Accident Pays you benefits for treatment and services regardless of other medical coverage. Accident : It couldn t be easier or more reasonable to be better protected. Get Accident Today! Simply complete and sign this form and the payroll deduction authorization. Then mail this postage-paid brochure back to the Club. Or, call the City Employees Club of Los Angeles at, and a friendly Club Counselor will take your information over the phone. Who is eligible to apply? This insurance program is open to members of the City Employees Club of Los Angeles. If you re a member, great! If not, as a new policy holder you will automatically be enrolled as a member of the. Members enjoy valuable benefits like big discounts on movie tickets, theme parks, attractions and events, the monthly Alive! newspaper, group-rated insurance, scholarships, and free notary service. Go to www.cityemployeesclub.com for all the details. Questions? Club Counselors are ready to answer your questions about Accident. Call today. CITY EMPLOYEES CLUB OF LOS ANGELES www.cityemployeesclub.com City Employees Club of Los Angeles 120 West 2nd Street Los Angeles, CA 90012 www.cityemployeesclub.com
? Accidents Why get Accident? are by nature unpredictable, and the costs arising from accident-related injuries can be startling. While some expenses may be covered by most medical plans, others such as travel to distant treatment facilities may not be. Guaranteed Approval - How does Accident work? Accident pays benefits when you or a family member (depending on your coverage) become injured as the result of a covered accident. If an accident results in an injury requiring medical attention: 1. Get the treatment you need. 2. File a claim on your Accident policy. 3. You ll receive a benefit for each covered treatment received. Traditional Medical compared to Accident Traditional Medical PAYS...typically pays directly to the hospital in the event of an accident. vs Accident PAYS...pays directly to you to help you pay for: Out-of-network costs Travel to nonlocal facilities Co-pays and deductibles Other expenses What can Accident from the Club offer me? When accidents happen, you need to focus your energy on getting well without the added stress of costs like family lodging, hospitalization, medical bills, treatment, x-rays, and ambulance service. As a member of the City Employees Club of Los Angeles, you are entitled to the added security of this Accident plan: Coverage is available for both spouse and dependents. Added Security Provides benefits for surgery-related services. Allows you to cover your spouse and children on the same policy. Coverage on and off the job. Financial Advantages Pays benefits for treatments and services, regardless of other medical coverage. Benefits paid directly to you, to use as you see fit. Budget-friendly rates. Convenience and Flexibility All eligible members are guaranteed acceptance. Premiums paid through payroll deduction no checks to write. Broad Coverage The plan covers a wide range of injuries, including most children s sports injuries, as well as expenses not usually addressed by traditional health plans, such as transportation and lodging costs for treatment at a non-local facility.
Accident Worksheet Personal information (all information required) MAILING THIS FORM: Fold this entire postage-paid brochure with the Business Reply panel showing, tape closed (don t staple) and drop in the mail. m Current Club Member -or- m New Club Member Social Secruity No. First Name Middle Initial Last Name Home Address City State Zip Home Phone Work Phone Cell Phone Date of Birth (MM/DD/YY) State/Country of Birth ( ) ( ) ( ) E-mail address* m Yes, please send me e-mail updates. Height (inches) Weight (lbs.) Mother s Maiden Name Driver's License # State Issued Are you a U.S. Citizen? m Yes m No If No... a) Date of entry b) VISA type c) Expiration date *The email address you provide will help us communicate with you regarding updates and benefits that may become available to you. Your e-mail address will be used solely by American General Life Company and the City Employees Club and will not be distributed to others. Employment (all information required) m City employee # City department # m DWP employee # Occupation Date Hired (MM/DD/YY) Annual Income Spouse (provide if applies to you) Date of Birth (MM/DD/YY) State/Country of Birth Height (inches) Weight (lbs.) Spouse Last Name Spouse First Name Dependents (provide if applies to you) Beneficiary (required) First Beneficiary Relationship to you Second Beneficiary Relationship to you Questions (required) Do you have any pending insurance in force? m Yes m No Are you actively at work for 30 hours per week? m Yes m No In the last 5 years, has any Proposed Insured had a reckless driving charge, had a driving while intoxicated charge, had a driver s license revoked or suspended, or within the last 3 years had multiple moving violations in any vehicle(s) operated by any Proposed Insured. m Yes m No Review the Plan Benefits and decide which plan is right for you: Instructions: Indicate your desired coverage level by checking one circle. Rates are listed as monthly deductions. Premiums DO NOT INCREASE with age! Accident Plan Rates (Rates listed are per month.) COVERAGE TIER SILVER GOLD Member m $23.13 m $34.95 Member & Spouse m $33.55 m $52.06 Member & Child(ren) m $35.33 m $54.90 Family m $47.66 m $74.30 Membership in the Club! As a new policyholder, you will automatically be enrolled as a member of the City Employees club of Los Angeles, a membership program of the Los Angeles City Employees Association, where you will get all Club benefits for a payroll deduction of only $4.50 per month. Annual membership fees of $54.00 include $24.00 for a one-year, non-deductible subscription to the Alive! Newspaper.
