CITYWIDE ASSOCIATION OF LAW ASSISTANTS OF THE CIVIL, CRIMINAL AND FAMILY COURTS IN THE CITY OF NEW YORK WELFARE TRUST FUND C/O ADMINISTRATIVE SERVICES ONLY, INC 303 MERRICK ROAD, SUITE 300 LYNBROOK, NY 11563 800-537-1238 WWW.NYSCALA.COM WWW.ASONET.COM Dear Participant: IMPORTANT INFORMATION REGARDING OPTIONAL TERM LIFE INSURANCE BENEFIT YOUR IMMEDIATE ATTENTION TO THIS MATERIAL IS REQUIRED YOUR RESPONSE REQUIRED BY SEPTEMBER 30, 2010 We are pleased to announce that, effective SEPTEMBER 1, 2010 all Active and Part-Time Employees (with over 20 hours per work week) will have the option of purchasing OPTIONAL TERM LIFE INSURANCE. This benefit would be in addition to the $25,000 Group Basic Term Life and Basic Accidental Death and Dismemberment Insurance Policy which is provided to you at no cost. Enclosed you will find important information on Optional Term Life Insurance. If you wish to elect this option, you MUST COMPLETE AND RETURN THE FORMS BY SEPTEMBER 30, 2010. You will have the option to purchase additional individual insurance for yourself. When purchasing additional insurance for yourself you may also purchase insurance for your spouse and/or dependent children. If you do not purchase additional insurance for yourself, you will not have the opportunity to purchase insurance for your spouse or dependent children. Coverage will be effective September 1, 2010. Any amounts elected over the guarantee will be subject to underwriting approval. If you enroll when first eligible, you may get a certain amount of coverage without having to answer any health questions or having a medical exam. The insurance carrier is in the process of printing a comprehensive booklet with detailed information regarding the provisions of the Plan. If you have any additional questions regarding this new Group Term Life Insurance or the Optional Life Insurance Benefit, please contact Administrative Services Only, Inc at 1-800-537-1238 ext 9475. Very truly yours, Board of Trustees M:DOC\CALA LIFE INSURANCE ENROLLMENT PACKAGE-OPTIONAL COVERAGE INITIAL FORM
INSTRUCTIONS Please review information regarding the Optional Term Life Insurance benefit options, enrollment requirements and chart of cost. Complete and return the Optional Term Life Insurance Election/Rejection Form. If electing Optional Term Life Insurance, please make your check payable to ASO BROKERAGE and indicate Life Insurance Premium in the memo field. If electing Optional Term Life Insurance for YOURSELF, the beneficiary form for the basic group term life insurance will serve as the beneficiary designation form for the optional life insurance. If electing Optional Term Life Insurance for your SPOUSE, please complete the Spouse Optional Life Insurance Beneficiary Designation Form. If electing Optional Term Life Insurance for DEPENDENT CHILDREN, there is one rate for all the children and the member is automatically the beneficiary. ***IMPORTANT NOTICE*** Information in this packet provides a brief general description, written in non-technical language, of the important provisions of the Group Term Life Insurance Policy and the Optional Term Life Insurance Policy as expressed in the Insurance Contract. If any conflict should arise between this notice and the Group Term Life Insurance Contract, the terms of the insurance contract will govern in all cases.
OPTIONAL TERM LIFE INSURANCE The Optional Term Life Insurance payment is in addition to the Basic Term Life Insurance coverage offered by the Fund. Your salary determines the maximum coverage amount available to you. See the enclosed charts for Coverage Options. MEMBER OPTIONAL TERM LIFE INSURANCE COVERAGE You may purchase coverage in increments of $25,000 to $500,000, not to exceed 7.0 times your covered annual earnings. During the initial open enrollment period, you may purchase up to $200,000- no medical questions asked. You may apply for additional coverage during the annual open enrollment period (SEPTEMBER 1 through SEPTEMBER 30). During subsequent annual open enrollment periods, if you have not been previously denied coverage, you may select to increase your current coverage amount up to $40,000, up to a total coverage amount of $200,000 without providing evidence of insurability to Prudential. SPOUSE OPTIONAL TERM LIFE INSURANCE COVERAGE You may purchase coverage for your spouse in increments of $5,000 to $250,000, not to exceed 50% of your Optional Term Life coverage amount. During the initial open enrollment period, your spouse may purchase up to $20,000- no medical questions asked. During subsequent annual open enrollment periods, evidence of insurability satisfactory to The Prudential Insurance Company of America is required for all increases in coverage amounts. CHILDREN OPTIONAL TERM LIFE INSURANCE COVERAGE You may purchase coverage for your eligible dependent children in increments of $2,000 to $10,000, not to exceed 50% of your Optional Term Life coverage amount. There are no health requirements for this coverage. Coverage begins from 14 days, and continues to age 19, if unmarried. If unmarried, dependent on you and a full-time student, coverage continues to age 25.
