Continuation of Coverage at Retirement or Termination

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1 Pecos-Barstow-Toyah ISD Continuation of Coverage at Retirement or Termination How do I continue insurance coverage after retirement or termination? Employees retiring or terminating must contact insurance carriers directly and submit required forms and payment within days of termination/retirement in order to continue coverage. Employees can continue coverage one of the following ways: COBRA (TRS Medical) Eligible for continuation under COBRA; notices sent within 30 days of loss. For ActiveCare plans contact Wellsystems at or COBRA@wellsystems.com. For FirstCare plans contact FirstCare at or cobra@firstcare.com for more information. COBRA (Dental, Vision, MEDlink*, and FSA**) Please update your address with your employer if you move. Continues coverage under the group policy for up to 18 months or longer. After termination with your district, you will receive a COBRA enrollment packet from NBS in the mail 2-3 weeks after the termination date. You have 60 days to enroll in this option. You can contact National Benefit Services at Health Savings Account (HSA Bank) Health Savings Accounts require no action to continue after separation from your employer. Your account and funds will remain open and available. Contact HSABank at Accident (American Public Life) Group #14986 This plan is portable and a bank draft form is required for payment. Please contact American Public Life at to set up your policy and coordinate payment. Cancer (Loyal American) Group #1495 This plan is eligible for continuation through direct billing basis with the insurance company. Please contact Loyal American at to set up your policy and coordinate payment (bank draft form required for payment). Critical Illness (Voya) Group # This plan is portable through direct billing basis with the insurance company. Voya will mail a Portability packet to you at the home address on file. Call for information. See reverse side for more information.

2 Pecos-Barstow-Toyah ISD Continuation of Coverage at Retirement or Termination Family Protection Plan (5 Star Life) #01902 Eligible for continuation thru direct billing bank draft with the insurance company. For more information, contact 5 Star Life at Heart & Stroke (Allstate) #69947 (Grandfathered) This plan is portable by calling Allstate at to advise the insurance company you would like to set up your policy on direct bill through bank draft for your premium payment. Individual Life Insurance (Texas Life SM2110 or Trustmark BG1670) Eligible for continuation thru direct billing bank draft with the insurance company. For more information, contact TX Life at or Trustmark at Voluntary Life Insurance (The Hartford Group) # This plan is eligible for conversion or portability. An application must be completed and payment made within 31 days. For more information, contact your Benefit Dept. or The Hartford at Forms are available at Telehealth (MDLIVE) Contact MDLIVE at or to sign up for an individual plan, different rates apply, no time limit. Portability Continues coverage under the Portability option if you have not reached your Social Security full retirement age. The amount of coverage is reduced by 75% at age 65 and coverage terminates at age 75. Portability does not create an individual policy. Your premiums may increase/decrease because they are solely based on the coverage functionalities under the rule and guidelines of the group policy. See Certificate for full details. Conversion Conversion moves coverage to an individual policy. Conversion premiums are much higher, but conversion gives you ownership of the policy. Coverage is not subject to the reduction schedule of the group policy. * Must also be covered on district health plan thru Cobra in order to be eligible to continue MEDlink coverage thru Cobra. ** Certain restrictions may apply 2175 N. Glenville Drive Richardson, TX

3 PRE-AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER LOYAL AMERICAN LIFE INSURANCE COMPANY THIS FORM MUST BE COMPLETELY FILLED OUT TO BE ACCEPTED Proposed Insured s Name Policy Number (Home Office Only) If the account to be drafted is a Dedicated (Checking or Savings) or Savings account, fill in the shaded boxes. If this is a Personal/Business Checking Account you must attach a voided check for processing. Staple voided checks on the box below. SEG Name (Selected Employer Group) if applicable: Name of Financial Institution: Address & Phone Number of Financial Institution: Transit No. & Routing Savings or Dedicated Account No. Bank account is (Check appropriate box) Personal checking account Dedicated Draft Checking account Personal savings account Dedicated Share Savings account Corporate/Business checking account Purpose for submitting this authorization (Check appropriate box/boxes): New pre-authorized payment plan Change in the Dedicated account noted above Change in checking account Change in bank Change in savings account Addition of new policy to plan Change in existing coverage Desired date for withdrawal from checking/savings account. (Any date between the 1 st and 28 th of each month): TOTAL AMOUNT OF PAYMENT FOR THIS POLICY $ Withdraw My Payment: Monthly Quarterly Semi-Annually Annually APPLICANT INFORMATION FOR FINANCIAL INSTITUTIONS: As a convenience to me, I hereby request and authorize you to pay and charge to my account, drafts drawn on my account by and payable to Loyal American Life Insurance Company provided there are sufficient funds in said account to pay the same on presentation. Such drafts will bear my printed name. This authorization shall remain in effect until revoked by me in writing, and until you actually receive such notice, I agree that you shall be fully protected in honoring any such draft. I agree that your rights in respect to any such draft shall be the same as if it were a check signed personally by me. I further agree that if any such draft is dishonored, whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in the forfeiture of insurance. APPLICANT INFORMATION FOR LOYAL AMERICAN LIFE INSURANCE COMPANY : It is understood that the drafts will be drawn on or about the requested date each month. The presentation of such drafts to the above Financial Institution shall constitute notice of premiums being due upon the contract, and no other notice of premiums due will be given. No premium shall be deemed to have been paid unless and until actual payment of the draft drawn for such premium payment has been received by Loyal American. The cancelled draft will constitute receipt of premium payment. The privilege of paying premiums under this Plan may be revoked by Loyal American if any draft is not not paid upon presentation. The payment of premiums under this Plan may be terminated by the Contract Owner, Financial Institution Depositor if other than Contract Owner, or by Loyal American upon 30 days written notice. Print name as it appears on account Date Signature of depositor L-3951 (R6/00)

