Accidental Death and Dismemberment Insurance

Transcription

1 Plan Administered by: United Pentecostal Church International 8855 Dunn Road Hazelwood, Missouri Phone: (314) Ext. 258 Accidental Death and Dismemberment Insurance The time you spend with your family is priceless, and you wouldn't trade those special moments together for anything in the world. But what would happen if you accidentally died or lost a limb? Would your family be financially prepared? By sponsoring group Voluntary AD&D insurance from Standard Insurance Company, United Pentecostal Church International (UPCI) offers you an excellent opportunity to help protect your loved ones. With Voluntary AD&D coverage, you or your beneficiaries, as applicable, may receive an AD&D insurance benefit in the event of death or dismemberment as a result of a covered accident. The advantages to you and your loved ones include: Choice - You decide how much coverage you need from the range of amounts available. flexibility - If your needs change, you may request to change the amount of coverage. Convenience - With premiums billed quarterly. Peace of Mind - You can take comfort and satisfaction in knowing that you have done something positive for your family's future. Becoming Insured You are eligible for Voluntary AD&D Insurance if you are an active minister or full-time church employee. You are not required to provide Evidence ofinsurability, nor do you have to meet an active work requirement to be eligible. Your Voluntary AD&D Insurance will become effective on the date you apply, provided you are an eligible member on that date. AD&D Insurance

2 When you enroll, you may include coverage for your eligible dependents. Eligible dependents include your spouse and your unmarried dependent children under age 21 (or under age 25 if attending an accredited school or college on a full-time basis and dependent upon you for their support and maintenance). Description of Coverage Your Voluntary AD&D Insurance protects you 24 hours a day, 365 days a year, against covered accidents in the course of business or pleasure. There are no geographical limits. Amounts of Insurance Voluntary AD&D Insurance allows you flexibility in meeting your life insurance needs. You may apply for any amount from $25,000 to $250,000 in increments of $25,000. The original amount of AD&D Insurance will be reduced by: 35% at age 70 55% at age 75 There are no additional reductions for ages above 75. If you elect to insure your eligible dependents, the maximum amount of insurance for each dependent is determined as follows: Insured Spouse Only - The spouse's insurance amount is 50% of the insured member's amount. Insured Children Only - The insurance amount for each child is 15% of the insured member's amount, not to exceed $25,000. Insured Spouse and Children - The spouse's insurance amount is 40% of the insured member's amount and each child's insurance amount is 10% of the insured member's amount. Benefits If you suffer a loss as a direct result of an accident, and satisfycertain requirements, an accidental death or dismemberment benefit will be paid. These requirements include the following: Standard must receive satisfactory written proof ofloss. The accident must occur while insured under the Group Policy. The loss must occur within 365 days after the date of the accident. The loss must be caused solely and directly by Accidental Bodily Injuries, and the loss must occur independently of all other causes. The entire amount is paid for these losses: Life Loss of both hands or both feet Loss of sight in both eyes Loss of one hand and one foot Loss of one hand or foot and sight in one eye Loss of speech and hearing One half the entire amount is paid for these: Loss of sight in one eye Loss of one hand or one foot Loss of speech or hearing One quarter the entire amount is paid for loss of thumb and index finger of same hand. Additional Benefits Seat Belt Benefit The amount of the Seat Belt Benefit is the lesser of (1) $10,000 and (2) the amount of AD&D Insurance payable on the insured person for Loss of life. 2 Standard Insurance Company AD&D Insurance 3

3 We will pay a Seat Belt Benefit if: 1. You or your Dependent dies as a result of an Automobile accident for which an AD&D Insurance benefit is payable; and 2. You or your Dependent was wearing a Seat Belt at the time of the accident, as evidenced by a police accident report. Seat Belt means a properly installed seat belt, lap and shoulder restraint, or other restraint approved by the National Highway Traffic Safety Administration. Automobile means a motor vehicle licensed for use on public highways. Benefit for Paralysis We will pay a Benefit For Paralysis if: 1. You or your Dependent suffers paralysis caused by an accident within 180 days of the date of that accident; 2. The paralysis continues for 12 calendar months; and 3. A licensed medical professional certifies that the paralysis is permanent, complete and irreversible. The amount payable is equal to a percentage of the AD&D Insurance in effect on the insured person on the date of the accident. The percentage is shown below: Loss Percentage Quadriplegia 100% Paraplegia 50% Hemiplegia 50% Quadriplegia means total paralysis of both upper and lower limbs. Paraplegia means total paralysis of both lower limbs. Hemiplegia means total paralysis of the upper and lower limb on the same side of the body. Benefit for Disappearance If you or your Dependent disappears as a result of an accident which could have caused Loss of life, and are not found within one year from the date of the accident, we,villpresume that you or your Dependent died. We will pay the amount of AD&D Insurance in effect on the insured person on the date of the accident. This benefit will be paid in place of any other AD&D benefits payable under the Group Policy for the same accident. Benefit for Loss Due to Exposure If you or your Dependent suffers a Loss caused by exposure to the natural elements, we will pay the amount of AD&D Insurance in effect for that Loss on the date of the accident. This benefit will be paid in place of any other AD&D benefits payable under the Group Policy for the same accident. Benefit for Loss of Speech or Hearing If you or your Dependent suffers a Loss of speech or hearing, we will pay 50% of the AD&D Insurance in effect on the insured person on the date of the accident. If you or your Dependent suffers a Loss of speech and hearing, we will pay 100% if the AD&D Insurance is in effect on the insured person on the date of the accident. With respect to speech or hearing, Loss means entire and irrecoverable loss of speech or hearing, as certified by a Diplomate of the American Board of Otolaryngology. Benefit for Loss of Thmnb and Index Finger of Same Hand If you or your Dependent suffers a Loss of thumb and index finger of same hand, we will pay 25 % of the AD&D Insurance in effect on the insured person on the date of the accident. With respect to thumb and index finger of same hand, Loss means actual and permanent severance from the body at or above the metacarpophalangeal joints. This benefit will not be paid if benefits are payable under the Group Policy for Loss of that entire hand. 4 Standard Insurance Company AD&D Insurance 5

