ACCIDENTassure SM accidental injury & disability income insurance AGENT GUIDE A3-BOOK-AGT For agent information only. This material should not be distributed to the public or used in any solicitation.
TABLE OF CONTENTS SECTION 1: PLAN DESCRIPTION... 1 SECTION 2: OPTIONAL RIDERS... 6 SECTION 3: ADMINISTRATIVE GUIDELINES... 9 SECTION 4: UNDERWRITING GUIDELINES...13 SECTION 5: EFFECTIVE DATES... 20 SECTION 6: SUBMITTING NEW BUSINESS... 21 SECTION 7: PREMIUM PAYMENTS... 22 SECTION 8: POLICY CHANGES... 24 SECTION 9: COMPENSATION... 28 SECTION 10: CLAIMS... 30 SECTION 11: MARKETING MATERIALS... 32 SECTION 12: FORMS... 33 SECTION 13: DEFINITIONS... 34
SECTION 1: PLAN DESCRIPTION In today s competitive environment, the key to your sales success is simplicity and flexibility. Washington National Insurance Company s ACCIDENTassure SM product offers both to meet the needs of today s consumers. ACCIDENTassure is an accident policy with built-in accidental dismemberment and death benefits. Optional disability benefits are also available. With two levels of coverage, the policy is easy to understand, easy to sell and suitable for all markets. Levels 1 and 2 offer the same helpful benefits, but Level 2 offers greater coverage amounts in most benefit categories. The information in this agent guide is based on standard policy language. For state variations, refer to the statespecific brochure and sample policy book for your state, available to order or download at wnbizlink.com. Note: The policy language takes precedence over all other references and sales materials. What are the differences between Accident Secure PLUS and ACCIDENTassure? SAME FEATURES Base AD&D benefits: Level 1 and Level 2 coverage Specific injury benefits Off-the-job and 24-hour disability Sickness Disability rider Public Safety rider Premium-return riders Base AD&D rates NEW FEATURES 2 riders: Waiver of Premium rider Physician s Office Additional Benefit 4 industry classes based on SIC codes Limitations on who can purchase the 24-hour disability benefit Disability rates Application 1
ACCIDENT BENEFITS 1 ACCIDENTassure pays these benefits if an insured is injured in a covered accident. LEVEL 1 LEVEL 2 Inpatient hospital confinement pays a daily amount for up to 365 days when the insured is admitted to a hospital for 24 or more hours within 30 days of a covered accident $300 per day $500 per day Intensive care unit $600 per day $1,000 per day is payable for up to 15 days per covered accident Ambulance Ground ambulance $150 $250 Air ambulance $1,000 $1,500 pays one lump sum for each covered accident within 72 hours of the covered accident Emergency room services Adult Child(ren) $300 $200 $500 $350 pays one amount per 24-hour period within 72 hours of the covered accident Transportation $400 $600 helps cover the cost when an insured person must travel to receive care more than 100 miles from the accident site or his/her residence. The benefit is payable for up to three trips per insured each calendar year Family lodging $100 per day $125 per day is payable for one hotel room for an immediate family member for up to 30 days when an insured is confined more than 100 miles from his/her residence Physician s office visit $30 per visit $50 per visit pays up to two visits, including chiropractic care, per insured for each covered accident Physical therapy $30 per visit $50 per visit helps cover expenses for up to eight visits per insured for each covered accident Medical imaging $150 $200 for CT, MRI and EEG exams, pays a one-time benefit per insured for each covered accident Medical appliances $100 $125 for wheelchairs, walkers, crutches, leg braces or back braces; is payable one time per insured for each covered accident Prostheses $500 $750 pays the insured when the required item is obtained within three years of a covered accident; the maximum benefit is specified per device, per covered accident, per insured Blood and plasma $100 $200 is available one time per covered accident, regardless of the number of units received 1 Premiums are based on the benefit level selected. Other terms and conditions apply. 2
Specific injury benefits To qualify for these benefits, the injury must be due to a covered accident and be diagnosed and treated by a physician within 90 days of the covered accident (within 72 hours for lacerations and burns; within 60 days for a ruptured disc, torn cartilage or hernia). INJURY TYPE LEVEL 1 LEVEL 2 Fracture Hip or thigh $2,400 $3,200 Vertebrae $2,200 $2,900 Pelvis $2,000 $2,550 Skull (depressed) $1,800 $2,400 Leg $1,500 $2,000 Foot, ankle or kneecap $1,200 $1,600 Forearm or hand $1,200 $1,600 Lower jaw $1,000 $1,300 Shoulder blade, collar bone or sternum $1,000 $1,300 Skull (simple) $900 $1,200 Upper arm or upper jaw $900 $1,200 Facial bones $750 $1,000 Vertebral processes $500 $750 Dislocation first complete or partial dislocation only Laceration requiring sutures combined length Injuries requiring surgery Coccyx, rib, finger, toe or nose $200 $250 Hip $2,200 $3,000 Knee (not kneecap) $1,600 $2,100 Shoulder $1,200 $1,600 Foot or ankle $1,000 $1,300 Hand $900 $1,200 Lower jaw $750 $1,000 Wrist $600 $800 Elbow $500 $650 Finger or toe $200 $250 More than 5 inches $300 $400 2 to 5 inches $150 $200 Up to 2 inches $75 $100 Eye injury $150 $200 Tendon or Single $600 $800 ligament Multiple $900 $1,200 Ruptured disc During first year of coverage $150 $200 After first year of coverage $600 $ 800 Torn cartilage During first year of coverage $150 $200 After first year of coverage $600 $ 800 Hernia During first year of coverage $150 $ 200 After first year of coverage $300 $ 400 Paralysis Paraplegia $5,000 $10,000 Quadriplegia $6,250 $12,500 Burn Second- or third-degree burn $900 $1,200 Other terms and conditions apply. 3
