Cverage Highlights Yur Plan Eligibility Cverage Amunts Tufts Health Plan Plicy # 425544 All full-time and part-time emplyees in active emplyment in the United States wrking at least 20 hurs per week. Cverage is effective upn date f hire. Yur Vluntary Term Life cverage ptins are: Emplyee: 1,2,3,4 r 5 times annual earnings t a maximum f the lesser f 5 times annual cmpensatin f $1,200,000. Spuse/DP: $10,000 increments t an verall maximum f $600,000. Child: 14+ days t 19 (26, if student) $5,000 r $10,000 ptin. Live Birth t 14 days: $500 NOTE: Insurance fr a dependent will nt be mre than 50% f the emplyee s life/ad&d insurance amunt if spuse nly and nt mre than 60% f the emplyees life/ad&d insurance amunt if spuse and child(ren). Yur Vluntary AD&D cverage ptins are: Emplyee: Increments f $10,000. Nt t exceed the lesser f 10 times annual earnings r $1,000,000. Family Cverage Schedule (Benefits will be paid t the emplyee) Spuse Only : 60% f emplyee amunt t a maximum f $300,000 Spuse with Child(ren): 50% f emplyee amunt t a maximum f $300,000 Child with Spuse: 15% f emplyee amunt t a maximum f $25,000 Child Only: 20% f emplyee amunt t a maximum f $25,000 In rder t purchase AD&D cverage fr yur spuse and/r child, yu must purchase AD&D cverage fr yurself. AD&D Benefit Schedule: The full benefit amunt is paid fr lss f: Life Bth hands r bth feet r sight f bth eyes One hand and ne ft One hand and the sight f ne eye One ft and the sight f ne eye Speech and Hearing Other lsses may be cvered as well. Please see yur Plan Dcuments. Cverage amunt(s) will reduce accrding t the fllwing schedule: Age: Insurance Amunt Reduces t: 65 65% f riginal amunt 70 50% f riginal amunt ADR1879-2001
EVIDENCE OF INSURABILITY Special Open Enrllment fr January 1, 2018: Cverage may nt be increased after a reductin. If yu and yur eligible dependents enrll during the annual enrllment windw between 11/1/2017 and 11/15/2017, yu may apply fr any amunt f Life insurance cverage up t the lesser f 3 times annual cmpensatin r $750,000 fr yurself and any amunt f cverage up t $30,000 fr yur spuse withut Evidence f Insurability. Any Life insurance cverage ver these Guarantee Issue amunt(s) will be subject t evidence f insurability. If yu and yur eligible dependents d nt enrll within this enrllment windw, yu can apply fr cverage nly during a subsequent annual enrllment perid r within 31 days f a change in status. Yu and yur spuse will be required t furnish evidence f insurability fr any increase in cverage. All child cverage and all AD&D cverage d nt require evidence f insurability. All ther enrllment pprtunities: If yu and yur eligible dependents enrll within 31 days f yur eligibility date, yu may apply fr any amunt f Life insurance cverage up t 3 times annual cmpensatin r $750,000 fr yurself and any amunt f cverage up t $30,000 fr yur spuse withut Evidence f Insurability. Any Life insurance cverage ver these Guarantee Issue amunt(s) will be subject t evidence f insurability. If yu and yur eligible dependents d nt enrll within 31 days f yur eligibility date, yu can apply fr cverage nly during an annual enrllment perid r within 31 days f a change in status. Yu and yur spuse will be required t furnish evidence f insurability fr the entire amunt f cverage. All child cverage and all AD&D cverage d nt require evidence f insurability. If yu and yur eligible dependents enrll within 31 days f yur eligibility date, and later, wish t increase yur cverage, yu must wait until the next annual enrllment r within 31 days f a change in status and any increase in Life insurance cverage will be subject t evidence f insurability. All child cverage and all AD&D cverage d nt require evidence f insurability. Please see yur Plan Administratr fr yur eligibility date. Additinal Benefits Life Planning Financial & Legal Resurces Prtability/Cnversin This persnalized financial cunseling service prvides expert, bjective financial cunseling t survivrs and terminally ill emplyees at n cst t yu. This service is als extended t yu upn the death r terminal illness f yur cvered spuse. The financial cnsultants are master level cnsultants. They will help develp strategies needed t prtect resurces, preserve current lifestyles, and build future security. At n time will the cnsultants ffer r sell any prduct r service. If yu retire, reduce yur hurs r leave yur emplyer, yu can take this cverage with yu accrding t the terms utlined in the cntract. Hwever, if yu have a medical cnditin which has a material effect n life expectancy, yu will be ineligible t prt yur cverage. Yu may als have the ptin t cnvert yur Term life cverage t an individual life insurance plicy.
