personal information we ollet about you; and upon request from you, we will provide you with a more detailed notie of our information praties and your rights with respet to suh information. Should you wish to reeive this notie, please ontat: The Prudential Insurane Company of Ameria, Group Medial Underwriting, P.O. Box 8796, Philadelphia, PA Information regarding your insurability will be treated as onfidential. We may, however, make a brief report thereon to MIB, In., a not-for-profit membership organization of insurane ompanies, whih operates an information exhange on behalf of its members. If you apply to another MIB member ompany for life, disability, or health insurane overage, or a laim for benefits is submitted to suh a ompany, MIB, upon request, will supply suh ompany with the information about you in its file. In addition, upon reeipt of a request from you, MIB will arrange dislosure of any information in your file. Please ontat MIB at If you question the auray of the information in MIB s file, you may ontat MIB and seek a orretion in aordane with the proedures set forth in the Federal Fair Credit Reporting At. The address of MIB s information offie is 50 Braintree Hill Park, Suite 400, Braintree, Massahusetts Information for onsumers about MIB may be obtained on its website at This poliy provides disability inome insurane only. It does NOT provide basi hospital, basi medial or major medial insurane as defined by the New York State Insurane Department. North Carolina Residents: THIS IS NOT A MEDICARE SUPPLEMENT PLAN. If you are eligible for Mediare, review the Guide to Health Insurane for People with Mediare, whih is available from the ompany. Coverage under the D.C. Long Term Disability Insurane Plan is issued by The Prudential Insurane Company of Ameria, 751 Broad Street, Newark, NJ Please refer to your ertifiate for Plan details, inluding any exlusions, limitations and restritions whih may apply. Contrat series This plan is not available in all states. Insurane Servies Prudential, the Prudential logo and the Rok symbol are servie marks of Prudential Finanial, In. and its related entities, registered in many jurisditions worldwide. Questions? We re happy to help. Call , ext NIS NFL 8633-E/F

4 D.C. Long Term Disability Insurane Plan Quarterly Group Premiums Ages Seleting your Monthly Benefit Amount Benefit amounts from $500 to $7,500 are available. Be ertain to hoose an amount that, when ombined with any other group or individual disability insurane you have, is not more than 60% of your monthly earnings at enrollment. Monthly earnings at enrollment means: Your average gross monthly inome as reported on your IRS federal inome tax returns for the two year period just prior to your date of enrollment. It inludes salary, profits, fees, ommissions, bonuses, and other ompensation for professional servies. It does not inlude investment returns, rent, royalties or other like inome not diretly produed by your oupation. Earnings are determined after dedution of normal business expenses and losses, but before dedution of any inome taxes. Multiply your monthly earnings by 12 for your annual inome. For example, if your monthly earnings are $4,000, your annual inome is $48,000. As listed on the hart below, the inome range of $45,001 $50,000 has a maximum monthly benefit amount of $2,250. Please note: The monthly benefit amount may be redued by other dedutible soures of inome you qualify for, suh as Soial Seurity, Workers Compensation, retirement benefits and other disability inome benefits. The quarterly premiums below are for ages only. (For premiums for other ages, ontat NCMIC Insurane Servies.) Write your requested monthly benefit amount on the Request for Coverage Form. Annual Inome Range Monthly Benefit Amount $10,001 $15,000 $500 $15,001 $20,000 $750 $20,001 $25,000 $1,000 $25,001 $30,000 $1,250 $30,001 $35,000 $1,500 $35,001 $40,000 $1,750 $40,001 $45,000 $2,000 $45,001 $50,000 $2,250 $50,001 $55,000 $2,500 $55,001 $60,000 $2,750 $60,001 $65,000 $3,000 $65,001 $70,000 $3,250 $70,001 $75,000 $3,500 $75,001 $80,000 $3,750 $80,001 $85,000 $4,000 $85,001 $90,000 $4,250 $90,001 $95,000 $4,500 $95,001 $100,000 $4,750 $100,001 $110,000 $5,000 $110,001 $120,000 $5,500 $120,001 $130,000 $6,000 $130,001 $140,000 $6,500 $140,001 $150,000 $7,000 $150,001 or more $7,500 Quarterly Premium for Ages Elimination Period 90 Days 180 Days $33.75 $50.75 $67.50 $84.50 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $28.75 $43.25 $57.50 $72.00 $86.25 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Choosing the right amount of disability overage is important. We reommend you onsult with your tax advisor or finanial planner for assistane. Premiums may hange on any renewal date or if you request a overage hange. Premiums will also inrease on the renewal