ACCIDENTAL DISMEMBERMENT BENEFITS ACCIDENTassure pays a benefit when an insured person is dismembered as the result of a covered accident. The dismemberment must occur within 365 days after the covered accident. LEVEL 1 TYPE of DISMEMBERMENT POLICYOWNER AND SPOUSE CHILD(REN) One finger or toe $1,250 $313 More than one finger and/or toe $1,500 $375 One eye, hand, foot, arm or leg $7,500 $1,875 More than one eye, hand, foot, arm or leg $25,000 $6,250 LEVEL 2 TYPE of DISMEMBERMENT POLICYOWNER AND SPOUSE CHILD(REN) One finger or toe $2,000 $500 More than one finger and/or toe $2,500 $625 One eye, hand, foot, arm or leg $12,000 $3,000 More than one eye, hand, foot, arm or leg $40,000 $10,000 ACCIDENTAL DEATH BENEFIT ACCIDENTassure pays a benefit when an insured person dies within 90 days as the result of a covered accident. LEVEL 1 TYPE of ACCIDENT POLICYOWNER AND SPOUSE CHILD(REN) Common carrier 1 $100,000 $25,000 Motorized vehicle or pedestrian 2 $75,000 $18,750 Accidental death 3 $50,000 $12,500 LEVEL 2 TYPE of ACCIDENT POLICYOWNER AND SPOUSE CHILD(REN) Common carrier 1 $150,000 $37,500 Motorized vehicle or pedestrian 2 $125,000 $31,250 Accidental death 3 $75,000 $18,750 1 Examples of common carrier: Commercial airline, railroad train licensed and operated for passenger service only, boat/ship licensed for passengers on a scheduled route. 2 Examples of motorized vehicle: Automobiles, trucks of all sizes, taxicabs, buses 3 Example of accidental death: Motorcycle accident Other terms and conditions apply. 4
OPTIONAL DISABILITY COVERAGE Off-the-job accident total disability benefit 1 $500, $1,000, $1,500 or $2,000 per month This benefit covers short-term disability when the policyowner is disabled due to a covered off-the-job accident. Benefits are payable for up to 12 months and are based on the applicant s gross monthly income at application. The applicant must be employed with his/her current employer for 90 days to select this benefit. The policyowner must meet all of the following to be considered eligible for this benefit: Be employed at least 27.5 hours per week at the time of the accident. Be totally disabled within 90 days of the covered accident. Be cared for on a regular basis (at least monthly) by a physician. Not be engaged in any employment or occupation for pay, benefit or profit. This benefit is available only for the employee through payroll deduction or as a credit union sale. Affinity groups such as unions, associations, etc., are not eligible to purchase disability coverage. This cannot be sold on a direct basis. The benefit will terminate when the policyowner attains age 70. 24-hour accident short-term disability benefit 1 $500, $1,000, $1,500 or $2,000 per month This benefit covers the policyowner when he or she experiences a short-term disability due to a covered on- or offthe-job accident. The benefit is payable for up to 12 months and is based on the applicant s gross monthly income at application. The applicant must be employed with his/her current employer for 90 days to select this benefit. The policyowner must meet all of the following to be eligible for this benefit: Be employed at least 27.5 hours per week at the time of the accident. Be totally disabled within 90 days of the covered accident. Be cared for on a regular basis (at least monthly) by a physician. Not be engaged in any employment or occupation for pay, benefit or profit. This benefit is available only for the employee through payroll deduction or as a credit union sale. Affinity groups such as unions, associations, etc., are not eligible to purchase disability coverage. This cannot be sold on a direct basis. The benefit will terminate when the policyowner attains age 70. 1 The applicant may choose off-the-job total disability or 24-hour accident short-term disability, but not both. If the policyowner becomes totally disabled again due to the same type of bodily injury within six months of the end of a period during which the policyowner was totally disabled, the disability is treated as the same disability. We will pay only one disability benefit for a period of total disability, even if the disability is caused by more than one covered accident. 5
SECTION 2: OPTIONAL RIDERS There is an additional cost for these optional riders. State abbreviations may apply to the rider form number. The text and definitions in this section may vary by state. All riders are not available in all states. Check wnbizlink.com or contact agent care to determine which riders are available in a specific state. SICKNESS DISABILITY RIDER (R1022SD) ACCIDENTassure offers an optional Sickness Disability rider to the policyowner through payroll deduction or as a credit union sale. Affinity groups such as unions, associations, etc., are not eligible to purchase disability coverage. The rider cannot be sold on a direct basis. It may be purchased only if off-the-job or 24-hour accident short-term disability is also purchased. Applicants may purchase up to the same amount of coverage selected for the off-the-job or 24-hour accident short-term disability ($500, $1,000, $1,500 or $2,000), but not more. All benefit payments under this rider are subject to a 14-day elimination period for each sickness. For a covered sickness to be considered, the policyowner must meet all of the following eligibility requirements: Employed at least 27.5 hours per week at the time the sickness is diagnosed. Totally disabled. Not engaged in any employment or occupation for pay, benefit or profit during the period of sickness. Being cared for on a regular basis (at least monthly) by a physician. Applicants must meet height and weight requirements in the underwriting guidelines in Section 4. Normal pregnancy is not covered, and cesarean section is not considered a complication of pregnancy. Any disability due to the same sickness occurring within six months after a disability period has ended is considered the same disability. The maximum benefit period for a covered disability is 12 months. We will pay only one monthly disability benefit, even if the disability is caused by more than one sickness. This rider is available to the employee only and will terminate when the policyowner attains age 70. WAIVER OF PREMIUM RIDER (R1057) The Waiver of Premium rider waives the premiums due when the insured is totally disabled and receiving disability benefits under the policy for up to 12 months. Premiums are waived for the base policy and any attached riders beginning on the first day of the month in which the disability occurs and ending the first day of the month after the disability ends. This allows the employer time to deduct premiums after the employee returns to work and before the next monthly premium is paid. This rider can be sold only if the off-the-job total disability or the 24-hour accident short-term disability benefit is purchased. This rider must be purchased with the base policy. It cannot be added after the policy has been issued. The Waiver of Premium rider cannot be added to an existing Accident Assure policy. If the policyholder cancels an Accident Secure PLUS policy in order to purchase a new ACCIDENTassure policy with the Waiver of Premium rider, he or she is subject to new waiting periods (if applicable), elimination periods, pre-existing condition periods and rate and industry class structures. A new ROP/CV period also must start and the ROP/CV rider on the previous policy may be forfeited, depending on how long the policy was in force. This option may not be in the policyholder s best interest. This rider is available to the employee only and will terminate when the policyowner attains age 70. The rider is not available for individual sales. Note: Requests to replace an existing accident policy with an ACCIDENTassure policy are handled as an internal replacement; reduced commissions apply. 6
