State of Louisiana Optional Term Life Dependent Term Life Personal Accident Insurance (Also known as Voluntary AD&D) The Prudential Insurance Company of America INST-A004728-0886
What Does This Plan Offer Me and My Family? Optional Term Life Insurance Employee Paid Employee Coverage Coverage is available for one, two or three times your current Basic or Basic/Supplemental coverage amount, not to exceed $200,000. No evidence of good health satisfactory to Prudential is required, if you apply within 30 days of eligibility. The Living Benefit Option allows for an early payment of of the Basic Term Life, Basic and Supplemental and Optional Term Life amounts, up to maximum of $100,000, if you are terminally ill with a life expectancy of six months or less. Your death benefit will be reduced by the amount you elect under this provision.* Payment of premium can be waived if you are totally disabled for 9 months, you are less than 60 years old when the disability begins, and you continue to be totally disabled. The amount of insurance reduces 25% at age 65, and at age 70. Coverage will end on your termination of employment. Insurance may be converted to a Prudential individual life insurance policy or you may continue your group insurance coverage through a portability provision. * Important Notice: The acceleration of life insurance benefits offered under this certificate are intended to qualify for favorable tax treatment under the Internal Revenue Code of 1986. If the acceleration of life insurance benefits qualify for such favorable treatment, the benefits will be excludable from your income and not subject to Federal taxation. Tax laws relating to acceleration of life benefits are complex. You are advised to consult with a qualified tax advisor about circumstances under which you could receive acceleration of life insurance benefits that are excludable from income under Federal law. Dependent Term Life Insurance Employee Paid Spouse and Child(ren)Coverage You must be enrolled for Optional Term Life to elect coverage for your dependents. Spouse and Child(ren): Coverage is available in increments of one, two or three times the amount of Dependent Term Life coverage they currently have in the Basic or Basic and Supplemental plans. Coverage for your child(ren) begins at live birth and continues to age 21, if unmarried. Spouse: If you apply within 30 days of eligibility, no evidence of good health satisfactory to Prudential is required. Child(ren): No evidence of good health is required satisfactory to Prudential. If your spouse or child(ren) are confined for medical care or treatment at home or elsewhere, coverage will begin when confinement ends. Coverage will end on your termination of employment. Insurance may be converted to a Prudential individual life insurance policy or you continue your group insurance coverage through a portability provision.
Personal Accident Insurance (PAI) (Also known as Voluntary AD&D) Employee Paid Employee, Spouse and Child (ren) Coverage Employee: Coverage is available in increments of $10,000 to $150,000. Family (includes employee and all dependents): -Spouse Only: Your spouse s coverage amount is of your PAI coverage amount. -Child(ren) Only: Your child(ren) s coverage amount is 15% of your PAI coverage amount. -Family: Your spouse s coverage amount is 40% of your PAI coverage amount. Your child(ren) s coverage amount is 10% of your PAI coverage amount. Benefits are paid in addition to Optional Term Life and Dependent Term Life benefits. Coverage will end on termination of employment or retirement. Benefits are paid at certain percentages of your coverage amount for specific accidental losses, as indicated in the chart below. Not more than of your coverage amount is payable for all losses due to the same accident. Life Sight in both eyes Both hands or both feet One hand & one foot Sight in one eye & one hand or one foot Speech & hearing in both ears Quadriplegia Paraplegia Hemiplegia One hand or one foot Sight in one eye Speech Hearing in both ears Thumb & index finger on the same hand Seat Belt Benefit - The plan pays an additional benefit of 10% of your coverage amount, up to a maximum of $10,000. Air Bag Benefit - The plan pays an additional benefit of 10% of your coverage amount, up to a maximum of $10,000. 75% 25% Additional Benefits - Loss Due to Exposure and Disappearance Benefit Loss Due to Coma Benefit Return of Remains Benefit Felonious Assault Benefit Spouse Tuition Reimbursement Benefit Child(ren) Tuition Reimbursement Benefit Day Care Expense Benefit PAI Exclusions - A loss is not covered if it results from suicide or attempted suicide; intentionally self-inflicted injuries or an attempt at same; sickness; medical or surgical treatment of sickness; certain bacterial or viral infections (unless the infection was the result of an accidental injury or bacterial infection which results from the accidental ingestion of contaminated substances); act of war; certain full-time military duty; commission of, or attempt to commit a felony; legal intoxication or drug use; certain hazardous sports; injury rising out of, or in the course of, any work for wage or profit (this exclusion only applies with non-occupational plans); certain travel or flight in a vehicle used for aerial navigation (This provision may vary by state. See your plan booklet for details). All benefit features may not be available in all states.