date ourring on or next following the date you move to a higher attained age premium band. On the first renewal date after you reah age 60, your monthly benefit amount will be dereased to a maximum of $2,000. (Your premium will be adjusted aordingly.) Questions? Call , ext Coverage under the D.C. Long Term Disability Insurane Plan is issued by The Prudential Insurane Company of Ameria, a Prudential Finanial Company, 751 Broad Street, Newark, NJ The Booklet-Certifiate ontains all details, inluding any poliy exlusions, limitations and restritions whih may apply. Contrat series This plan is not available in all states. This poliy provides disability inome insurane only. It does NOT provide basi hospital, basi medial or major medial insurane as defined by the New York State Insurane Department. North Carolina Residents: THIS IS NOT A MEDICARE SUPPLEMENT PLAN. If you are eligible for Mediare, review the Guide to Health Insurane for People with Mediare, whih is available from the ompany NIS NFL

5 Contrat Holder: CN NIS NFL 8640-E/F D.C. Long Term Disability Insurane Request for Coverage Form Return this ompleted form with the Payment Information Form to: NCMIC Insurane Servies University Avenue Clive, IA Phone: , ext Fax: Please print all answers using blak ink. Tell us about yourself: First Name: MI: Last: Street: Apt: City: State: ZIP ode: Date of Birth (mm/dd/yyyy): Soial Seurity Number: Daytime Telephone Number: Sex: Height: Weight: Fax Number: * Male * Female 0ft. 00 in. 000 lbs Address: 2. My annual earned inome for the 12 months immediately preeding the date of this request form is: $. (Annual earned inome inludes salary, profits, fees, ommissions, bonuses, and other ompensation for professional servies. It does not inlude investment returns, rent, royalties or other like inome not diretly produed by your oupation. Earnings are determined after dedution of normal business expenses and losses, but before dedution of any inome taxes.) Selet your overage options: Monthly Benefit Applied for: $ per month. Monthly benefit amounts available are $500 to $7,500, not to exeed 60% of your monthly earned inome when ombined with all other individual or group disability insurane. To determine this amount, see the enlosed insert. Elimination Period: (Choose one.) 90-day 180-day Other Coverage: Do you now have or are you now applying for other disability insurane whih provides benefits if you are unable to work beause of disability?... Yes* No * If you answered Yes please provide full details below. (Attah a sheet of paper if additional spae is needed.) Company Plan Monthly Benefit Benefit Period Elimination Period GL IA Coverage issued by The Prudential Insurane Company of Ameria Ed. 06/2006 Page 1 of 3

6 3. Please answer the following: Yes No 1. Are you urrently performing all the duties of your job for the number of hours required (at least 30 hours per week)? If no, please explain:. 2. Within the last five years, have you been evaluated for, medially treated for, diagnosed with, taken mediations for, or experiened symptoms of any of the following onditions: a. Disease or disorder of the heart, blood or irulatory system b. High blood pressure. Caner or tumors d. Lung, respiratory or breathing disorders e. Diabetes f. Liver or kidney disorders g. Gastrointestinal, stomah or intestine disorders, inluding ulers or gallstones h. Mental or nervous illness or disorder, aloholism or drug addition i. Chroni pain or fatigue syndromes j. Neurologial disorders suh as Multiple Slerosis or Parkinson s Disease k. Musuloskeletal disorders inluding arthritis, fratures, or arpal tunnel syndrome l. HIV, Aquired Immune Defiieny Syndrome (AIDS) or AIDS-Related Complex (ARC) or any other immune defiieny disorder (suh as Lupus)? 3. Within the last five years, have you been in a hospital or other institution for observation, rest, diagnosis or treatment? 4. Within the last five years, have you been attended by a dotor or liensed pratitioner for anything other than a routine physial? 5. Do you have any known symptoms, physial or mental impairments not mentioned in the previous questions? 6. Are you taking any mediation or being treated for any ondition, inluding pregnany, or disease not mentioned in the previous questions? If you answered Yes to any of questions 2-6, please provide full details below. (Attah a sheet of paper if additional spae is needed.) Question Number Date of Illness Date of Full Reovery Details of nature of illness, number of attaks, duration, severity, treatments and mediations presribed and taken Names, omplete addresses and phone numbers of physiians Primary Care Physiian Information: Name: Address: Date last seen: / / Telephone: Your signature and date are required on Page 3. GL IA Coverage issued by The Prudential Insurane Company of Ameria Ed. 06/2006 Page 2 of 3