PHYSICIAN S OFFICE ADDITIONAL BENEFIT RIDER (R1058) The Physician s Office Additional Benefit rider provides the insured person flexibility to receive treatment in a number of nonemergency-room medical facilities, such as a physician s office, dentist s office 1 or urgent/immediate care center. With this option, your clients receive an enhanced benefit when they seek care at a physician's office after an accident, regardless of the treatment needed or scope of the injury. The benefit is payable in one of two ways: 1. A $200 benefit is payable to diagnose and treat injuries not covered by the base policy, such as broken natural teeth, sprains, first-degree burns and other noncovered injuries. The $200 benefit pays in addition to the physician s office visit benefit included in the base policy, as shown in example 1. OR 2. When the physician s office benefit is paid along with other benefits that are covered in the base policy, this rider pays an additional $50 (instead of $200), as shown in example 2. Example 1 INJURY CAUSE Fall Example 2 INJURY CAUSE Fall TREATMENT DIAGNOSIS BENEFIT AMOUNT 2 Doctor office visit, x-ray (to determine if the bone is fractured), pain medication Arm pain and NO fracture Physician s office visit $ 50 benefit Physician s Office $200 Additional Benefit rider TOTAL BENEFIT $250 TREATMENT DIAGNOSIS BENEFIT AMOUNT 2,3 Doctor office visit, x-ray (to determine if bone is fractured and then set correctly), cast, sling, pain medication Arm pain and fracture Physician s office visit $50 benefit Physician s Office $50 Additional Benefit rider $1,600 Fracture TOTAL BENEFIT $1,700 The Physician s Office Additional Benefit rider can be added to an ACCIDENTassure or Accident Secure PLUS policy. When adding the rider to an existing Accident Secure PLUS policy, use application AP-1059 or the state variation. 1 Benefits are not payable for loss contributed to, caused by or resulting from your treatment for dental care or dental procedures, unless treatment is the result of a covered accident. Dental procedures that result from a covered accident are limited to natural teeth. 2 This information is provided for illustration purposes only. Benefit examples are based on Level 2 coverage. 3 Other benefits may be payable under the policy and may vary by the type of covered accident. 7
PUBLIC SAFETY RIDER (R1022PS) This rider is offered only to public-sector law enforcement officers, correctional officers, EMTs, paramedics and firefighters. It pays $2,000 for a gunshot wound received from a conventional firearm while in the line of duty. The policyowner must receive treatment for the wound within 24 hours from a physician at a hospital. If multiple gunshot wounds are received within a 24-hour period, the benefit is paid for one wound. This benefit is available only to the policyowner. RETURN OF PREMIUM RIDER (R1056ROP) With the Return of Premium (ROP) rider, all premiums paid (minus any claims incurred) are returned to the policyowner at the end of every 20 years or on the rider anniversary date following the policyowner s 75th birthday, whichever comes first. If the policyowner has reached age 66 when the ROP period begins, we will return one-half of premiums paid, (minus claims incurred), at the end of every 10 years. When the ROP rider is purchased, it must apply to the base policy and any riders attached. The rider may be purchased at the same time as the base policy only and cannot be added after the policy is issued. CASH VALUE RIDER (R1056CV) Our Cash Value (CV) rider returns all paid premiums to the policyowner, (minus any claims incurred), at the end of every 25 years or on the rider anniversary date following the policyowner s 75th birthday, if that comes first. If the policyowner is age 60 or older when a CV period begins, we will return the premiums paid, minus any claims incurred, at the end of every 15 years. Beginning with the sixth year, the policyowner is eligible to receive a percentage of paid premium, minus any claims incurred, upon surrender of the policy. The longer the policy is in force during a CV period, the larger the percentage becomes. When the CV rider is purchased, it must apply to the base policy and any riders attached. The rider may be purchased at the same time as the base policy only and cannot be added after the policy is issued. Due to IRS regulations, ROP/CV riders are not available for individuals who have a Section 125 plan. 8
SECTION 3: ADMINISTRATIVE GUIDELINES The text and definitions in this section may vary by state. What is an accidental injury? An accidental injury is a bodily injury solely caused by and resulting from a sudden, unexpected and unforeseen event. The best way to understand this definition is by asking these qualifying event questions: Was the act that caused the injury a sudden, unexpected and unforeseen event? AND Is the injury related to the act? For an injury to be considered accidental, the answer to both questions must be yes. Example 1: A person is moving some furniture and strains his back. Would this claim be paid? NO. The act of moving the furniture was not sudden, unexpected and unforeseen. The person intended or planned to move the furniture. Example 2: A person is moving furniture, drops the sofa on his foot and injures his toe. Would this claim be paid? YES. The act of dropping the sofa was sudden, unexpected and unforeseen, and the resulting injured toe was related to the act of dropping the sofa. An accidental injury does not include an injury that is the result of a bodily or mental infirmity, disease or medical treatment. An example of bodily infirmity is an allergic reaction, such as a bee sting. An allergic reaction is not accidental. It is the result of a weakness in an individual s body. Not everyone is allergic to bee stings. The same logic applies to other allergic reactions, such as bites from small