Diocese of Lafayette/Lake Charles Group Policy #164075 Group Life and AD&D Insurance Help protect your loved ones from financial hardship. Life insurance coverage is designed to help provide financial support and stability to your family should you pass away. Accidental Death & Dismemberment (AD&D) insurance provides an extra layer of protection if you die or become dismembered in an accident. You can also cover your eligible spouse and child(ren). This plan offers: Competitive group rates The convenience of payroll deduction Benefits if you are dismembered, become terminally ill or die An annual enrollment opportunity. See Annual Enrollment section for additional details. About This Coverage Life Insurance How Much Can I Apply For? The coverage amount for your spouse cannot exceed 100 percent of your Life coverage. The coverage amount for your child(ren) cannot exceed 100 percent of your Life coverage. For You: For Your Spouse: $10,000 $500,000 in increments of $10,000 $10,000 $250,000 in increments of $10,000 For Your Child(ren): $10,000 What is the Guarantee Issue Maximum? Depending on your eligibility, this is the maximum amount of coverage you may apply for during initial enrollment without answering health questions. For You: For Your Spouse: Up to $50,000 Up to the lesser of 3 times your annual earnings or $200,000 1
AD&D Insurance The benefit is paid if you or your dependents are seriously injured or pass away as a result of a covered accident. What Does My AD&D Benefit Provide? Note: You cannot buy more coverage for your spouse or child(ren) than you buy for yourself. For You: The AD&D insurance coverage amount matches what you elect for Life insurance. For Your Spouse: The AD&D insurance coverage amount matches what you elect for Dependents Life insurance. For Your Child(ren): The AD&D insurance coverage amount matches what you elect for Dependents Life insurance. Keep in mind that the amount payable for certain losses is less than 100 percent of the AD&D insurance benefit. See the Important Details section for more information, including requirements, exclusions, age reductions and definitions. Annual Enrollment During Diocese of Lafayette/Lake Charles's Annual Enrollment Period For You. If you are currently enrolled in Life insurance for an amount less than 3 times your annual earnings or $200,000, you may elect to increase your coverage by $10,000 annually, up to, but not to exceed, the guarantee issue amount of the lesser of 3 times your annual earnings or $200,000 without having to answer health questions. If you are not currently enrolled in Life insurance, you may elect $10,000 of coverage without having to answer health questions. For Your Spouse. If your spouse is currently enrolled in Dependents Life insurance for an amount less than $50,000, you may elect to increase coverage by $10,000 annually, up to, but not to exceed, the guarantee issue amount of $50,000 without having to answer health questions. If your spouse is not currently enrolled in Dependents Life insurance, you may elect $10,000 of coverage without having to answer health questions. For Your Child(ren). If your child(ren) is/are not currently enrolled in Dependents Life insurance, you may elect the maximum coverage amount of $10,000 without having to answer health questions. If you, and/or your spouse and/or your child(ren) were previously declined coverage by The Standard, you, and/or your spouse and/or your child(ren) will need to submit a medical history statement in order to apply for any amount of coverage during the Annual Enrollment period. Visit www.standard.com/mhs to complete and submit a medical history statement online. 2