7 4. Please read, sign and date: AUTHORIZATION For the Release of Information. This authorization is intended to omply with the HIPAA Privay Rule. I authorize any health plan, physiian, health are professional, hospital, lini, laboratory, medial faility, or other health are provider that has provided payment, treatment, or servies to me or on my behalf within the past 5 years ( My Providers ) to dislose the entire medial reord and any other health information onerning me to The Prudential Insurane Company of Ameria ( Prudential ) and through it, to its reinsurers, authorized agents, and the MIB, In.. This inludes information on the diagnosis or treatment of Human Immunodefiieny Virus (HIV) infetion (In Vermont, this information is exluded) and sexually transmitted diseases. This also inludes information on the diagnosis and treatment of mental illness and the use of alohol and/or drugs, but exludes psyhotherapy notes. I also authorize the MIB, In. to release any data it may have about me to Prudential. By my signature below, I aknowledge that any agreements I have made to restrit my health information do not apply to this Authorization and I instrut My Providers to release and dislose the entire medial reord for me without restrition. This health information is to be dislosed under this Authorization so that Prudential may: 1) underwrite an appliation for overage and make risk determinations; 2) obtain reinsurane; 3) administer laims and determine or fulfill responsibility for overage and provision of benefits; 4) administer overage; and 5) ondut other legally permissible ativities that relate to any overage I have or have applied for with Prudential. This Authorization shall remain in fore for 24 months following the date of my signature below, and a opy of this Authorization is as valid as the original. I understand that I have the right to revoke this Authorization in writing, at any time, by sending a signed request for revoation to The Prudential Insurane Company of Ameria, Group Medial Underwriting, P. O. Box 8796, Philadelphia, PA 19176, Attention: Senior Medial Underwriting Consultant. I understand that a revoation is not effetive to the extent that Prudential has relied on this Authorization or to the extent that Prudential has a legal right to ontest a laim under insurane overage or to ontest the overage itself. I understand that any information that is dislosed pursuant to this Authorization may be redislosed and no longer overed by federal rules governing privay and onfidentiality of health information. (In Montana only: I may request a reord of any subsequent dislosures of proteted health information.) I understand that if I refuse to sign this Authorization to release the entire medial reord for me, Prudential may not be able to proess an appliation for overage, or if overage has been issued, may not be able to make any benefit payments. I understand that I have the right to request and reeive a opy of this Authorization. Statement of Understanding: I represent that all statements and answers made within or attahed to this Request Form are true and omplete to the best of my knowledge and belief. I understand that overage shall be in effet only after all of these onditions have been met: this appliation has been approved by Prudential; the Contrat has been issued while all persons to be insured thereunder are alive, and; the answers and statements in this appliation ontinue to be true and omplete until the Effetive Date. I also understand that overage will not take effet if the fats have hanged. I have also read and understand and agree to the additional terms, onditions and requirements as stated in the Authorization for the Release of Information and Important Notie setions. I understand that ompletion of this appliation in no way implies that I will be aepted for insurane overage. Florida Residents: Any person who knowingly and with intent to injure, defraud, or deeive any insurer files a statement of laim or an appliation ontaining any false, inomplete or misleading information is guilty of a felony of the third degree. X Member Signature X Agent Signature X Date X Date 5. Please read: Important Notie: For residents of all states exept Alabama, Distrit of Columbia, Florida, Kentuky, Maryland, New Jersey, Pennsylvania, Utah, Rhode Island, Vermont, Virginia and Washington: Warning: Any person who knowingly and with intent to injure, defraud, or deeive any insurane ompany or other person, or knowing that he is failitating ommission of a fraud, submits inomplete, false, fraudulent, deeptive, or misleading fats or information when filing an insurane appliation or a statement of laim for payment of a loss or benefit ommits a fraudulent insurane at, is or may be guilty of a rime and may be proseuted and punished under state