Accident Application INSTRUCTIONS: Complete the Accident Worksheet (previous page). Then complete and sign this Payroll Deduction Authorization. Mail both pages to: 350 South Spring Street, Suite 1300 Los Angeles, CA 90013 Complete and sign this Payroll Dedcution Authorization as part of your Accident application. Payroll Deduction Authorization In addition to payroll deductions for group benefits, if any, you will receive all Club benefits for a payroll deduction of only $4.50 per month. You authorize these monthly deductions by signing the Payroll Deduction Authorization form. Annual membership fees of $54.00 for active employees include $24.00 for a one-year, non-deductible subscription to the Alive! newspaper. Sign Here Name: City Department #: (5 or 6 digits) m City Employee #: m DWP Employee #: To: Controller City of Los Angeles, or Fire and Police Pension, or City Employees Retirement System, or 311 South Spring Street, Suite 1300 Los Angeles, CA 90013 Paymaster Department of Water and Power I hereby authorize the deduction from my salary or pension of amounts sufficient to cover premiums/membership fees on any of my group benefits provided by City Employees Club of Los 1-800-464-0452 info@cityemployeesclub.com www.cityemployeesclub.com Angeles. In the event any premiums should change due to age, increase in salary or benefits, or a general rate increase for the FOR OFFICE USE ONLY entire Association, I authorize you to make such change upon notification from the and such deduction to remain in force until canceled by me in writing. Sign Here X City/DWP Employee Date Code Deduction See Plan Benefits and Terms and Conditions on the next page.
Accident Plan Benefits COVERAGE TIER Hospital Cash Benefit SILVER GOLD (Maximum of 30 consecutive days paid per admission; 365 days lifetime maximum) Maximum per admission $350 $1,400 Daily benefit, when confined to hospital 75 300 Daily benefit, when confined to intensive care unit (15 days per accident) 75 300 Daily benefit, when confined to rehabilitation facility (30 days per confinement, 60 per year) 20 80 Ambulance Benefit Schedule Ground Ambulance $225 $300 Flight Ambulance 1,500 2,000 Burns Benefit Schedule Third degree burns over 10% of body $1,500 $2,000 Third degree burns over 20% of body 3,000 4,000 Third degree burns over 30% of body 7,500 10,000 Dislocation Benefit Schedule (Open Reduction) Hip $5,100 $6,800 Knee (not kneecap) 1,350 1,800 Shoulder 1,350 1,800 Foot or Ankle 1,350 1,800 Wrist 600 800 Elbow 600 800 Lower Jaw (mandible) 1,350 1,800 Dislocation Benefit Schedule (Closed Reduction) Hip $1,350 $1,800 Knee (not kneecap) 450 600 Shoulder 450 600 Foot or Ankle 450 600 Wrist 600 800 Elbow 600 800 Lower Jaw (mandible) 750 1,000 Fracture Benefit Schedule (Compound) Hip or Thigh $6,000 $8,000 Leg 3,000 4,000 Hand, Wrist or Forearm 1,500 2,000 Foot, Ankle or Kneecap 1,500 2,000 Shoulder Blade or Collarbone 1,500 2,000 Lower Jaw (mandible) 1,500 2,000 Vertebrae or Pelvis 3,000 4,000 Upper Jaw, Upper Arm or Face 1,500 2,000 Rib 600 800 continued opposite side Tear form on perforation to retain the Plan Benefits table. Plan Benefits, continued Fracture Benefit Schedule, cont. (Compound) Nose or Heel 1,050 1,400 Coccyx 600 800 Vertebral Processes 3,000 4,000 Skull (depressed) 3,750 5,000 Fracture Benefit Schedule (Closed) COVERAGE TIER SILVER GOLD Hip or Thigh $3,000 $4,000 Leg 1,500 2,000 Hand, Wrist or Forearm 750 1,000 Foot, Ankle or Kneecap 750 1,000 Shoulder Blade or Collarbone 750 1,000 Lower Jaw (mandible) 750 1,000 Vertebrae or Pelvis (excluding coccyx) 1,500 2,000 Upper Jaw, Upper Arm or Face (excluding nose) 750 1,000 Rib 300 400 Nose or Heel 300 400 Coccyx 300 400 Vertebral Processes 450 600 Skull (simple) 1,200 1,600 Paralysis Benefit Schedule (payable for primary insured and spouse only) Paraplegia $3,000 $4,000 Hemiplegia 4,500 6,000 Quadriplegia 7,500 10,000 Surgical Benefit Schedule Tendons or Ligaments $600 $800 Torn Rotator Cuffs 600 800 Ruptured Disc 600 800 Torn Knee Cartilage 