Your Retiree Supplemental Group Term Life Insurance Handbook... SUPPLEMENTAL GROUP TERM LIFE INSURANCE Just as the name implies, Supplemental Group Term Life (SGTL) coverage supplements other life insurance you may have You pay the entire cost for coverage; your former employer does not contribute You take advantage of group rates To qualify, you must be at least 55 years old and have 10 years of eligible credit You must also apply for coverage before you retire Coverage is also available for your spouse and eligible dependent children Make sure your beneficiary designations are always up to date (the form is at www.dmba.com) NAME: FIRST MIDDLE INITIAL LAST BENEFICIARY DESIGNATION, continued from Section D, designate a trust as a beneficiary or list additional beneficiaries DESERET MUTUAL ID NO.: BIRTH DATE (MM/DD/YYYY): Full Given Name of Beneficiary Relationship Birth Date Contact Phone # PRIMARY TELEPHONE: ALTERNATE TELEPHONE: Benefit MARITAL STATUS: MARRIED WIDOWED SINGLE (NEVER MARRIED) SEPARATED DIVORCED B. PARTICIPANT AUTHORIZATION PRIMARY Participant s Signature: Date: C. SPOUSAL CONSENT WAIVER (IF APPLICABLE) See the back page for more information! If you re married and you choose a primary beneficiary other than, or in addition Notary Stamp to, your spouse including a trust, your spouse must give his/her consent, ALTERNATE according to federal regulations.* Your signature must be witnessed by a notary public or an authorized Deseret Mutual representative. Spouse s Signature Date 150 Social Hall Avenue, Suite 170 P.O. Box 45530, Salt Lake City, Utah 84145 Telephone 1-801-578-5600 Toll free 1-800-777-3622 Fax 1-801-578-5933 Website: www.dmba.com A. PARTICIPANT INFORMATION Name of Trust Date of Trust Notary Public or Deseret Mutual Representative Signature BENEFICIARY FORM Contact DatePhone # FOR DESERET MUTUAL USE ONLY CONTRACT NUMBER: For the waiver to be valid, spouse s signature date and notary date must be the same. D. BENEFICIARY DESIGNATION E. IMPORTANT INFORMATION TO KNOW If you WHEN want to NAMING designate YOUR different BENEFICIARIES beneficiaries for each plan, you must complete a separate form for each plan. Please include your name, Deseret Mutual identification number, date, and signature. 1. Types of beneficiaries: CHECK BOX FOR ALL PLAN(S) THAT APPLY : a. Primary person to receive benefits LIFE INSURANCE when you die SAVINGS RETIREMENT b. Alternate person to receive the primary benefits GROUP when TERM you die LIFE if beneficiary THRIFT is deceased 401(k) RETIREE GROUP TERM LIFE* 2. SUPPLEMENTAL GROUP TERM LIFE TAX SHELTERED ANNUITY 403(b) RETIREE SUPPLEMENTAL GROUP TERM LIFE* If you name multiple primary or multiple alternate beneficiaries, benefits will be split equally, unless otherwise noted on the 24-HOUR ACCIDENTAL DEATH & RETIREMENT PLUS MASTER RETIREMENT PLAN (PENSION)* form. If you re allocating the percentage of benefit, please verify that the total for primary beneficiaries equals 100% and DISMEMBERMENT SAVINGS ANNUITY * You cannot preselect your beneficiaries. the total for alternate beneficiaries equals 100%. Available only on or after you apply for retirement 3. If you name minor children as beneficiaries, LIST ALL BENEFICIARIES: we must have Beneficiary legal guardianship payments are papers paid from for each the most child recent, at the valid time beneficiary of your designation. (To name more beneficiaries, use than the 18. back This of could this page.) mean To legal designate expenses a trust for the as a beneficiary, and see delay the back benefit of this page. death if they are unmarried and younger payments. Please consider this when naming ALL PRIMARY your beneficiaries. BENEFICIARIES SHARE EQUALLY ALL ALTERNATE BENEFICIARIES SHARE EQUALLY 4. Spousal Consent Waiver: Full Given Name of Beneficiary Relationship Birth Date Contact Phone # Benefit a. Thrift Plan and Retirement PLUS Plan required if you re married and choose a primary beneficiary other than or in addition to your spouse, including a trust* b. Savings Annuity: i. Term Certain & Life Payment Options (2 ½, 5, 7 ½, 10, 15, or 20 years) required if you re married and choose a primary beneficiary other than or in addition to your spouse, including a trust* ii. Joint & Survivor Payment Options PRIMARY not required. Your beneficiary must be someone other than your spouse c. Master Retirement Plan: i. Term Certain & Life Payment Options (10, 15, or 20 years) required if you re married and choose a primary beneficiary other than or in addition to your spouse, including a trust* ii. Joint & Survivor Payment Option not required. Your beneficiary must be someone other than your spouse d. Life Insurance Plans (Group Term Life, Supplemental Group Term Life, Occupational Accidental Death & Dismemberment, and 24-Hour Accidental Death BENFRM0115 & Dismemberment) PLEASE not required SEE THE BACK FOR INSTRUCTIONS ON COMPLETING YOUR BENEFICIARY DESIGNATIONS 5. When you die, Deseret Mutual will contact your primary beneficiary to request additional information, including a certified death certificate. Benefit *If you re married, the law requires your spouse to be your primary beneficiary. But you may choose a beneficiary other than or in addition to your spouse with your spouse s written, notarized consent. If you don t have a valid beneficiary designation on file when you die, the Qualified Preretirement Survivor Annuity (QPSA) benefit will be in effect. From the QPSA, 50 your benefit or account balance will be paid to your current spouse, and the remaining 50% will be paid to your estate or named beneficiary. A more detailed explanation of the QPSA is available upon request. COMPANY CODE Retiree Supplemental Group Term Life Insurance Table of Contents Enrollment................................ 