Massachusetts Institute of Technology: Supplemental Life Insurance Plan 2016 Open Enrollment Period: October 26 November 6, 2015 MetLife Supplemental Term Life Insurance Coverage For You For Your Spouse/ Domestic Partner For Your Dependent Children Coverage Coverage levels from 1 to 7 times your base annual salary**, to a maximum coverage amount of $2,000,000. Coverage level is subject to scheduled reductions after age 65.* New beginning January 1, 2016! new plan options of 6x and 7x base annual salary Option 1 - $50,000 Option 2 - $100,000; maximum issue amount. 15 days to 6 months - $100 per child Over 6 months - $10,000 per child Enrollment Requirements Current plan participants can increase coverage by one level with no health questions to answer. Any election over one level would require five health questions to be answered. Non-participants will be required to answer five health questions for all coverage amounts. If you answer Yes to any of the health questions, you will be required to complete a full Statement of Health. Answer five health questions for all coverage amounts. If you answer Yes to any of the health questions, you will be required to complete a full Statement of Health. No health questions are required. At least 15 days old, under age 26, unmarried and supported by You. *View the Supplemental Term Life scheduled age-reduction chart on the MIT Benefits website at http://hrweb.mit.edu/benefits/supplemental-life-insurance **Supplemental Life Insurance for Faculty members and other academics with 9-month MAP appointments is based on 11/9ths of base annual salary. MetLife will review your information and evaluate your request for coverage based upon your answers to the health questions, MetLife s underwriting rules and other information you authorize us to review. In certain cases, MetLife may request additional information to evaluate your request for coverage. WHEN YOUR COVERAGE WILL BECOME EFFECTIVE: You must be actively at work on the date your coverage becomes effective, and your spouse/domestic partner and eligible child(ren) must not be confined to a hospital on the enrollment date, or at home for any medical reason or be receiving or entitled to receive disability income for any medical reason on the date the coverage is scheduled to become effective. Coverage will become effective on 1/1/2016 following the receipt of your completed application for all requests that do not require additional medical information. Requests for amounts that require additional medical information and are not approved by 1/1/2016 will not be effective until the date coverage is approved by MetLife provided the policy s active at work requirements are met, and for spouse/domestic partner and eligible child(ren) coverage, the date that they are no longer confined to a hospital or at home for any medical reason or receiving or entitled to receive disability income for any medical reason.
Monthly Costs for Supplemental Term Life Insurance You have the option to purchase Supplemental Term Life Insurance. Listed below are your monthly rates as well as those for your spouse/domestic partner (based on your age and the amount of coverage you want). Rates to cover your child(ren) are also shown. Your Age Your Monthly Cost Per $1,000 of Coverage (based on your age on 1/1) Spouse/Domestic Partner Monthly Cost Per $1,000 of Coverage (based on your age on 7/1) Under 25 $0.030 $0.034 25-29 $0.030 $0.043 30 34 $0.039 $0.060 35 39 $0.039 $0.069 40 44 $0.049 $0.086 45 49 $0.097 $0.121 50 54 $0.146 $0.198 55 59 $0.233 $0.344 60 64 $0.323 $0.568 65 69 $0.565 $1.025 70-74 $0.900 $1.654 75 79 $1.365 $1.654 80 + $2.060 $1.654 Cost for your Child(ren) Rates are guaranteed through 12/31/2019 $1.19 per covered child
HOW YOU PAY FOR COVERAGE: Coverage is paid through convenient payroll deductions. How to calculate your Employee Supplemental Term Life Insurance Monthly Cost: Example: 33 year old applying for $150,000 of coverage. Steps Example Calculate for Yourself A. Find your age-based rate in the Supplemental Term Life chart table (example age 33): $ 0.039 $ B. Determine how much coverage you are applying for: $150,000 $ C. Divide that coverage amount by 1,000 D. Multiply Rate (A) x Coverage Amount in $1,000 s (C) to get your Monthly Cost: 150 ($150,000 1,000) $5.85 ($0.039 x 150) $ METLIFE ADVANTAGES SM : Your plan includes access to MetLife Advantages SM a comprehensive suite of valuable services for support, planning and protection when you need it most. Services include: Face-to-Face Will Preparation Services 1 Offers you and your spouse/domestic partner face-to-face meetings with an attorney, from Hyatt Legal Plans network of over 13,500 participating attorneys, to prepare or update a will, living will, Power of Attorney and other estate documents. WillsCenter.com 2 Helps you or your spouse/domestic partner prepare a will, living will, Power of Attorney and HIPAA Authorization form on your own, at your own pace, 24 hours a day, 7 days a week. Face-to-Face Estate Resolution Services 1 Estate