Additional Features Your coverage comes with some added features: Life Insurance Accelerated Benefit If you become terminally ill, you may be eligible to receive up to 75 percent of your Life benefit to a maximum of $500,000. Travel Assistance 1 Available 24 hours a day, this service connects you to resources when you re traveling at least 100 miles from home or in a foreign country for up to 180 days. Life Services Toolkit 2 This service allows you and your beneficiaries access to online content for will preparation, identity theft support and other tools and calculators, and provides your beneficiaries with services for grief, and legal and financial matters. AD&D Insurance Seat Belt and Air Bag Benefit(s) The Standard may pay an additional benefit if you die while wearing a seat belt, provided certain conditions are met. If the car s air bags deploy during an accident, an air bag benefit may also be payable. Family Benefits Package This benefit is designed to help surviving family members maintain their standard of living and pursue their dreams. Included in the package are benefits to help with child care, career adjustment for your spouse and higher education for your child(ren). 1 This service is provided through an arrangement with a service provider who is not affiliated with The Standard. Travel Assistance is not an insurance product in all states except Oregon. For more information, visit www.standard.com/travel-info. 2 The Life Services Toolkit is offered through an arrangement with a service provider that is not affiliated with The Standard. For more information, visit www.standard.com/mytoolkit-info. How Much Life Insurance Do You Need? After a serious accident or death in the family, there are many unexpected expenses. Your benefits could help your family pay for: Outstanding debt Burial expenses Medical bills Your children s education Daily expenses To estimate your insurance needs, you ll need to consider your unique circumstances. Use our online calculator at www.standard.com/life/needs. 3
How Much Your Coverage Costs Because this insurance is offered through Diocese of Lafayette/Lake Charles, you ll have access to competitive group rates, which may be more affordable than those available through individual insurance. You ll also have the convenience of having your premium deducted directly from your paycheck. How much your premium costs depends on a number of factors, such as your age and the benefit amount. 4
Employee Life with AD&D Monthly Premiums Coverage Employee s Age as of January 1 Amount < 30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69* 70-74* 75+* $10,000 0.85 0.95 1.05 1.25 1.75 2.85 4.55 6.15 7.05 12.23 31.13 $20,000 1.70 1.90 2.10 2.50 3.50 5.70 9.10 12.30 14.11 24.45 62.27 $30,000 2.55 2.85 3.15 3.75 5.25 8.55 13.65 18.45 21.16 36.68 93.40 $40,000 3.40 3.80 4.20 5.00 7.00 11.40 18.20 24.60 28.21 48.90 124.53 $50,000 4.25 4.75 5.25 6.25 8.75 14.25 22.75 30.75 35.26 61.13 155.66 $60,000 5.10 5.70 6.30 7.50 10.50 17.10 27.30 36.90 42.32 73.35 186.80 $70,000 5.95 6.65 7.35 8.75 12.25 19.95 31.85 43.05 49.37 85.58 217.93 $80,000 6.80 7.60 8.40 10.00 14.00 22.80 36.40 49.20 56.42 97.80 249.06 $90,000 7.65 8.55 9.45 11.25 15.75 25.65 40.95 55.35 63.47 110.03 280.19 $100,000 8.50 9.50 10.50 12.50 17.50 28.50 45.50 61.50 70.53 122.25 311.33 $110,000 9.35 10.45 11.55 13.75 19.25 31.35 50.05 67.65 77.58 134.48 342.46 $120,000 10.20 11.40 12.60 15.00 21.00 34.20 54.60 73.80 84.63 146.70 373.59 $130,000 11.05 12.35 13.65 16.25 22.75 37.05 59.15 79.95 91.68 158.93 404.72 $140,000 11.90 13.30 14.70 17.50 24.50 39.90 63.70 86.10 98.74 171.15 435.86 $150,000 12.75 14.25 15.75 18.75 26.25 42.75 68.25 92.25 105.79 183.38 466.99 $160,000 13.60 15.20 16.80 20.00 28.00 45.60 72.80 98.40 112.84 195.60 498.12 $170,000 14.45 16.15 17.85 21.25 29.75 48.45 77.35 104.55 119.89 207.83 529.25 $180,000 15.30 17.10 18.90 22.50 31.50 51.30 81.90 110.70 126.95 220.05 560.39 $190,000 16.15 18.05 19.95 23.75 33.25 54.15 86.45 116.85 134.00 232.28 591.52 $200,000 17.00 19.00 21.00 25.00 35.00 57.00 91.00 123.00 141.05 244.50 622.65 $210,000 17.85 19.95 22.05 26.25 36.75 59.85 95.55 129.15 148.10 256.73 653.78 $220,000 18.70 20.90 23.10 27.50 38.50 62.70 100.10 135.30 155.16 268.95 684.92 $230,000 19.55 21.85 24.15 28.75 