Continuation of Coverage at Retirement or Termination

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1 Red Oak 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: for ActiveCare, contact WellSystems at cobra@wellsystems.com (call ). For Scott&White, contact Conexis at COBRA (Dental, Vision, Medical Supplement* and Medical FSA**) 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 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 for additional information. Telehealth (MDLIVE) You can contact MDLive at or for an individual plan. Health Savings Account (HSA Bank) The HSA is an individual account. You will receive a letter in the mail from HSA Bank regarding changes to your account and the ongoing fees as long as you maintain a balance in the account. Contact HSA Bank for more information at Cancer (Loyal American) Group 1407 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. Accident (Loyal American) Group 1407 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. Emergency Transportation Contact MASA at for information on an individual plan, different rates and plans available. See reverse side for more information.

2 Red Oak ISD Continuation of Coverage at Retirement or Termination Individual Life 5Star Family Protection Plan Life Insurance (5Star) is Eligible for continuation with no increase in cost to age 100 thru direct billing bank draft with the insurance company. Contact FiveStar at to arrange for direct payment or with any questions. Voluntary Life Insurance (UNUM) Group Voluntary Life plans are eligible for conversion or portability. An application must be completed and payment made within 31 days. Visit to print the forms or see forms attached. Contact UNUM at Accidental Death & Dismemberment (AD&D) Insurance (UNUM) This plan is eligible for portability. An application must be completed and payment made within 31 days. Visit to print the forms or see forms attached. Contact UNUM at Portability Continues coverage under the group policy. Portability does not create an individual policy. You are not eligible for Portability if you have an injury or sickness which has a material effect on life expectancy. Premiums change as premiums change for the group policy and coverage functions under the rules/guidelines of the group policy. Coverage amounts will follow the same reduction schedule of the group policy. Ported coverage that has terminated due to the cancellation of the group policy may be converted. See policy 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 continue district Medical coverage thru COBRA ** Restrictions 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 Portability and Conversion Benefits and Features Comparison CXC PORTABILITY VS. CONVERSION BENEFITS/FEATURES COMPARISON CXC PORTABILITY Employees and dependents can port both their Life and AD&D coverage. CONVERSION Only Life coverage can be converted Employees can port coverage for themselves and their dependents if employment ends, the employee retires, or the employee reduces hours below the minimum required for eligibility. Once dependents lose their dependent status, their portable coverage would cease. Employees and dependents can convert their coverages when their group coverage ends for any reason, their portable coverage ends, or if they have been insured for at least 5 years under the group plan and either their group policy (summary of benefits) is canceled with UNUM or changes so the insured s insurance class is no longer eligible (refer to maximum conversion amount). Portable insurance is a continuation of group insurance with group rates. Converted insurance is an individual, whole-life level, premium plan. The insured may elect one year of preliminary term insurance under the whole life plan. Rates are significantly higher than group rates. Employees may NOT port coverage for themselves if they are sick or injured. A dependent s coverage cannot be ported if the dependent is sick or injured. Employees must certify that they and their dependents are not sick or injured in order to port coverage on the port application (sick or injured means a sickness or injury that has a material effect on life expectancy). Employees and dependents may convert coverage if they are sick or injured. 2/26/2016 Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

5 Portability and Conversion Benefits and Features Comparison CXC PORTABILITY The employee s maximum coverage amount is the least of (a) the employee s group maximum benefit, (b) 5X the employee s annual salary, or (c) $750,000 from all UNUM Life and AD&D plans combined. Spouse maximum ported Life coverage will not be more than 50% or 100% of the employee s ported coverage depending on the state. The 50%/100% does not apply to spouse AD&D. In all instances, AD&D cannot exceed the Life amount ported. The maximum child benefit is the lessor of 50% or 100% (varies by state) of the employee s amount or $20,000. CONVERSION The maximum coverage amount is the amount that the employee and dependents are insured for under the plan. If the employee and dependent have been insured for at least 5 years and the policy (summary of benefits) is canceled with UNUM or changes so their insurance group (class) is no longer eligible, the maximum will be the lessor of $10,000 or the employee s or dependent s coverage amount under the plan less any amounts that become available under any other group life plan offered by their employer within 45 days after cancellation. Amounts of Life Insurance may be decreased or increased with Evidence of Insurability up to the maximum noted above. An employee s or dependent s covered amount of a lower amount of insurance may be converted. Once the coverage is converted, the amount of coverage cannot be increased. Portability includes Accelerated Death Benefits, Waiver if Premium, and AD&D as long as they are available under then group plan. Supplementary services such as Survivor Support and Assist America are not included. The individual whole life plan under conversion does not contain supplementary benefits such as Accelerated Death Benefits, Waiver of Premium, Survivor Support, or AD&D Benefits. There is a 31-day portability application period. There is a 31-day conversion application period. Employees that port their coverage, return to work, and again become insured under the plan are eligible to port their coverage again, subject to the maximums noted above. Employees that convert, return to work, and again become insured under the plan are not eligible to convert to an individual policy again. However, the employee need not surrender the individual life policy when they return to work. 2/26/2016 Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

6 Portability and Conversion Benefits and Features Comparison CXC PORTABILITY Portability rates may be changed for reasons which affect the risk assumed. CONVERSION Conversion premium is a level premium for the life of the policy. If an employee dies under the group plan, the dependents can port their current coverage (the spouse must port in order for the children to port). If an employee dies under the group plan, the dependents can convert their coverage (spouse and/or child). Employee and dependent s coverage amounts will reduce according to the group plan. Converted amounts do not reduce. Note that the ported coverage that is reduced may be converted. Once an employee elects the portability, dependents may be added at any time for the amounts allowed under the group plan (subject to Evidence of Insurability). Once coverage is converted, dependents that did not initially convert coverage may not do so at a later date. 2/26/2016 Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

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