insects like spiders, mosquitoes, etc. WHO IS COVERED Four coverage options are available: Individual Individual plus spouse Individual plus child(ren) Family Spouse means the insurable person named as spouse on the application. The person must be legally married to the insured on the policy effective date. Children means the insured and spouse s natural children, stepchildren, legally adopted children and children placed with the insured for adoption; or court-appointed guardianship of a child, including grandchild, placed with the insured under court-appointed guardianship. Children must be insurable and named on the application. They must be unmarried, chiefly dependent on the insured or spouse for support and: Have a limiting age younger than 22, or younger than 26 if they are full-time students in a licensed or accredited school. Be handicapped (mentally or physically), have become handicapped prior to the limiting age and be unable to support themselves because of such handicap. 9
Note: Newborn children are insured from the moment of birth. If the insured selects family or individual plus child(ren) coverage, no notice or additional premium is required. If the insured selects individual coverage or individual plus spouse coverage, a newborn child is covered from the moment of birth for 31 days. Coverage for such child may be extended beyond the initial 31-day period by notifying us in writing within 31 days after the child s birth and paying any required additional premium. AGE REQUIREMENTS The ACCIDENTassure product may be sold to anyone aged 18 to 69. These age guidelines apply to the main insured and the spouse. NEW SALES ACCIDENTassure can be sold on a direct or payroll basis. The base accidental death and dismemberment plan is available for individual, individual plus spouse, individual plus child(ren) and family coverage. The disability benefits, Sickness Disability rider and Waiver of Premium rider are available only to purchase for the primary applicant and are sold only on a payroll-deduction basis. The disability benefits and Sickness Disability rider is not available through employee nonpayroll (ENP) or association sales. Sales to 1099 employee groups are considered on a case-by-case basis and must be approved by underwriting before enrollment may begin. MINIMUM GROUP SIZE (PAYROLL SALES) The minimum group size for ACCIDENTassure is five applications from five different individuals. A group case profile form (WIS-GRPPRO-PRD or WIS-GRPPRO-CU) must be submitted for group setup. COVERAGE FOR AGENTS New or actively producing representatives or managers may purchase this policy. The normal requirements and all underwriting guidelines apply. Washington National Insurance Company is not able to deduct premiums for a representative s policy from his or her commission checks. Premiums must be paid through automatic checking deductions or semiannual or annual billing, and the first modal premium must be included or authorized for initial bank draft deduction. Representatives are not eligible to purchase disability benefits or the Sickness Disability rider. WAITING PERIOD The base ACCIDENTassure policy has no waiting period. Benefits are available beginning on the policy effective date. If the Sickness Disability rider is selected, a 14-day elimination period applies. 10
EMPLOYERS WITH MULTIPLE LOCATIONS When selling ACCIDENTassure to an employer group with employees located in multiple states, agents must use the application and rates that apply to the state where the application is signed. Example 1: The employer is located in Kentucky and has subsidiaries in Indiana and Oregon. For employees in Kentucky, use Kentucky applications and rates. For employees in Indiana, use Indiana applications and rates. For employees in Oregon, use Oregon applications and rates. Example 2: The employer is located in Kentucky and has employees who commute to work from Ohio and Indiana. Use the Kentucky application and rates for all employees. ELECTRONIC APPLICATION SOFTWARE WNezAPP2.0 SM is the easiest, most efficient way to submit applications for worksite and direct business. The WNezApp2.0 electronic enrollment software helps ensure that all required information is included in an application, eliminating the most common reasons for pending business and allowing business to be processed more efficiently. The software presents all required forms during the application process. Rates are calculated for the agent. If information is not entered into a required field, the agent can t move to the next section until it is fixed. An error message quickly prompts the user to input the missing information. The free WNezApp2.0 software is available at wnbizlink.com. For technical assistance with the software, call (800) 888-4918, ext. 72269. PRIVACY OVERVIEW Washington National Insurance Company ( the company ) must adhere to various legal and regulatory requirements. The company, and its agents, each have a responsibility to be in compliance with state insurance laws and regulations. It is the obligation of each licensed insurance agent to be aware of all laws, regulations and requirements for their state so that they conduct all sales activities in a manner that complies with these laws and regulations. Additionally, we have set high standards in connection with the sale and servicing of our insurance products. Agents are expected to conduct business with honesty and integrity, as outlined in the Washington National sales representative agreement. This agreement provides an overview of ethical and compliance expectations as they relate to advertising, field conduct, disclosure, suitability, replacement and unfair trade practices. This agreement is not intended to be a complete listing of all compliance requirements. Personally Identifiable Information ( PII ) is information that clearly identifies a distinct individual (a consumer, customer, associate or agent). Examples of PII are name, address, social security number, information about health and finances, and other information that is not generally available to the public. A copy of the consumer privacy notice is available at wnbizlink.com under materials. Agents should review this form to familiarize themselves with how we handle PI and what consumers can do to change or access it. 11