FREQUENTLY ASKED QUESTIONS When can I enroll for Optional Term Life Insurance coverage? The easiest way to enroll and guarantee a certain level of coverage is to sign up when first eligible. If you enroll at any other time or for more than the guaranteed coverage amount, you may need to provide evidence of good health satisfactory to Prudential. When is a medical exam required and who pays for it? A medical exam may be required if you elect more coverage than the guaranteed amount. Prudential will pay the cost of any required medical exam when you are first eligible. Late entrants must pay for medical exams. Generally, medical exams are conducted by an examiner who is chosen by Prudential. When will coverage go into effect? For your coverage to become effective, you must be actively at work during the enrollment period and on the effective date of your coverage. If you apply for an amount that requires evidence of good health, you must be actively at work, on the date of approval for the amount requiring evidence of good health. If your dependents are confined for medical treatment at home or elsewhere, their coverage will begin when confinement ends. Refer to the Booklet- Certificate for details. Can I increase my coverage in the future? Yes, you can increase your coverage up to your plan s maximum coverage amount. However, evidence of good health satisfactory to Prudential may be required as previously noted. How can I enroll? To enroll, simply complete the Election/Rejection Form. Then, return it as instructed. After the date your group insurance becomes effective, you will receive a booklet-certificate that details your plan provisions. Conversion to Individual Insurance Coverage- Upon termination of Employment, you may convert your coverage to a Prudential individual life Insurance policy, without having to provide evidence of good health. Waiver of Premium- Payment of your premium can be waived if you meet all these conditions: 1) you are less than 60 years old when your disability begins, 2) you are totally disabled and unable to work for at least 9 continuous months, And 3) you continue to be totally disabled. The Waiver of Premium Benefit Terminates at age 65. This provision may vary by state. If any of the conditions above apply YOU MUST CONTACT THE FUND OFFICE IMMEDIATELY. Accelerated Benefit Option- If terminally ill, you can get a partial payment of Your group term life insurance benefit. You can use this payment as you see fit. In the event of your death, your beneficiary will receive a benefit payout which has been reduced by the amount you receive. Receipt of accelerated death benefits may affect eligibility for public assistance programs and May be taxable. There is no administrative fee to accelerate death benefits. The accelerated amount is not discounted. Portability of Group Insurance Coverage- Upon termination of Employment, you may continue a certain level of your Member and Dependent coverage, without having to provide evidence of good health
CITYWIDE ASSOCIATION OF LAW ASSISTANTS OF THE CIVIL, CRIMINAL AND FAMILY COURTS IN THE CITY OF NEW YORK WELFARE TRUST FUND OPTIONAL GROUP TERM LIFE INSURANCE ELECTION/REJECTION FORM YES, I WISH TO PURCHASE OPTIONAL INSURANCE COVERAGE AT THE AMOUNT INDICATED BELOW NO, I DO NOT WISH TO PURCHASE ANY ADDITIONAL OPTIONAL LIFE INSURANCE Please return this form to: ADMINISTRATIVE SERVICES ONLY, INC. PO Box 9005 Lynbrook, NY 11563 I understand that if I wish to purchase any additional optional insurance in the future, proof of insurability may be required. MEMBER SOCIAL SECURITY NUMBER DATE OF BIRTH XXX-XX- / / LAST NAME FIRST NAME MI PHONE ADDRESS APT NO. CITY STATE ZIP IF YOU HAVE ANY QUESTIONS WHEN SELECTING COVERAGE AMMOUNT AND CALCULATING THE PREMIUM DUE, PLEASE CONTACT ASO AT 1-800-537-1238 EXT 9475. PLEASE MAKE CHECK PAYABLE TO ASO BROKERAGE SERVICES INCORPORATED and return to the address above. COVERAGE AMOUNT* MONTHLY COST** SEMI-ANNUAL BILLING CYCLE*** AMOUNT DUE FOR OPTIONAL LIFE INSURANCE**** MEMBER X 6 = SPOUSE-coverage amount may not exceed 50% of coverage selected for Member Optional Life Insurances X 6 = DEPENDENTS X 6 = TOTAL X 6 = * Please Indicate Coverage Amount. Please refer to chart. Amount selected may not exceed 7 x annual salary. ** Monthly Cost-Cost of Coverage Amount from your Age Bracket and Coverage Amount *** Billing Cycle-Premiums will be billed on a six month cycle. **** Amount Due for Optional Life Insurance- Monthly Cost x 6 Months SECTION IV MEMBER SIGNATURE MEMBER S SIGNATURE: DATE: / /