40.25 65.55 104.65 141.45 162.21 281.18 716.05 $240,000 20.40 22.80 25.20 30.00 42.00 68.40 109.20 147.60 169.26 293.40 747.18 $250,000 21.25 23.75 26.25 31.25 43.75 71.25 113.75 153.75 176.31 305.63 778.31 $260,000 22.10 24.70 27.30 32.50 45.50 74.10 118.30 159.90 183.37 317.85 809.45 $270,000 22.95 25.65 28.35 33.75 47.25 76.95 122.85 166.05 190.42 330.08 840.58 $280,000 23.80 26.60 29.40 35.00 49.00 79.80 127.40 172.20 197.47 342.30 871.71 $290,000 24.65 27.55 30.45 36.25 50.75 82.65 131.95 178.35 204.52 354.53 902.84 $300,000 25.50 28.50 31.50 37.50 52.50 85.50 136.50 184.50 211.58 366.75 933.98 $310,000 26.35 29.45 32.55 38.75 54.25 88.35 141.05 190.65 218.63 378.98 965.11 $320,000 27.20 30.40 33.60 40.00 56.00 91.20 145.60 196.80 225.68 391.20 996.24 $330,000 28.05 31.35 34.65 41.25 57.75 94.05 150.15 202.95 232.73 403.43 1,027.37 $340,000 28.90 32.30 35.70 42.50 59.50 96.90 154.70 209.10 239.79 415.65 1,058.51 $350,000 29.75 33.25 36.75 43.75 61.25 99.75 159.25 215.25 246.84 427.88 1,089.64 $360,000 30.60 34.20 37.80 45.00 63.00 102.60 163.80 221.40 253.89 440.10 1,120.77 $370,000 31.45 35.15 38.85 46.25 64.75 105.45 168.35 227.55 260.94 452.33 1,151.90 $380,000 32.30 36.10 39.90 47.50 66.50 108.30 172.90 233.70 268.00 464.55 1,183.04 $390,000 33.15 37.05 40.95 48.75 68.25 111.15 177.45 239.85 275.05 476.78 1,214.17 $400,000 34.00 38.00 42.00 50.00 70.00 114.00 182.00 246.00 282.10 489.00 1,245.30 $410,000 34.85 38.95 43.05 51.25 71.75 116.85 186.55 252.15 289.15 501.23 1,276.43 $420,000 35.70 39.90 44.10 52.50 73.50 119.70 191.10 258.30 296.21 513.45 1,307.57 $430,000 36.55 40.85 45.15 53.75 75.25 122.55 195.65 264.45 303.26 525.68 1,338.70 $440,000 37.40 41.80 46.20 55.00 77.00 125.40 200.20 270.60 310.31 537.90 1,369.83 $450,000 38.25 42.75 47.25 56.25 78.75 128.25 204.75 276.75 317.36 550.13 1,400.96 $460,000 39.10 43.70 48.30 57.50 80.50 131.10 209.30 282.90 324.42 562.35 1,432.10 $470,000 39.95 44.65 49.35 58.75 82.25 133.95 213.85 289.05 331.47 574.58 1,463.23 $480,000 40.80 45.60 50.40 60.00 84.00 136.80 218.40 295.20 338.52 586.80 1,494.36 $490,000 41.65 46.55 51.45 61.25 85.75 139.65 222.95 301.35 345.57 599.03 1,525.49 $500,000 42.50 47.50 52.50 62.50 87.50 142.50 227.50 307.50 352.63 611.25 1,556.63 Coverage amounts for ages 65 and over reduce due to age reduction (see Life Insurance Age Reductions section). 5
Spouse Life with AD&D Monthly Premiums Coverage Employee s Age as of January 1 Amount < 30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69* 70-74* 75+* $10,000 0.85 0.95 1.05 1.25 1.75 2.85 4.55 6.15 7.05 12.23 31.13 $20,000 1.70 1.90 2.10 2.50 3.50 5.70 9.10 12.30 14.11 24.45 62.27 $30,000 2.55 2.85 3.15 3.75 5.25 8.55 13.65 18.45 21.16 36.68 93.40 $40,000 3.40 3.80 4.20 5.00 7.00 11.40 18.20 24.60 28.21 48.90 124.53 $50,000 4.25 4.75 5.25 6.25 8.75 14.25 22.75 30.75 35.26 61.13 155.66 $60,000 5.10 5.70 6.30 7.50 10.50 17.10 27.30 36.90 42.32 73.35 186.80 $70,000 5.95 6.65 7.35 8.75 12.25 19.95 31.85 43.05 49.37 85.58 217.93 $80,000 6.80 7.60 8.40 10.00 14.00 22.80 36.40 49.20 56.42 97.80 249.06 $90,000 7.65 8.55 9.45 11.25 15.75 25.65 40.95 55.35 63.47 110.03 280.19 $100,000 8.50 9.50 10.50 12.50 17.50 28.50 45.50 61.50 70.53 122.25 311.33 $110,000 9.35 10.45 11.55 13.75 19.25 31.35 50.05 67.65 77.58 134.48 342.46 $120,000 10.20 11.40 12.60 15.00 21.00 34.20 54.60 73.80 84.63 146.70 373.59 $130,000 11.05 12.35 13.65 16.25 22.75 37.05 59.15 79.95 91.68 158.93 404.72 $140,000 11.90 13.30 14.70 17.50 24.50 39.90 63.70 86.10 98.74 171.15 435.86 $150,000 12.75 14.25 15.75 18.75 26.25 42.75 68.25 92.25 105.79 183.38 466.99 $160,000 13.60 15.20 16.80 20.00 28.00 45.60 72.80 98.40 112.84 195.60 498.12 $170,000 14.45 16.15 17.85 21.25 29.75 48.45 77.35 104.55 119.89 207.83 529.25 $180,000 15.30 17.10 18.90 22.50 31.50 51.30 81.90 110.70 126.95 220.05 560.39 $190,000 16.15 18.05 19.95 23.75 33.25 54.15 86.45 116.85 134.00 232.28 591.52 $200,000 17.00 19.00 21.00 25.00 35.00 57.00 91.00 123.00 