Agents are required by law to take an active role in preventing PII from being disclosed to unauthorized parties. If you suspect PII is lost, stolen or disclosed to an unauthorized party, it is critical that you immediately report the situation to the home office by submitting a DATA ALERT form. This form and instructions for submitting it are located on wnbizlink.com. It may be completed online and submitted by e-mail to privacy@cnoinc.com. Since independent agents are legally responsible for consumers personal information while under an agents control, completing and submitting a DATA ALERT should be approached with a sense of urgency and priority. Questions about privacy regulations should be directed to privacy@cnoinc.com. If you have concerns about fraud, ethical issues, harassment or other questionable activities, you can call InTouch at (855) 835-5266. Your call is completely anonymous. An independent company will answer your call, transcribe your message and send it to Washington National in writing. Also, you can e-mail your issues to tellcno@getintouch.com. 12
SECTION 4: UNDERWRITING GUIDELINES ISSUE LIMITS Keep in mind a few guidelines when selling the ACCIDENTassure product. An individual cannot own more than one accident product from Washington National. An individual can own Level 1 or Level 2, but not both and not multiple forms of the same level for this product (e.g., two Level 1 policies). Hospital confinement benefits are limited to $1,000 per person per day for policies sold through payroll deduction, and $600 per person per day for policies sold through direct sales. These limits include coverage from all carriers combined. - An applicant must list all insurance policies owned that pay an indemnity benefit for hospital confinement. Policies that should be listed include accident, sickness and hospital indemnity. Policies that should not be listed include major medical and specified disease, like cancer, heart/stroke and critical illness. - When comparing a per confinement benefit to a per day benefit, divide the per confinement benefit by a factor of 5. For example: - $1,000 per confinement benefit = $200 per day benefit - $1,500 per confinement benefit = $300 per day benefit - $2,000 per confinement benefit = $400 per day benefit - $2,500 per confinement benefit = $500 per day benefit ICU confinement benefits are limited to $1,500 per person per day for policies sold through payroll deduction, and $1,050 per person per day for policies sold through direct sales. These limits include coverage from all carriers combined. The ACCIDENTassure base accidental death and dismemberment policy is guarantee renewable for life as long as premiums are paid. The off-the-job total disability and 24-hour short-term disability benefits, Sickness Disability rider and Waiver of Premium rider terminate once the policyowner attains age 70. EMPLOYMENT REQUIREMENTS There are no employment requirements for direct sales or prohibited payroll groups to purchase the base ACCIDENTassure product. If the applicant selects the off-the-job total disability or the 24-hour short-term disability benefits, or the Sickness Disability rider, a 90-day employment requirement applies. Individuals must actively be at work at least 27.5 hours per week to be eligible to purchase any disability benefit or rider. The disability benefits, Sickness Disability rider and Waiver of Premium rider can be purchased only through payroll deduction. These benefits/riders cannot be sold to prohibited groups or through credit unions. 1099 employees are not eligible for disability benefits/riders. 13
INCOME REQUIREMENTS An individual is not allowed to purchase ACCIDENTassure disability income benefits if doing so would cause the combined total monthly short-term disability coverage he/she owns from all sources to exceed 66-2/3% of his/her gross monthly income. Short-term disability is defined as any coverage with an elimination period of 30 days or less. Coverage can be purchased up to 66-2/3% of the individual s gross monthly income from all sources. This does not mean that ACCIDENTassure will provide disability coverage for up to 66-2/3% of the applicant s gross monthly income. ACCIDENTassure will provide coverage only up to the maximums listed in the gross monthly income table based on the individual s income and current insurance from other sources. When calculating the maximum amount of disability benefits an applicant may purchase, agents must take into consideration any state disability benefit programs available in the applicant s resident state (e.g., California State Disability Insurance program). Benefits available from the workers compensation program should not be included. If an employee holds multiple jobs, only his/her income from the employer through which the ACCIDENTassure product is offered can be considered in determining the disability income coverage amount he/she may purchase. GROSS MONTHLY INCOME TABLE to determine disability benefit/rider maximums Gross monthly income Maximum amount $0 $749 $0 $ 750 $1,499 $500 $1,500 $2,249 $1,000 $2,250 $2,999 $1,500 $3,000 and up $2,000 14
HEIGHT AND WEIGHT REQUIREMENT This requirement applies to the Sickness Disability rider only. An applicant s height and weight are not required on the application for an accident-only policy. Applicants must include their height and weight when adding a Sickness Disability rider, obesity guidelines apply. If the applicant exceeds the maximum allowable parameters in the table, the Sickness Disability rider will be rejected. MEN WOMEN Height Weight Height Weight 5 2 210 lbs. 4 10 183 lbs. 5 3 214 lbs. 4 11 188 lbs. 5 4 218 lbs. 5 0 192 lbs. 5 5 224 lbs. 5 1 196 lbs. 5 6 230 lbs. 5 2 200 lbs. 5 7 235 lbs. 5 3 206 lbs. 5 8 241 lbs. 5 4 211 lbs. 5 9 246 lbs. 5 5 217 lbs. 5 10 252 lbs. 5 6 223 lbs. 5 11 258 lbs. 5 7 228 lbs. 6 0 263 lbs. 5 8 234 lbs. 6 1 269 lbs. 5 9 238 lbs. 6 2 276 lbs. 5 10 242 lbs. 6 3 283 lbs. 5 11 246 lbs. 6 4 290 lbs. 6 0 251 lbs. 6 5 297 lbs. 6 1 256 lbs. 6 6 304 lbs. 6 2 261 lbs. 6 7 311 lbs. 6 3 266 lbs. 6 8 318 lbs. 6 4 271 lbs. 6 9 325 lbs. 6 5 276 lbs. 6 10 332 lbs. 6 6 281 lbs. INDUSTRY CLASSIFICATION Because some industries are more hazardous than others, ACCIDENTassure uses Standard Industrial Classification (SIC) codes to determine the risk of injury to employees within an employer group. This code is used to determine premium rates and available disability benefits. For the ACCIDENTassure product, industry classes apply when any of the following are purchased: Off-the-job total disability benefit 24-hour accident short-term disability benefit Sickness Disability rider Waiver of Premium rider With the ACCIDENTassure product, employer groups are rated as industry class 1, 2, 3, 4 or prohibited based on their SIC code. The industry class assigned applies to all employees regardless of their duties, unless otherwise 15