1 Coverage................................. 1 Spousal Coverage........................ 1 Coverage for Your Surviving Spouse........... 1 Coverage for Dependent Children............ 1 Premiums................................. 2 Receiving Insurance Benefits................... 2 Eligible Dependents.......................... 3 Exclusions................................ 3 Filing Claims.............................. 3 Definitions................................ 3 Claims Review & Appeal Procedures............. 3 Notification of Discretionary Authority........... 3 Notification of Benefit Changes................. 3 2015 TABLE OF CONTENTS
Your Retiree Supplemental Group Term Life Insurance Handbook... No one wants to leave family or loved ones behind without some financial protection. Finding affordable life insurance is vital to establishing a secure financial future. And to help provide this security, Deseret Mutual offers several different life insurance plans to meet your needs. This section of your Benefits Handbook outlines the major provisions of Deseret Mutual s Supplemental Group Term Life insurance plan for retirees as of January 1, 2015. This document also serves as your summary plan description, or SPD. Retiree Supplemental Group Term Life Insurance Just as the name implies, Retiree Supplemental Group Term Life insurance is supplemental to all other life insurance coverage you may have. You pay the entire cost for coverage. But you have the advantage of low group rates. Enrollment To enroll in Retiree Supplemental Group Term Life insurance, you apply at the time you retire as part of the Online Retirement Application. is application may also include a health questionnaire to measure whether you meet Deseret Mutual s health standards. If you don t enroll within 30 days of your retirement, you will not be eligible for life insurance in the future. Coverage To qualify for this coverage, you must be at least 55 years old and have 10 years of eligible credit in Deseret Mutual s benefit program. Also, you must apply for this coverage before you retire. After you retire, you cannot enroll or increase your levels of coverage. You can select one of four coverage amounts, depending on your age: $10,000, $15,000, $25,000, or $35,000. If you had Group Term Life (GTL) insurance before you retired, you do not have to meet Deseret Mutual s health standards for $10,000 of SGTL coverage. And if you had both GTL and SGTL coverage before you retired, you do not have to meet Deseret Mutual s health standards for $15,000 of SGTL coverage. e $35,000 coverage amount reduces to $25,000 when you turn 75. Additional coverage requires that you meet health standards. SPOUSAL COvERAGE Your spouse can select $5,000, $10,000, $15,000, or $25,000 of coverage, depending on his or her age. For additional coverage, your spouse must meet Deseret Mutual s health standards for all levels if he or she was not enrolled before you retired. COvERAGE FOR YOUR SURvIvING SPOUSE If your spouse s Retiree Group Term Life or Retiree Supplemental Group Term Life insurance is in force at the time of your death, your spouse does not need to meet health standards to continue at the same level of Retiree Supplemental Group Term Life coverage as a surviving spouse. If your spouse does not have any Retiree Group Term Life in effect at the time of your death, your surviving spouse can apply for $5,000 of Survivor Supplemental Group Term Life coverage. For more information about surviving spouse benefits, please contact Deseret Mutual. COvERAGE FOR DEPENDENT CHILDREN If your dependents were enrolled before you retired, they can continue the same levels of coverage without 2015 PAGE 1
meeting Deseret Mutual s health standards. If they weren t previously enrolled, they must enroll within 30 days of your retirement and must meet Deseret Mutual s health standards for all options. You may choose between three insurance options for your eligible dependent children: Birth to 6 months 6 months to 26 years Option 1 $ 1,000 $ 3,000 Option 2 $ 7,500 Option 3 $ 15,000 ese levels of coverage may continue during your retirement. If you acquire a new dependent after you retire, you can enroll him or her within 60 days of the date you acquired the dependent. e dependent must meet Deseret Mutual s health standards for coverage Option 2 or Option 3. Premiums To determine the monthly premium for you and your spouse, see the table on page 4. Find the amounts per thousand opposite your age, or your spouse s age, as of last January 1. en multiply these amounts by the number of thousands of coverage for which you or your spouse is applying. Because this is supplemental coverage, you pay the entire cost of the premium for the coverage you choose. If your monthly retirement check is large enough to cover the premium, your premiums are automatically deducted from your check. Otherwise, you will be billed monthly. PREMIUMS FOR DEPENDENT CHILDREN e following premiums apply to children of active or retired employees as of April 