THE SPOUSE OF THE PLAN MEMBER MUST COMPLETE THIS FORM ONLY IF SPOUSAL COVERAGE IS PURCHASED. CITYWIDE ASSOCIATION OF LAW ASSISTANTS OF THE CIVIL, CRIMINAL AND FAMILY COURTS IN THE CITY OF NEW YORK WELFARE TRUST FUND ***Spouse Optional Term Life Insurance Beneficiary Designation Form *** Please complete & sign this form in ink. MAKE A COPY FOR YOUR RECORDS & RETURN THE SIGNED ORIGINAL TO: SECTION I MEMBER INFORMATION Administrative Services Only, Inc. PO Box 9005 Lynbrook, NY 11563 LAST NAME FIRST NAME MI SOC SEC NO. DATE OF BIRTH XXX-XX- SECTION II SPOUSE INFORMATION LAST NAME FIRST NAME MI SOC SEC NO. DATE OF BIRTH XXX-XX- Please make your beneficiary designation(s) below. If you need more space, attach another sheet to this form. You may designate more than one Primary or Contingent Beneficiary. If you do, make sure to indicate the percentage share each should receive. The total within each class (Primary and Contingent) must equal 100%. If you do not specify percentages, surviving beneficiaries within each class will share the proceeds equally. If you do not name a beneficiary, or if no beneficiaries are alive at the time of your death, proceeds will be payable to your estate. SECTION III PRIMARY BENEFICIARY INFORMATION FOR SPOUSE OPTIONAL LIFE INSURANCE Please indicate who should receive your Optional Term Life Insurance Proceeds in the event of your death FULL NAME LAST, FIRST, MI RELATIONSHIP (need not be a family member) ADDRESS PHONE NUMBER % SHARE OF PROCEEDS SECTION IV CONTINGENT BENEFICIARY INFORMATION FOR SPOUSE OPTIONAL LIFE INSURANCE Please indicate who should receive the Optional Term Life Insurance proceeds in the event that ALL of your Primary Beneficiaries are not living at the time of your death. FULL NAME LAST, FIRST, MI RELATIONSHIP (need not be a family member) ADDRESS PHONE NUMBER % SHARE OF PROCEEDS SECTION V SIGN AND DATE THIS FORM FOR YOUR DESIGNATION TO BECOME EFFECTIVE MAKE A COPY FOR YOUR RECORDS AND RETURN THE SIGNED ORIGINAL Member Signature Date
BENEFICIARY FORM INSTRUCTIONS These instructions will assist you in properly completing the Primary and Contingent Beneficiary sections of the Beneficiary Designation Form. If you have any questions, please call Administrative Services Only, Inc. at 800-537-1238 ext 9475, 516-394-9475 It is very important that you take the time now to designate who will receive the Group Life Insurance proceeds in the event of your death. If you do not do so, the benefit will go to your estate. In order to designate a beneficiary to receive any benefits payable in the event of your death, you must sign and date the Beneficiary Designation Form on the reverse side of this notice and return it to the Administrative Services Only, Inc. PO Box 9005, Lynbrook NY 11563. IF YOUR SPOUSE IS ELECTING OPTIONAL/SUPPLEMENTAL LIFE, PLEASE COMPLETE AND RETURN THE BENEFICIARY DESIGNATION FORM FOR SPOUSE OF PLAN MEMBER IN ADDITION TO THE BENEFICIARY DESIGNATION FORM FOR PLAN MEMBERS. THE VALIDITY OF YOUR DESIGNATION UNDER THE LAW IS YOUR RESPONSIBILITY. BE PRECISE AND CLEAR BEFORE MAKING BENEFICIARY DESIGNATIONS, YOU MAY WANT TO CONSULT WITH YOUR TAX OR LEGAL ADVISOR. YOU MAY CHANGE A BENEFICIARY DESIGNATION AT ANY TIME. Please Note: You cannot name your employer as a beneficiary for Group Life Insurance proceeds under the Group Policy. If a beneficiary is living at the time of the employee s death but dies before receiving full benefits, the remaining proceeds will be paid to the beneficiary s estate. Proposed Beneficiary(ies) Suggested Wording 1. Estate Estate 2. One Beneficiary Martha Doe, wife 3. More than one beneficiary in equal shares Jane Doe, Mary Doe and Richard Doe, children, or survivor(s) of them, in equal share 4. Two beneficiaries, in succession Primary: Martha Doe, wife; Contingent: Richard Doe, son (Richard will only receive proceeds if Martha Doe is not living at the time of employee s death.) 5. One Beneficiary followed by two beneficiaries in equal shares 6. More than one Beneficiary in equal shares per descendent order Primary: Martha Doe, wife; Contingent: Jane Doe and Mary Doe, children in equal shares, or the survivor of them (Jane and Mary will only receive proceeds if Martha Doe is not living at the time of the employee s death.) Jane Doe, Mary Doe and Richard Doe, or the survivor(s) of them, in equal shares. However, if any of my children predecease me and leave issue who survive me, the issue of the deceased child will receive their parents share in equal shares. 7. One or more minor children. John Smith, as custodian for Jane Doe, a minor under the Uniform Transfers to Minors Act (UTMA) so that proceeds can be paid before the child reaches the age of majority. 8. To a church or non-profit Name and address of the beneficiary organization. organization 9. Beneficiaries shown in percentages John Smith, brother 40%, or in the event of his death, to my estate; Alan Smith, brother 60%, or in the event of his death, to my estate. 10. Trust under Last Will and Proceeds to be paid to the Trustee under my Last Will and Testament Testament. 11. Existing Trust Jane Doe, Trustee of the Doe Family Trust, dated 1/1/2001