R A T E S H E E T STATE OF LOUISIANA Rates Effective: October 1, 2002 Optional Term Life* (Employee and Spouse) Age (Initial rates based on age as of effective date of your coverage. Rates will change based on the following age schedule.) For Employee For Spouse Under 25 $ 0.07 $ 0.10 25-29 $ 0.09 $ 0.12 30-34 $ 0.12 $ 0.16 35-39 $ 0.13 $ 0.18 40-44 $ 0.15 $ 0.20 45-49 $ 0.22 $ 0.30 50-54 $ 0.34 $ 0.46 55-59 $ 0.63 $ 0.86 60-64 $ 0.97 $ 1.32 65-69 $ 1.87 $ 2.54 70+ $ 3.03 $ 4.12 Dependent Term Life* (Children - Regardless of the number of children) Insured Personal Accident Insurance* Insured Child(ren) $ 0.08 Employee $ 0.026 Employee and Family $ 0.039 *This is optional coverage and the entire cost of coverage is employee paid. The cost of insurance will depend upon having a specific percentage of all eligible employees enrolling in the plans. If this enrollment level is not achieved, the cost of these coverages may change from the rates noted here. Cost of insurance for all coverages, which are deducted from your paycheck, may increase or decrease in the future based upon the claims experience of participants. All provisions that apply to these coverages are governed by the Certificate. Optional Term Life, Dependent Term Life and Personal Accident Insurance coverages are underwritten by The Prudential Insurance Company of America, 751 Broad Street, Newark, NJ 07102, 1-800-524-0542. This brochure is intended to be a summary of your benefits and does not include all plan provisions, exclusions and limitations. A Certificate, with complete plan information, including limitations and exclusions, will be provided. If there is a discrepancy between this document and the Group Contract/Certificate issued by Prudential, the terms of the Group Contract will govern. Contract provisions may vary by state. Contract Series: 83500. Prudential Financial is a service mark of The Prudential Insurance Company of America, Newark, NJ, and affiliates. INST-A004728-0886 Ed. 9/2001 5.2002 PDF
Enrollment Form State of Louisiana Control # 33624 Optional Term Life and PAI Agency ID # General Information Last Name First Name Middle Initial Date of Birth Month Day Year Spouse Date of Birth Month Day Year Social Security No. Single Marital Status Married Divorced Widowed Optional Employee Term Life (Please indicate your coverage selection) If you do not enroll for coverage within 30 days of your date of hire or within any specified enrollment period, you will need to provide evidence of good health for all coverage amounts. 1x current Basic or Basic/Supplemental amount 2x current Basic or Basic/Supplemental amount 3x current Basic or Basic/Supplemental amount No coverage chosen. Dependent Term Life (Please indicate your coverage selections) You must be enrolled for Optional Term Life to elect coverage for your dependents. If your spouse or children are confined for medical care or treatment at home or elsewhere, coverage will begin when confinement ends. 1x current Basic or Basic/Supplemental amount Spouse Only 2x current Basic or Basic/Supplemental amount Spouse and Child(ren) 3x current Basic or Basic/Supplemental amount Child(ren) Only No coverage chosen. PAI (Indicate your coverage selection) Employee Coverage amount chosen: Available in increments of $10,000 to $150,000. Family (Includes employee and all dependents) Family coverage Coverage for dependents is as follows: Spouse Only: of the employee s amount Child(ren) Only: 15% of the employee s amount Family: Spouse 40% and Child(ren) 10% of employee s amount No coverage chosen. Acceptance or Waiver of Coverage I am enrolling for coverage and I authorize my employer to deduct from my earnings until further notice my contributions for insurance under a contract issued by The Prudential Insurance Company of America. I understand that if I desire to increase the amount of my insurance or add dependent coverage hereafter, I may be required to furnish evidence of insurability for myself and/or my dependents. I declare the statement above is true and understand it is the basis for determining the monthly contribution for coverage. I do not wish to enroll for any of the above optional coverages. I certify that I have been given the opportunity by my above named employer to enroll for coverage. I understand that if I desire to enroll hereafter, I may be required to furnish evidence of insurability for myself and/or my dependents. Employee Signature Date (Month, Day, Year) For Office Use Only Your Current Inforce Amount (for office use only) $ Please indicate your beneficiary designation(s) on the reverse side. Please return your completed Enrollment Form to your Agency. Effective Date of Coverage (for office use only) Date Employed Month Day Year (for office use only) INST-A004728-0886 Ed. 9/2001 5.2002 1PDF
Beneficiary Designation State of Louisiana Control # 33624 Optional Term Life Agency ID # Employee General Information Last Name First Name Middle Initial Social Security No. Beneficiary Designation If more than one beneficiary is desired, please write their name(s) and relationship(s) on the lines below. Do not name a beneficiary for Dependent Term Life Coverage; these benefits are paid to you while living. If more than one beneficiary is designated, settlement will be made in equal shares to such of the designated beneficiaries (or beneficiary) as survive you, unless otherwise provided in the designation. If no designated beneficiary survives you, the settlement will be made to your estate, unless otherwise provided in the Group Contract. Optional Term Life - Primary Beneficiary Designation (1) Last Name First Name Middle Initial Social Security No. Relationship Percentage (2) Last Name First Name Middle Initial Social Security No. Relationship Percentage Optional Term Life - Contingent Beneficiary Designation (1) Last Name First Name Middle Initial Social Security No. Relationship Percentage (2) Last Name First Name Middle Initial Social Security No. Relationship Percentage Employee Signature Date (Month, Day, Year) If you have any questions, please see Human Resources for details. (Please see Important Notice.) Please refer to the Booklet-Certificate for all plan details, including any exclusions, limitations and restrictions which may apply. Optional Term Life, Dependent Term Life and Personal Accident Insurance coverages are underwritten by The Prudential Insurance Company of America, 751 Broad Street, Newark, New Jersey 07102, 1-800-524-0542. Contract provisions may vary by state. Contract Series: 83500. Prudential Financial is a service mark of The Prudential Insurance Company of America, Newark, NJ, and affiliates. INST-A004728-0886 Ed. 9/2001 5.2002 1PDF
Important Notice WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. Please refer to the Booklet-Certificate for all plan details, including any exclusions, limitations and restrictions which may apply. Optional Term Life, Dependent Term Life and Personal Accident Insurance coverages are underwritten by The Prudential Insurance Company of America, 751 Broad Street, Newark, New Jersey 07102, 1-800-524-0542. Contract provisions may vary by state. Contract Series: 83500. Prudential Financial is a service mark of The Prudential Insurance Company of America, Newark, NJ, and affiliates. INST-A004728-0886 Ed. 9/2001 5.2002 1PDF