4 Higher Education Benefit If you suffer Loss oflife, we ",rillpay a Higher Education Benefit to each insured Child who is: 1. Registered and in full-time attendance at an accredited institution of higher education beyond the 12th grade; or 2. In the 12th grade and \rillbe registered and in full-time attendance \rithinone year at an accredited institution of higher education beyond the 12th grade. The Higher Education Benefit is payable annually, for a maximum of four years, pro\rided we receive proof that the Child continues to meet 1 and 2 above. The amount payable per year is 5% of your AD&D Insurance in effect on the date of the accident, subject to a maximum of $5,000. The Higher Education Benefit \rillbe paid in addition to other AD&D benefits payable under the Group Policy for the same Loss. If there is no Child eligible to receive the Higher Education Benefit, it will not be paid. Career Adjustment Benefit If you suffer Loss of life, and you and your Spouse are insured under the Group Policy, we will pay your Spouse a Career Adjustment Benefit. The amount payable is 5% of your AD&D Insurance in effect on the date of the accident, subject to a maximum of $5,000. The Career Adjustment Benefit will be paid in addition to other AD&D benefits payable under the Group Policy. If you have no survi\ring Spouse, this benefit \rillnot be paid. Exclusions No payment will be made for losses caused by war; suicide or any other self-inflicted injury; committing an assault or felony or active participation in a violent disorder or riot; the voluntary use of drugs, unless used in accordance \ }y with the direction of a physician; sickness, illness, disease, pregnancy, childbirth or related medical condition existing at the time of the accident; heart attack or stroke; medical or surgical treatment for any of the aforementioned items; aircraft travel as a pilot or crew member or flight as a passenger in any aircraft operated by or for the United Pentecostal Church International. When Insurance Ends Insurance ends for you and your dependents if you enter the military or stop paying premiums. It also terminates if you cease to be a member of the Group, or if the Group Policy terminates. If a dependent enters the military or reaches the limiting age, insurance for that dependent \rillcease. Cost Quarterly Cost* Coverage Amount Member Only Member and Family $ 25,000 $ 4.00 $ , , , , , , , , , *The above costs include an administrative fee of $1.00 payable to UPCI to cover administrative expenses involved in this insurance program. Residents of North Carolina and Louisiana are exempt from paying the $1.00 administration fee. 6 Standard Insurance Company AD&D Insurance 7

5 About This Brochure This brochure is written in non-technical language, and is not intended as a complete description of the coverage. The controlling provisions are in the Group Voluntary Accidental Death and Dismemberment Insurance Policy, and this brochure does not modify that document or the insurance in any way.you will receive a Voluntary Accidental Death and Dismemberment Certificate. That Certificate will provide a more detailed description of the coverage. How to Enroll 1. Use the enclosed Enrollment Form. 2. Please print or type all information on the form. 3. Indicate the amount selected. 4.,Date and sign. 5. Return it along with your premium payment to United Pentecostal Church International, 8855 Dunn Road, Hazelwood, Missouri enc PJ () '1J ro \1) c 5' Q N' 0 0 c o' en o :;; \1) to en 0' () o < " tij C (I) = : Z!2. D> o' 3 iii' (I) -» I a. () 0 (I) 3 "E- D> (I) 5. CD (J) 0- o (') _.» c!!!.. I/O (J) C (I) _ (') : C en :::::!. c:. Q1 '"' : (') (I)... J (f) c: x' 2: s::: :::s.-+ II)... m :::s.. 2 3CD :::s.-+"ọ.. 3 () 0' S. o' JJ (I) 1:'- : III ::r -5" ffioj OJ tn CD m OJ S' co tn"o 3 --i : 0;' m 3-0 o DD S;:I 9 :---; 8 Standard InsuranceCompany

6 Group Administrator: Do not send this card to Standard unless asked to do so. Keep this card in your file. Standard Insurance Co. PLEASE PRINT Policyowner Use Only: (Use this area to record initial amounts as well as future changes) Effective Date Class Voluntary AD&D Amount 1========1==== Complete for AD&D coverage. Give full name, address, and relationship of your beneficiary. Examples: A. One Beneficiary Dorothy Q. Smith, 777 America St., Any town, USA 77777, Wife (not Mrs. John Smith) B. Two Beneficiaries Peter Smith, Father, and Anna Smith, Mother, equally, or the survivor C. Two Beneficiaries in Unequal Shares Peter Smith, Father, three-fourths (%), and Anna Smith, Mother, one-fourth (%), or the survivor D. One Primary and One Contingent Beneficiary Dorothy Q. Smith, Wife, if living; otherwise Quincy Smith, Son E. One Primary and Two Contingent Beneficiaries Dorothy Q. Smith, Wife, if living; otherwise Quincy Smith, Son, and Mary Smith, Daughter, equally, or the survivor F. Trustee Dorothy Q. Smith, Trustee under trust agreement dated 1 1. G. Insured's Estate My Estate Do you know that if death occurs and a minor (a person not of legal age) or the insured's estate is the beneficiary, it may be necessary to have a guardian or a legal representative appointed before any death benefit can be paid? This means legal expenses for the beneficiary and delay in the payment of the insurance. Please take this into consideration when naming your beneficiary.