law. Penalties may inlude fines, ivil damages and riminal penalties, inluding onfinement in prison. In addition, an insurer may deny insurane benefits if false information materially related to a laim was provided by the appliant or if the appliant oneals, for the purpose of misleading, information onerning any fat material thereto. Alabama Residents: Any person who knowingly presents a false or fraudulent laim for payment of a loss or benefit or who knowingly presents false information in an appliation for insurane is guilty of a rime and may be subjet to restitution fines or onfinement in prison, or any ombination thereof. Distrit of Columbia and Rhode Island Residents: Any person who knowingly presents a false or fraudulent laim for payment of a loss or benefit or knowingly presents false information in an appliation for insurane is guilty of a rime and may be subjet to fines and onfinement in prison. Kentuky Residents: Any person who knowingly and with intent to defraud any insurane ompany or other person files an appliation for insurane ontaining any materially false information or oneals, for the purpose of misleading, information onerning any fat material thereto ommits a fraudulent insurane at, whih is a rime. Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent laim for payment of a loss or benefit or who knowingly or willfully presents false information in an appliation for insurane is guilty of a rime and may be subjet to fines and onfinement in prison. New Jersey Residents: Any person who inludes any false or misleading information on an appliation for an insurane poliy is subjet to riminal and ivil penalties. Pennsylvania and Utah Residents: Any person who knowingly and with intent to defraud any insurane ompany or other person files an appliation for insurane or statement of laim ontaining any materially false information or oneals for the purpose of misleading, information onerning any fat material thereto ommits a fraudulent insurane at, whih is a rime and subjets suh person to riminal and ivil penalties. Vermont Residents: Any person who knowingly presents a false or fraudulent laim for payment of a loss or knowingly makes a false statement in an appliation for insurane may be guilty of a riminal offense under state law. Washington Residents: Any person who knowingly provides false, inomplete, or misleading information to an insurane ompany for the purpose of defrauding the ompany ommits a rime. Penalties inlude imprisonment, fines, and denial of insurane benefits. Please keep this notie for your reords. GL IA Coverage issued by The Prudential Insurane Company of Ameria Ed. 06/2006 Page 3 of 3

8 Contrat Holder: CN NIS NFL 8640 D.C. Long Term Disability Insurane Payment Information Form Return this ompleted form with the Request for Coverage Form to: NCMIC Insurane Servies University Avenue Clive, IA Phone: , ext Fax: Complete this Payment Information Form and return it with your D.C. Long Term Disability Insurane Request for Coverage Form. 1. General Information: Name: First Middle Initial Last 2. Aount Information: Reurring Bank Aount Withdrawal I request NCMIC Insurane Company eletronially debit my bank aount to pay my premium on eah quarterly due date. I agree that NCMIC s rights in respet to eah debit shall be the same as if it were a hek signed by me. Should my bank aount hange, it is my responsibility to notify NCMIC. I verify that I am the aountholder. Bank Name: ABA/Routing #: Aount #: or Reurring Credit/Debit Card Payment with MasterCard or VISA I request NCMIC Insurane Company harge my redit/debit ard to pay my premium on eah quarterly due date. Should my redit/debit ard hange (inluding an updated expiration date), it is my responsibility to notify NCMIC. I verify that I am the aountholder. Card #: Expiration Date: 3. Authorization: By providing my aount information and signing below, I hereby authorize reurring payments for my D.C. Long Term Disability Insurane Plan. This authorization will remain in effet until I notify NCMIC to ease reurring payments. Signature of Appliant: X Date: X 4. NBAC Membership: Not an NBAC member yet? To be eligible for the D.C. Long Term Disability Plan, you must be a member of NBAC. If you d like to beome a member right now, simply sign and date below. Non-refundable membership dues are just $15 per year. The payment method for your NBAC membership will be the same as your disability plan payment. (It will appear as two separate transations on your statement.) By signing and dating, you give your permission for NCMIC Insurane Servies to verify that you are a malpratie poliyholder. Signature: X Date: X 5. Return this form with your Request for Coverage to NCMIC Insurane Servies: By fax: San and it to: By mail: submissions@nmi.om NCMIC Insurane Servies PO Box 9118 Des Moines, IA 50306