noted under Office Staff or further defined within the industry description. Some industries are not assigned an industry class but are instead noted as Contact Home Office. In those situations, contact Washington National s worksite services department to determine the employer group s industry class. Employer groups assigned industry class 4 cannot purchase the 24-hour accident short-term disability benefit. They may purchase the off-the-job total disability benefit, Sickness Disability rider and Waiver of Premium rider when they meet all other qualifications. For purposes of job classification, Office Staff is defined as employees who spend 80% or more of the workday at a desk inside an office. The off-the-job total disability and 24-hour short-term disability benefits, Sickness Disability rider and Waiver of Premium rider cannot be sold to prohibited groups. An industry class manual (A3-BR-SIC) is available on wnbizlink.com to help you determine the SIC code for each employer group. Please note: Industry classes do not apply to the base accident policy, and there are no restrictions on who may purchase that coverage. GUARANTEE ISSUE ACCIDENTassure can be offered on a guarantee issue (GI) basis to worksite clients. The application asks, Within the past 5 years, have you or any person applying for coverage been convicted of a felony, reckless driving or driving under the influence of drugs or alcohol? (State variations to the question may apply.) Generally, a person who answers yes to this question is excluded from coverage. If the yes answer applies to the primary applicant, coverage cannot be issued at all. With the GI option, we allow the base accident policy to be issued with a yes answer when these guidelines are followed: Participation is the greater of 10 applications or 20% of eligible employees. Existing Accident Secure PLUS and ACCIDENTassure policyholders in the group count toward the overall participation requirement. You submit a new case profile stating that you are requesting GI for the group. Applications are submitted using the WNezApp2.0 enrollment software. GI applies to the base accident policy, Physician s Office Additional Benefit rider, Public Safety rider and premium return riders. GI is not available for disability benefits, the Sickness Disability rider or the Waiver of Premium rider. If group participation requirements are not met, the application will be declined if the yes answer applies to the primary applicant. If the yes answer applies to a dependent, that individual will be excluded from coverage. As a reminder, disability benefits and riders are not permitted for any policy issued as GI with a yes answer to the above question. Example 1: An application has a yes answer to the above question and participation requirements are met. The policy is issued. 16
Example 2: An application has a yes answer to the above question, but participation requirements are NOT met. If the yes answer applies to the primary applicant, the application is declined. If the yes answer applies to a dependent, the policy is issued but that dependent is excluded from coverage. GI is not available for individual sales. PRE-EXISTING CONDITIONS A pre-existing condition is defined in the policy as any injury or condition that was diagnosed by, or for which a physician was consulted, within 12 months prior to the policy effective date. Washington National will not pay benefits related to any such injury during the first 12 months after the coverage effective date. For information relating to pregnancy, refer to the Sickness Disability rider information in Section 2. EXCLUSIONS All applicants, including the spouse and children, need to answer questions 1 through 3 in Section IV of the application. If a group is applying for coverage under the GI option, see the guarantee issue information on the previous page. If the group is not applying for GI or the application is for individual (nonworksite) coverage, a person who answers yes to question 3 is excluded from coverage. The name of the excluded person must be listed on the application under question 3. If the yes answer applies to the primary applicant, do not submit the application. If the off-the-job or the 24-hour short-term disability benefit is selected, questions 4 through 8 must be answered on the application. If the answer to any question from 5 through 8 is yes, the applicant is not eligible for disability coverage or the Sickness Disability rider. In this case, a policy can be issued only for the base accidental death and dismemberment coverage. If the Sickness Disability rider is chosen, questions 9 through 13 on the application must be answered. If any question from 10 to 13 is answered yes, the applicant is not eligible for the Sickness Disability rider. The Sickness Disability rider can be purchased only if the off-the-job or 24-hour short-term disability benefit is selected. Note: Disability coverage, including the Sickness Disability rider and Waiver of Premium rider, is not available for the applicant s spouse or child(ren) and is available through payroll deduction or credit union sales. Failure to answer questions fully and accurately may result in the denial of a claim or in policy rescission at the time of the claim. PARTIAL ISSUES If an individual applies for accident coverage and optional riders, but does not qualify for all of the coverage applied for, the following procedures may be followed: If the applicant does not qualify for base coverage, the entire application will be denied. If the applicant qualifies for base coverage but does not qualify for one or more of the optional benefits or riders, a base policy will be issued along with any rider the applicant qualifies for. A corrected application is required. 17