4 AUTHORIZATION TO HONOR CHECKS OR ELECTRONIC TRANSFER OF FUNDS DRAWN BY AND PAYABLE TO THE AMERICAN PUBLIC LIFE INSURANCE COMPANY JACKSON, MISSISSIPPI TO: (BANK) BRANCH NAME, IF ANY BANK ADDRESS BANK ADDRESS As a convenience to me, I hereby request and authorize you to pay and charge to my bank checking account checks or electronic transfer of funds drawn by and payable to the order of American Public Life Insurance Company, Jackson, Mississippi, provided there are sufficient collected funds in said account to pay the same upon presentation. It will not be necessary for any officer or employee of American Public Life Insurance Company to sign such checks or electronic transfer of funds. I agree that your rights in respect to each check or electronic transfer of funds shall be the same as if it were a check drawn on you and signed personally by me. This authority is to remain in effect until revoked by me in writing, and until you actually receive such notice I agree that you shall be fully protected in honoring any such check or electronic transfer of funds. I further agree that if any such check or electronic transfer of funds be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in the forfeiture of insurance. Account Holder Name (please print) Account Holder Address Account Holder Address Account Number Bank Routing Number Account Holder Signature Date Please mail form to: American Public Life Insurance Company Attn: Customer Service P. O. Box 925 G-112R (12/02) Jackson, MS 39205

5 Notice of Conversion and/or Portability Rights As a terminated employee or as an active employee or retiree losing coverage or a portion of coverage for you or your dependents under your employer s Group plan(s), you and/or your dependents may be eligible to continue all or a portion of that coverage without submitting evidence of good health. Potential options are explained below. The specific options available to you are based on the provisions as defined in the Group plan. Included with this notice is a form you can submit to obtain additional information. Based on your selection, you will receive a personalized quote, details on the specific coverage options available to you, and the necessary forms to enroll. Life Conversion The Life Conversion option provides the opportunity for you to obtain an individual life insurance policy that accumulates cash value and is offered at individual insurance rates. There are no mandatory age reductions and coverage can continue with premium payment until the Scheduled Maturity Date (standardly age 121) at which time the cash surrender value is paid to the insured. If coverage is ending because The Hartford Group Life policy is terminating or coverage for a class of employees is terminating, some restrictions may apply. If coverage is ending for any other reason, you can generally convert up to the full amount of your terminating coverage. Conversion is also available to your dependents if they had coverage under your group plan. You may have the option to obtain a one year term policy prior to the permanent life policy becoming effective. Please refer to The Hartford Group Life policy for information. Premiums for a Life Conversion policy are substantially higher than your Employer Group plan rates. Portability Under the Portability option you may obtain a group life insurance policy to continue 100%, 75%, or 50% of the amount of life insurance coverage (Basic, Supplemental, or both) you had under your Group plan up to a maximum amount, generally $250,000 depending upon the provisions of your Group plan. The Portability policy provides group term coverage and is available to you provided you have not yet reached your Social Security full retirement age. The Portability option may also be available to your dependents if you carried dependent coverage under your employer s group plan and if the group plan includes portability as an option for dependents. The amount of coverage you elect to port is reduced by 75% at age 65 and coverage terminates at age 75. Portability is not available if your employer is terminating the group plan. Note: if you choose to elect the Waiver of Premium provision as outlined in your contract you are not eligible for Portability. The same applies if you choose to elect Portability; Waiver of Premium would not be available. Additional restrictions may also apply. Premiums for a Life Portability policy may be higher than your Employer Group plan rates and rates increase every five years (years in which your age on your birthday ends in 5 or 0). ********************************* The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are subject to terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. 1 GR