representatives and beneficiaries may receive face-to-face legal assistance with probating your and your spouse s/domestic partner s estates. Beneficiaries can also consult an attorney, from Hyatt Legal Plans network of more than 13,500 participating attorneys, for general questions about the probate process. Funeral Planning Guide Allows employees to outline their final wishes for their loved ones and beneficiaries. It highlights details of pertinent information, including how to plan for funeral costs, the death claim process, personal funeral preferences and more. Face-to-Face Grief Counseling 3 Provides you and your dependents up to five private counseling sessions with a professional grief counselor per event to help cope with a loss, no matter what the circumstances. Sessions may also be held over the phone. Total Control Account 4 The Total Control Account (TCA) is a settlement option that provides your loved ones with a safe and convenient way to manage life insurance proceeds. They'll have the convenience of immediate access to any or all of their proceeds through an interest bearing account with unlimited check-writing privileges. The Total Control Account also allows beneficiaries time to decide what to do with their proceeds. Delivering the Promise 5 This service is designed to provide beneficiaries with the support and assistance they need during an especially difficult time. Specialists are available to assist in filing life insurance claims, discuss financial options and answer questions that arise upon the loss of a loved one. MetLife Center for Special Needs Planning Provides services and assistance from specially trained representatives to families planning for the financial future of dependents with special needs. Face-to-face or phone conversations are available.
Portability 6 Gives you an opportunity to continue your Group Life insurance coverage with MetLife should you leave Massachusetts Institute of Technology for any reason. Competitive rates apply but will likely be higher than your current rates. MetLife will bill you directly. To take advantage of this feature, you must have coverage of at least $20,000 up to a maximum of $1,000,000. Generally, there is no minimum time for you to be covered by the plan before you can take advantage of the portability feature. Please see your plan administrator for specific details. ADDITIONAL PLAN FEATURES: Conversion You can generally convert your Group Term Life Insurance benefits to an Individual Whole Life, Universal Life or Variable Universal Life Insurance policy if your coverage terminates in whole or in part due to your retirement, termination of employment, or a change in your employee class. Conversion is available on all Group Life Insurance coverages. Accelerated Benefits Option 7 You can receive up to 80% of your Supplemental Life Insurance proceeds to a maximum of $500,000 in the event that you become terminally ill and are diagnosed with less than 24 months to live. This can go a long way toward helping your family meet medical and other related expenses at this difficult time. WHAT S NOT COVERED: Supplemental Life: Like most insurance plans, this has exclusions. For instance, Supplemental and Dependent Insurance do not provide payment of benefits for death caused by suicide within the first two years (one year in North Dakota) of the effective date of the certificate, or payment of increased benefits for death caused by suicide within two years (one in North Dakota or Colorado) of an increase in coverage. There is a two-year contestability period during which any material misstatements made by you can be used by MetLife to deny a claim. 1 Will Preparation Services and Estate Resolution Services are offered by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, Will Preparation Services and Estate Resolution Services are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, RI. These services are provided at no additional cost to those who purchase Supplemental Life Insurance only. Certain services are not covered by Estate Resolution Services, including matters in which there is a conflict of interest between the executor and any beneficiary or heir and the estate; any disputes with the group policyholder, MetLife and/or any of its affiliates; any disputes involving statutory benefits; will contests or litigation outside probate court; appeals; court costs, filing fees, recording fees, transcripts, witness fees, expenses to a third party, judgments or fines; and frivolous or unethical matters. 2 WillsCenter.com is a document service provided by SmartLegalForms, Inc., an affiliate of Epoq Group, Ltd. SmartLegalForms, Inc. is not affiliated with MetLife and the WillsCenter.com service is separate and apart from any insurance or service provided by MetLife. The WillsCenter.com service does not provide access to an attorney, does not provide legal advice, and may not be suitable for your specific needs. Please consult with your financial, legal, and tax advisors for advice with respect to such matters. 