300 400 Arthroscopy (without surgical repair) 300 400 Open Abdominal (excluding exploratory Laparotomy) 1,200 1,600 Cranial, Hernia or Thoracic 1,200 1,600 Miscellaneous Surgery (requires general anesthesia) 300 400 Other Benefits Emergency Treatment Benefit $150 $200 Accident Follow-up Benefit 45 60 Family Lodging Benefit (maximum of 30 nights) 150 200 Laceration Benefit (minimum of 2 stitches) 150 200 Diagnostic Exams 225 300 Physical Therapy Benefit (per treatment) 30 40 Prosthesis (non-surgical and non-implant) 750 1,000 Transportation Benefit (per treatment) 450 600 AGLC104806-BS R04/11 www.cityemployeesclub.com Tear form on perforation to retain this Plan Benefits table. Accident TERMS AND CONDITIONS Pre-existing Conditions and Exclusions: No benefits are payable if covered services are not related to a covered accident. No benefits are payable for a pre-existing condition until the policy has been in force for two years from its effective date or most recent reinstatement date. All benefits payable are subject to the terms and conditions of the policy, including benefits, limitations and exclusions. We will not pay any benefit for any accident or sickness of the insured caused in whole or in part by, or resulting in whole or in part from: (a) the insured s suicide, attempt at suicide, intentional self-inflicted injury or sickness, or attempt at intentional self-inflicted injury or sickness, while sane or insane; or (b) the insured s being under the influence of an excitant, depressant, hallucinogen, narcotic; other drug; or intoxicant including those taken as prescribed by a physician; or (c) the insured s commission of or attempt to commit a felony or assault; or (d) the insured s engagement in an illegal activity or occupation; or (e) the insured s voluntary participation in any riot or civil insurrection; or (f) declared or undeclared war, or any act of declared or undeclared war; or (g) the insured s operating, learning to operate, serving as a crew member of, or jumping, parachuting, or falling from an aircraft or hot air balloon, including those not motor driven; or (h) the insured s engaging in hang gliding, bungee jumping, parachuting, sail gliding, parasailing or parakiting, or any similar activity; or (i) the insured s riding in or driving any motor-driven vehicle in a race, stunt show or speed test; or (j) the insured s practicing for or participating in any semiprofessional or professional competitive athletic contest for which the insured receives any type of compensation or remuneration; or (k) the insured s operating any type of land, water or air vehicle while having a blood alcohol content at or above the level made illegal for operation of such vehicle by the jurisdiction where the accident occurred; or (l) any illness, loss or condition specifically excluded from the definition of accident under the policy. Effective Date: You will be insured on the date stated in writing by American General Life Company, provided the required premium is paid. You must be actively at work on the date your insurance is to take effect. End Date: As long as you continue to pay your premiums on time, your coverage will not end. 311 South Spring Street, Suite 1300 Los Angeles, CA 90013 www.cityemployeesclub.com Policies issued by: American General Life Company Houston, Texas Policy Form Number: 04120 The underwriting risks, financial and contractual obligations and support functions associated with products issued by American General Life Company (AGL) are its responsibility. AGL does not solicit business in the state of New York. Policies and riders not available in all states. Guarantees are subject to the claims-paying ability of the issuing insurance company. This is a summary only of products and services offered. All products are subject to the terms, conditions, limitations and exclusions of the policy. Please see policy and certificate for details. 2011. All rights reserved. LACEA-AI AGLC104806-BS R04/11 -FOR USE IN CALIFORNIA ONLY-