6 Attached is a form that contains additional information about continuing coverage. You can use this to request a quote and the necessary forms to enroll. Please note that there is a designated timeframe during which you can exercise your coverage continuation options. To continue coverage, you must mail or fax this form to request information within 15 days from the date of this notice or 31 days from your group coverage termination date, whichever is later. Under no circumstances, however, will continuation of coverage be available beyond 91 days from your group coverage termination date. Any issues regarding late notification by your employer must be addressed with the employer. If you have questions about this information, your eligibility, or the status of any request you have submitted, please call a representative at The Hartford, Portability and Conversion Unit P.O. Box Cleveland, OH Fax GROUP LIFE INSURANCE PORTABILITY AND CONVERSION Side By Side Employee Guide To decide whether Portability or Conversion is the right choice for your personal situation, you need to understand the differences. We help you see them clearly with our side-by-side comparison. Please visit to view the complete side-by-side comparison table. If you do not have access to the internet you may obtain a copy of this comparison by calling Frequently Asked Questions Q: If I request a quote, how does The Hartford determine the amount of coverage to quote? A: The Hartford will contact your employer to obtain the amount of coverage you had in effect under the group plan. The quote is based on this amount as well as applicable plan provisions. Q: If I receive a quote for coverage, does this mean I qualify for the coverage amount quoted? A: The amount quoted is not a guarantee that a policy will be issued in that amount. Upon receipt of your application for coverage, The Hartford will perform an eligibility review to determine if the amount of coverage you have requested can be granted based on the coverage you had in effect under the group plan as well as plan provisions. Q: What is my policy effective date? A: The effective date of a Life Conversion policy is the 32 nd day following the group coverage termination date. The effective date of a Life Portability Policy is the day following group coverage termination date. Q: If my application for coverage is not approved by the effective date, am I still covered? A: Yes, if your application is approved, the effective date of your policy will be retroactive to the date indicated above. Q: I understand that there is no medical underwriting or physical exam required but can I still be denied for coverage? A: Your request for coverage can be denied if you do not meet the timeliness requirement. You must mail or fax this form to request information within 15 days from the date of this notice or 31 days from your group coverage termination date, whichever is later. Under no circumstances will continuation of coverage be available beyond 91 days from your group coverage termination date. Coverage can also be denied if it exceeds the amount you had in effect under your employer s Group plan or if it does not align with your employer s plan provisions. In addition, any request for coverage that is not available under your employer s Group plan will also be denied. Q: If I start to work for a new employer and obtain coverage under that employer s Group plan, will that Group coverage impact any conversion or portability policy that I may have purchased? A: If you obtain coverage under a new employer s Group plan, your portability or conversion policy will remain in effect provided you continue to pay the required premiums. However, benefits payable under conversion policies may be affected by the amount of your other coverage. The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are subject to terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. 2 GR

7 Notice of Conversion and/or Portability Rights Employer: Policy #: The following information is to be completed by Employer or Employer Representative Employee Name: Employee ID#: Date: Last Day Worked (or date employee is no longer in an eligible class): Date of Group Coverage Termination: Termination Reason: Signature Print Name Address Telephone As noted above, Conversion and Portability options are available without submission of evidence of good health. The rates for Life Conversion will be substantially higher than your employer Group plan rates. The rates for Portability are based on the employer s standard industry code and/or Group plan provisions and may be higher than your employer Group rates. Portability rates increase every 5 years (years in which your age on your birthday ends in 5 or 0). Employee: To request specific rates and enrollment information, please complete the information below and mail or fax this entire page to: The Hartford, Portability and Conversion Unit, P.O. Box , Cleveland, OH Fax , Phone Yes, I am interested in receiving the information checked below. Life Conversion Quote Portability Enrollment Form Please print the following information: Name: Date of Birth: Social Security # (indicate last 4 digits only): Address: City: State: Zip Code: Telephone Number: I am interested in receiving information for the following persons: Myself My Spouse My Child(ren) Please print the name(s), relationship, and date(s) of birth for each dependent who may be eligible for coverage. Include an additional sheet if necessary. I understand that I have only 31 days from the date of my group coverage termination OR 15 days from the date of this notice, whichever is later, to complete and submit this form to The Hartford. In no event, however, will my eligibility to continue coverage exceed 91 days from my group coverage termination date. Signature (required) You may be contacted by a licensed agent Date The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are subject to terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. 3 GR