3 Grief Counseling services are provided through an agreement with Harris, Rothenberg International, Inc. HRI is not an affiliate of MetLife, and the services HRI provides are separate and apart from the insurance provided by MetLife. HRI has a nationwide network of 46,700 counselors. Counselors have master s or doctoral degrees and are licensed professionals with extensive experience working with people who have suffered a loss. Subject to state availability. 4 Subject to state law, and/or group policyholder direction, the Total Control Account is provided for all Life and AD&D benefits of $5,000 or more. The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing TCA are maintained in MetLife s general account and are subject to MetLife s creditors. MetLife bears the investment risk of the assets backing the TCA, and expects to earn income sufficient to pay interest to TCA Accountholders and to provide a profit on the operation of the TCAs. 5 Delivering The Promise Specialists are Financial Services Representatives of MetLife or New England Financial, a MetLife company. 6 To take advantage of this benefit, coverage of at least $10,000 must be elected. Increases, decreases, minimum and maximum coverage amounts are subject to state availability. Please contact your plan administrator or refer to your certificate for specific details. 7 The Accelerated Benefits Option is subject to state regulation and is intended to qualify for favorable federal income tax treatment, in which case the benefits will not be subject to federal income taxation. This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are complex and limitations may apply. You are advised to consult with and rely on an independent tax advisor about your own particular circumstances. Receipt of accelerated benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to consult with social service agencies concerning the effect that receipt of accelerated benefits will have on public assistance eligibility for you, your spouse or your family. This summary provides an overview of your plan s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and Massachusetts Institute of Technology and are subject to each state s laws and availability. Specific details regarding these provisions can be found in the booklet certificate. Life coverage is provided under a group insurance policy (Policy Form GPNP99/G2130-S) issued to your employer by MetLife. Life coverage under your employer s plan terminates when your employment ceases, when your Life contributions cease, or upon termination of the group contract. Should your life insurance coverage terminate for reasons other than nonpayment of premium or voluntary cancellation, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability. L0915437930[exp1116][All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, New York, N.Y.
MIT SUPPLEMENTAL LIFE INSURANCE ENROLLMENT/CHANGE FORM Group Number: 112757 EMPLOYEE PERSONAL INFORMATION (NAME, ID AND PHONE CONTACT INFORMATION MUST BE COMPLETED) Last Name: First Name: Middle: MIT ID: Home Address: Date of Hire: P.O. Box: City: State: ZIP Code: MIT Phone Number: MIT Email Address: Office Address (Building/Room): Home Phone Number: SUPPLEMENTAL LIFE INSURANCE ENROLLMENT & COVERAGE OPTIONS Supplemental Life Insurance coverage is optional and is in addition to your Basic Life coverage. If you would like to add or make changes to your beneficiary information, please complete a beneficiary form. Beneficiary forms, supplemental life coverage costs, coverage limits and effective dates are located at: http://hrweb.mit.edu/benefits/supplemental-life-insurance Reason for Enrollment/Change (check one box): New Enrollment Change in Coverage Cancel Coverage Please select a coverage level: 1x base salary 2x base salary 3x base salary 4x base salary 5x base salary 6x base salary 7x base salary New enrollment or change in coverage level may require medical evidence of good health. See Medical Evidence Requirements below. MEDICAL EVIDENCE REQUIREMENTS The MIT Benefits Office will review your Supplemental Life Insurance Enrollment/Change form and, if necessary, will send you a Statement of Health form. You are responsible for completing and sending the Statement of Health form to MetLife. You must furnish medical evidence of your good health satisfactory to MetLife Insurance Company if: 1) Supplemental Life Insurance is elected upon initial eligibility (within 31 days from Date of Hire or Date of Benefits Eligibility) and the election results in Supplemental Life coverage which is more than either 3 times your base salary or $500,000. 2) If you elect to increase your coverage level or coverage amount after your initial eligibility. MetLife Insurance Company will contact you directly regarding the status of your application. Employee signature Date Massachusetts Institute of Technology - Human Resources Department 77 Massachusetts Avenue, Building E19-215, Cambridge, MA 02139 Phone: 617-253-6151 Fax: 617-253-2694 Email: benefits@mit.edu Revised 01/16