OUTLINE OF COVERAGE Department of insurance regulations require that an outline of coverage (OC1022R or state variation) is provided to the client at the time of sale. Outlines of coverage are included in the application booklets available at wnbizlink.com. SALES TO PERSONS ELIGIBLE FOR MEDICARE OR MEDICARE The comments regarding Medicare/Medicaid simply reflect our current interpretation of the programs. It is not our intent to give advice on Medicare or Medicaid. Please consult a qualified adviser. Federal statute makes it illegal to issue a health insurance policy that duplicates Medicare benefits to anyone who is eligible for Medicare, unless the policy pays without regard to other insurance and at the time of application the applicant is shown a disclosure statement prescribed in the regulation for that type of insurance. Persons may qualify for Medicare if they are aged 65 or older, have permanent kidney failure or are disabled regardless of age. Because our policies pay without regard to other insurance, we may sell them to people who qualify for Medicare as long as they sign the appropriate disclosure statement and submit it with the application. The application will not be processed if the statement is not signed or attached. The disclosure form number is CIC1023. This statute only applies if the policyowner is eligible for Medicare; we do not need a disclosure statement if only a spouse or dependent child is eligible for Medicare. The disclosure statements and the pamphlet Guide to Health Insurance for People with Medicare (MEDICARE-GUIDE-2011) are available to order from our supply department. These guidelines apply to new business and conversions, but not reinstatements. Persons eligible for Medicaid MUST understand that participating in Medicaid will likely reduce or eliminate their Washington National benefits. Even though each state s Medicaid regulations vary, the use of taxpayer dollars to pay these medical expenses mandates that we reimburse the public program first, based on those regulations. LIMITATIONS AND EXCLUSIONS The limitations and exclusions are standard in most states. State variations may apply. Refer to the consumer brochures (A3-BR-WS or A3-BR-DIR or state variation) for state-specific details. This policy/rider does not cover any sickness, accidental injury or condition that was diagnosed by or for which an insured consulted a physician within 12 months prior to the effective date of the coverage; or for losses related to such injury or condition that occur during the first 12 months after the effective date of coverage. We will not pay for loss contributed to, caused by or resulting from the insured being exposed to war or any act of war (declared or not); participating in or contracting with the armed forces (including Coast Guard) of any country or international authority; committing or attempting to commit suicide, regardless of mental capacity; injuring or attempting to injure oneself intentionally, regardless of mental capacity; being in an accident more than 40 miles outside the territorial limits of the United States, Canada, Mexico, Puerto Rico, the Bahamas, Virgin Islands, Bermuda or Jamaica (except under the accidental death benefit); riding in or driving any motor-driven vehicle in any race, stunt show or speed test or on any race course or speedway; operating, learning to operate, serving as a crew member on or jumping or falling from any aircraft, including those that are not motor-driven; hang-gliding, bungee jumping, parachuting, sail-gliding, parasailing, parakiting or mountaineering; being legally intoxicated or so intoxicated that mental or physical abilities are seriously impaired; being under the influence of any narcotic, unless such narcotic is taken under the direction of a physician; participating or attempting to participate in an illegal act; working at an illegal job; participating in any sporting event for pay or prize money; and having any disease, bodily or mental illness, or degenerative process. We also will not pay benefits for any related medical treatments or diagnostic procedures. 18
Sickness Disability rider: The policyowner must be employed at least 27.5 hours per week at the time the sickness is diagnosed; be totally disabled; not be engaged in any employment or occupation for pay, benefit or profit; and be cared for on a regular basis (at least monthly) by a physician. The same sickness occurring within six months of the end of the disability period will be treated as the same disability. A 14-day elimination period applies to each sickness. We will not pay for loss contributed to, caused by or resulting from an insured having a normal pregnancy; having a behavioral or psychological disorder, disease or syndrome without demonstrable organic origin; and having alcoholism, drug abuse or chemical dependency. We will not pay for loss contributed to, caused by or resulting from an insured having a cosmetic/plastic surgery that is not for the diagnosis or treatment of a covered sickness based upon generally accepted medical practice and that is not considered medically necessary. The following procedures are not covered under any circumstances, even if performed for diagnosis or treatment of a covered sickness or considered medically necessary: abdominoplasty (tummy tuck); mammaplasty (breast enlargement); rhinoplasty (nose job); or suction-assisted lipectomy (liposuction). Complications from any cosmetic/plastic surgery are not covered. We will not pay for loss contributed to, caused by or resulting from an insured undergoing elective surgery that is not for the diagnosis or treatment of a covered sickness based upon generally accepted medical practice and that is not considered medically necessary. The following surgeries are not covered under any circumstances: gastric bypass surgeries, even if performed for diagnosis or treatment of a covered sickness or medically necessary; voluntary abortion (except where the policyowner would be endangered if the fetus were carried to term or where medical complications have arisen from abortion); and sex changes. Complications from any elective surgery are not covered. No postpartum benefits will be paid for any postpartum disability under the disability benefits. Public Safety rider: For multiple gunshot wounds within a 24-hour period, the benefit is payable only for one wound. If death occurs as a result of the same shooting, we will pay only the largest of the benefits for which the policyowner is eligible. This rider does not cover gunshot wounds received off-the-job or from nonconventional firearms. A conventional firearm is defined as a weapon from which a bullet or shot is fired by gunpowder or compressed gas. Physician s Office Additional Benefit rider: Benefits are not payable for loss contributed to, caused by or resulting from your treatment for dental care or dental procedures, unless treatment is the result of a covered accident. Dental procedures as a result of a covered accident are limited to natural teeth. 19