141.05 244.50 622.65 $210,000 17.85 19.95 22.05 26.25 36.75 59.85 95.55 129.15 148.10 256.73 653.78 $220,000 18.70 20.90 23.10 27.50 38.50 62.70 100.10 135.30 155.16 268.95 684.92 $230,000 19.55 21.85 24.15 28.75 40.25 65.55 104.65 141.45 162.21 281.18 716.05 $240,000 20.40 22.80 25.20 30.00 42.00 68.40 109.20 147.60 169.26 293.40 747.18 $250,000 21.25 23.75 26.25 31.25 43.75 71.25 113.75 153.75 176.31 305.63 778.31 Coverage amounts for ages 65 and over reduce due to age reduction (see Life Insurance Age Reductions section). Child Life with AD&D Monthly Premiums Coverage Amount Premium $10,000 2.40 6
Important Details Here s where you ll find the nitty-gritty details about the plan. Life and AD&D Insurance Eligibility Requirements To be eligible for coverage, you must be: An active employee of Diocese of Lafayette/Lake Charles Regularly working at least 30 hours per week Temporary and seasonal employees, full-time members of the armed forces, leased employees and independent contractors are not eligible. If you buy Life and AD&D insurance for yourself, you may also buy Life and AD&D coverage for your eligible children and/or spouse. This is called Dependents Life and AD&D insurance. You can choose to cover your spouse, meaning a person to whom you are legally married. You may also choose to cover your child. Child means your child from live birth through age 25. Your child cannot be insured by more than one employee. Your spouse or child(ren) must not be full-time member(s) of the armed forces. You cannot be insured as both an individual and a dependent. Medical Underwriting Approval for Life Coverage Required for: Coverage amounts higher than the guarantee issue maximum amount All late applications (applying 31 days after becoming eligible) Requests for coverage increases Reinstatements Employees eligible but not insured under the prior life insurance plan Visit www.standard.com/mhs to submit a medical history statement online. Coverage Effective Date for Life Coverage To become insured, you must Meet the eligibility requirements listed in the previous sections, Serve an eligibility waiting period*, Receive medical underwriting approval (if applicable), Apply for coverage and agree to pay premium, and Be actively at work (able to perform all normal duties of your job) on the day before the insurance is scheduled to be effective. If you are not actively at work on the day before the scheduled effective date of insurance including Dependents Life insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee. You may have a different effective date for Life coverage below and above the guarantee issue amount. *If you are already a member on the date the group policy is effective, you are eligible on the date you become a member. If you become a member after the group policy effective date, you are eligible on the first day that follows 30 consecutive days as a member. Life and AD&D Age Reductions Under this plan, your coverage amount reduces to 65 percent at age 65, to 50 percent at age 70 and to 35 percent at age 75. Your spouse s coverage amount reduces by your spouse s age as follows: to 65 percent at age 65, to 50 percent at age 70 and to 35 percent at age 75. If you or your spouse are age 65 or over, ask your human resources representative or plan administrator for the amount of coverage available. Life Insurance Waiver of Premium Your Life premiums may be waived if you: Become totally disabled while insured under this plan, Are under age 60, and Complete a waiting period of 180 days. If these conditions are met, your Life insurance coverage may continue without cost until age 65, provided you give us satisfactory proof that you remain totally disabled. Life and AD&D Insurance Portability If your insurance ends because your employment terminates, you may be eligible to buy portable group insurance coverage from The Standard. Life Insurance Conversion If your insurance reduces or ends, you may be eligible to convert your existing Life insurance to an individual life insurance policy without submitting proof of good health. Life Insurance Exclusions Subject to state variations, you and your dependents are not covered for death resulting from suicide or other intentionally self-inflicted injury, while sane or insane. The amount payable will exclude amounts that have not been continuously in effect for at least two years on the date of death. AD&D Benefits 7