1, 2012. e monthly premium covers all of your eligible children, regardless of how many children you have. If you have a child who has less coverage than the others, you pay the higher amount. $0.44 for $3,000 of coverage $0.96 for $7,500 of coverage $1.74 for $15,000 of coverage Receiving Insurance Benefits If one of your insured dependents dies, benefits are paid to you. If you die, the SGTL insurance benefits are paid to your named beneficiary. Please be aware that Deseret Mutual can only release information to your designated primary beneficiary. If you designated multiple beneficiaries and a primary beneficiary dies before you do and you don t designate a new beneficiary, the benefit payment for the predeceased primary beneficiary is equally distributed among the remaining living primary beneficiary(ies). The same applies to predeceased alternate beneficiary(ies) if no primary beneficiaries exist. If you die without naming a beneficiary or if your beneficiary dies before you do and you have not named an alternate beneficiary or you do not have a valid beneficiary benefits are paid to your estate. e court may recognize the personal representative you named in your estate plan. Or a family member may be appointed as your personal representative through the court system. is personal representative files the necessary paperwork with Deseret Mutual, and we release your funds to the personal representative on behalf of your estate. You may change your beneficiary at any time on our website (or in writing). We suggest you always provide an alternate beneficiary and make sure your beneficiaries are current. A named beneficiary may die or you may divorce and remarry. So you need to review your beneficiaries on a regular basis. 2015 PAGE 2
If you have named a trust as your beneficiary, Deseret Mutual will request a full copy of the trust for legal review before benefit payments can be made. If your beneficiary is a minor and a trustee has not been named to receive the minor s share, a guardian must be appointed through a court proceeding, and a certificate of appointment and qualification must be sent to Deseret Mutual. If a guardian is not appointed, Deseret Mutual will hold the funds at simple interest until the minor is of age and requests the payment. Eligible Eligible Dependents Your eligible dependents include your spouse and dependent children. Your spouse is defined as a person of the opposite sex who is your legal husband or wife. Exclusions Retiree Supplemental Group Term Life insurance benefits are not available for loss caused wholly or partly, directly or indirectly, by: suicide (if the coverage was in force for less than two years before the suicide) any falsification, omission, or misstatement regarding information used to determine eligibility for coverage during the application and underwriting process may be grounds to void coverage war or act of war, or service in the military forces of any country at war, declared or undeclared. War includes hostilities made by force or arms by one country against another, or between countries or factions within a country, either with or without a formal declaration of war Filing Filing Claims Claims To receive benefits, you or your beneficiary must: Step 1: Contact Deseret Mutual. Deseret Mutual then sends an information packet to you or your beneficiary. Step 2: Complete the forms in the packet. Step 3: Send the completed forms and a copy of the death certificate to Deseret Mutual. Definitions For definitions of words and terms applicable to the retiree life insurance plans, please refer the Definitions section of your Benefits Handbook. Claims Review & Appeal Procedures If Deseret Mutual denies your claim and you want to appeal because you think it was denied inappropriately, or if you have other claim concerns or complaints, please bring them to our attention. You must submit your appeals within 12 months from the date we send your benefit decision notification. For more information about how to appeal a claim, please refer to the General Information section of your Benefits Handbook. Notification of Discretionary Authority Deseret Mutual has full discretionary authority and the sole right to interpret the plan and to determine eligibility. All Deseret Mutual decisions relating to plan terms or eligibility are binding and conclusive. Notification of Benefit Changes Deseret Mutual is subject to the Employee Retirement Income Security Act (ERISA) and reserves the right to amend or terminate this plan at any time. If benefits change, we will notify you at least 30 days before the effective date of change. 2014 PAGE 3
Age Last January 1 Amount per $1,000 Premiums as of January 1, 2015 Amounts of Coverage $5,000 $10,000 $15,000 $25,000 $35,000 Younger than 55 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 85 and older 0.20 0.34 0.54 0.86 1.38 2.21 3.54 6.37 1.00 1.70 2.70 4.30 6.90 11.06 17.70 31.86 2.00 3.40 5.40 8.60 13.80 22.10 35.40 63.70 3.00 5.10 8.10 12.90 20.70 33.16 53.10 95.56 5.00 8.50 13.50 21.50 34.50 55.26 88.50 159.26 7.00 11.90 18.90 30.10 48.30 Notes: Enrollment Coverage Spousal Coverage Coverage for Your Surviving Spouse Coverage for Dependent Children Premiums Receiving Insurance Benefits Exclusions Filing Claims Definitions Claims Review & Appeal Procedures Notification of Discretionary Authority Notification of Benefit Changes 2014 PAGE 4