SECTION 5: EFFECTIVE DATES WORKSITE BUSINESS The effective date of worksite payroll-deduction business can be no earlier than the date the application is received in the home office. All payroll business is given an effective date of the 1st of the month. If the application is received on or before the 15th of the month, the application is given an effective date on the 1st of the month after that date. If the application is received after the 15th of the month, the application is given an effective date on the 1st of the next month after that date. Payroll deductions should begin on the policy effective date so that funds are available to remit when the first bill is due. Examples: Application received date 1st 15th Effective date 1st of the following month Applications and payroll-deduction authorization cards received in the home June 1 15 office Effective date July 1 First bill date July 1 First due date August 1 Application received date Effective date 20 16th 30th 1st of next month (following month + 1) June 16 30 Applications and payroll-deduction authorization cards received in the home office Effective date August 1 First bill date August 1 First due date September 1 CREDIT UNION SALES If enrollment forms are received on the 1st through the 15th of the month, the effective date is 60 days from the first day of the month after those forms are received. Example: Enrollment forms received in home office July 1 15 Effective date September 1 For enrollment forms received on the 16th through the 31st of the month, the effective date is 90 days from the first day of the month after those forms are received. Example: Enrollment forms received in home office July 16 31 Effective date October 1 DIRECT BUSINESS The effective date is the date the enrollment form is received in the home office, unless otherwise requested. It cannot be earlier than the date the enrollment form is received in the home office. Exceptions to these guidelines must be approved by the new business department.
SECTION 6: SUBMITTING NEW BUSINESS Submit all new applications to: DIRECT & CREDIT UNION SALES WORKSITE SALES Attn: New Business Attn: Worksite New Business Washington National Insurance Company Washington National Insurance Company 11825 N. Pennsylvania St. 11825 N. Pennsylvania St. Carmel, IN 46032 Carmel, IN 46032 OR OR P.O. Box 1908 P.O. Box 2036 Carmel, IN 46082-1908 Carmel, IN 46082-2036 OR OR Fax: (800) 906-3926 Fax: (800) 981-8413 OR E-mail: wis@washingtonnational.com DIRECT BUSINESS Include form CI-747 for the initial bank draft. We will draft the initial premium payment from the applicant s checking account. This form also may serve as authorization for subsequent monthly premium drafts. FAXED BUSINESS No paper check is required. To help avoid confusion and delays when faxing business, do not send the original copy of the application to the home office. Set your fax machine to provide a transmission report. This confirms that the fax was completely transmitted. If your fax machine doesn t have this capability, you ll need to monitor it to be certain the submission is received. If the transmission report shows the submission was not received, please fax the entire document again. All new business should be submitted with a new business transmittal form (C-NBT). DELIVERY RECEIPTS With ACCIDENTassure, agents may hand-deliver a policy packet to a policyholder. For the agent to receive the policy packet, the mail to agent box on the application must be marked. Otherwise, the policy will be mailed directly to the policyholder. If the mail to agent option is selected on the application, the agent must have the policyholder sign the delivery receipt included in the policy packet. If this form is not returned to the address listed above, we will send the policyholder a follow-up letter requesting the delivery receipt be returned. If the policy is mailed directly to the policyholder, the delivery receipt will be included in the policy packet. We will send a follow-up letter to the policyholder asking for the policy receipt if it is not returned. No adverse action will be taken if the receipt is not returned. 21
SECTION 7: PREMIUM PAYMENTS The ACCIDENTassure product is designed to be sold in payroll and individual markets. Rates are the same for both. Premiums for the accidental death and dismemberment coverage are based on age, health and the benefit plan selected. Disability premiums are based on the industry class and benefit amount selected. MINIMUM PREMIUM There is no minimum premium on ACCIDENTassure. BILLING METHOD ACCIDENTassure may be written as payroll deduction, monthly bank draft or semiannual or annual direct-bill. WORKSITE GROUPS ACCIDENTassure may be written on payroll deduction. Available billing frequencies include 9, 10, 12, 13, 24 or 26 per year. If at least one modal premium is received under the original payment method, coverage under the Accident Secure PLUS product may be continued when the policyholder changes jobs retires or leaves the group for any reason. CREDIT UNION GROUPS Credit Union group premiums are collected via electronic funds transfer (EFT) on a monthly basis. When submitting business, be sure to attach an EFT form (CI-747) for initial and future deductions. DIRECT BUSINESS Direct-billing modes include monthly bank draft and semiannual or annual direct-bill. When submitting monthly bank draft business, attach these forms: Electronic funds transfer form (CI-747) for initial and future deductions or the applicant s check, payable to Washington National Insurance Company, for one modal premium. A voided check with bank routing transit numbers and account number printed on the slip for the account from which deductions will be made. Experience shows there are far fewer bank processing errors when a voided check is provided. Deductions can be made from checking or savings accounts. Please indicate the type of account on the authorization form. The automatic check-deduction day is the day each month that a policyholder s premium is automatically deducted from his or her checking or savings account. Policyholders should select the day of the month (between the 1st and the 28th) on the electronic funds transfer form (CI-747). If no day is specified on the form, the deduction day will be the date the application is received in the home office. (Applications received on the 29th, 30th or 31st are assigned deduction days of the 1st, 2nd and 3rd, respectively.) 22