The amount of the AD&D benefit is equal to the amount payable for your or your spouse s or child(ren) s Life benefit on the date of the accident. For all other covered losses, the amount is shown as a percentage of the amount payable for the benefit on the date of the accident. No more than 100 percent of the AD&D benefit will be paid for all losses resulting from one accident. Any loss must be caused solely and directly by an accident within 365 days of the accident. A certified copy of the death certificate is needed to prove loss of life. All other losses must be certified by a physician in the appropriate specialty determined by The Standard. Covered loss: Percentage of AD&D benefit payable: Life 100% One hand or one foot 50% Sight in one eye 50% Two or more of the losses listed above 100% AD&D Insurance Exclusions You are not covered for death or dismemberment caused or contributed to by any of the following: Committing or attempting to commit an assault or felony, or actively participating in a violent disorder or riot Suicide or other intentionally self-inflicted injury, while sane or insane War or any act of war (declared or undeclared), and any substantial armed conflict between organized forces of a military nature Voluntary consumption of any poison, chemical compound, alcohol or drug, unless used or consumed according to the directions of a physician Sickness or pregnancy existing at the time of the accident Heart attack or stroke Medical or surgical treatment for any of the above When Your Insurance Ends Your insurance ends automatically when any of the following occur: The date the last period ends for which a premium was paid The date your employment terminates The date you cease to meet the eligibility requirements (insurance may continue for limited periods under certain circumstances) The date the group policy, or your employer s coverage under the group policy, terminates For each elective insurance coverage, the date that coverage terminates under the group policy The date your Life coverage ends, your AD&D coverage will end as well In addition to the above requirements, your Dependents Life and AD&D coverage ends automatically on the date your dependent ceases to meet the eligibility requirements for a dependent. For more details on when your insurance ends, contact your human resources representative or plan administrator. Group Insurance Certificate If coverage becomes effective and you become insured, you will receive a group insurance certificate containing a detailed description of the insurance coverage, including the definitions, exclusions, limitations, reductions and terminating events. The controlling provisions will be in the group policy. The information present in this summary does not modify the group policy, certificate or the insurance coverage in any way. About For more than 100 years, we have been dedicated to our core purpose: to help people achieve financial well-being and peace of mind. Headquartered in Portland, Oregon, The Standard is a nationally recognized provider of group employee benefits. To learn more about products from The Standard, visit us at www.standard.com. The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by of Portland, Oregon, in all states except New York. Product features and availability vary by state and are solely the responsibility of. GP190-LIFE/S399, GP399-LIFE/TRUST, GP899-LIFE, GP190-LIFE/A997/S399, GP411-LIFE 1100 SW Sixth Avenue Portland OR 97204 www.standard.com SI 12505-D-VLVA-LA-164075 (8/18) 5708682-225371 8