Accelerated Benefit Waiver f Premium Retained Asset Accunt Additinal AD&D Benefits If yu becme terminally ill and are nt expected t live beynd a certain time perid as stated in yur certificate bklet, yu may request up t 75% f yur BASIC and VOLUNTARY life insurance amunt up t $250,000, withut fees r present value adjustments. A dctr must certify yur cnditin in rder t qualify fr this benefit. Upn yur death, the remaining benefit will be paid t yur designated beneficiary(ies). This feature als applies t yur cvered dependents. If yu becme disabled (as defined by yur plan) and are n lnger able t wrk and are apprved fr waiver f premium, yur premium payments will be waived during the perid f disability. Benefits f $10,000 r mre are paid thrugh the Unum Retained Asset Accunt. This interest bearing accunt will be established in the beneficiary's name. He r she can then write a check fr the full amunt r fr $250 r mre, as needed. Educatin Benefit: If yu r yur insured spuse die within 365 days f an accident, an additinal benefit is paid t yur dependent child(ren). Yur child(ren) must be a full-time student beynd grade 12. Seat Belt/Air Bag Benefit: If yu r yur insured dependent(s) die in a car accident and are wearing a prperly fastened seat belt and/r are in a seat with an air bag, an amunt will be paid in additin t the AD&D benefit. Limitatins/Exclusins/ Terminatin f Cverage Suicide Exclusin Life benefits will nt be paid fr deaths caused by suicide in the first twenty-fur mnths after yur effective date f cverage. N increased r additinal benefits will be payable fr deaths caused by suicide ccurring within 24 mnths after the day such increased r additinal insurance is effective. AD&D Benefit Exclusins AD&D benefits will nt be paid fr lsses caused by, cntributed t by, r resulting frm: Disease f the bdy r diagnstic, medical r surgical treatment r mental disrder as set frth in the latest editin f the Diagnstic and Statistical Manual f Mental Disrders; Suicide, self-destructin while sane, intentinally self-inflicted injury while sane, r self-inflicted injury while insane; War, declared r undeclared, r any act f war; Active participatin in a rit; Attempt t cmmit r cmmissin f a crime; The vluntary use f any prescriptin r nn-prescriptin drug, pisn, fume, r ther chemical substance unless used accrding t the prescriptin r directin f yur r yur dependent s dctr. This exclusin des nt apply t yu r yur dependent if the chemical substance is ethanl; Intxicatin. ( Intxicated means that the individual s bld alchl level
equals r exceeds the legal limit fr perating a mtr vehicle in the state r jurisdictin where the accident ccurred.) Travel r flight in any vehicle r device fr aerial navigatin, including barding r alighting frm it while it is being used fr test r experimental purpses; yu r yu dependent is perating, learning t perate, r serving as a member f the crew; it is being perated by, r fr, r under the directin f any military authrity. (This exclusin des nt apply t transprt type aircraft perated by the Military Airlift Cmmand f the United States; r similar air transprt service f any ther cuntry.) Travel r flight in any aircraft r device fr aerial navigatin, including barding r alighting frm it, wned r leased by, r n behalf f yur emplyer. Service n full-time active duty in the Armed Frces f any cuntry r internatinal authrity. Treatment rendered by a Physician, Nurse r any ther persn wh is: Emplyed r retained by the Subscriber; Prviding hmepathic, arme-therapeutic r herbal therapeutic services; Living in the Cvered persn s husehld; A parent, sibling, spuse r child f the Cvered Persn Participatin in hazardus sprts; aut racing, bat racing, scuba diving, bungee jumping, skydiving, parachuting, hang gliding, ballning, flying ultra lights, muntain climbing, r any similar sprt r avcatin. Terminatin f Cverage Delayed Effective Date f Cverage Yur cverage and yur dependents cverage under the Summary f Benefits ends n the earliest f: The date the plicy r plan is cancelled; The date yu n lnger are in an eligible grup; The date yur eligible grup is n lnger cvered; The last day f the perid fr which yu made any required cntributins; The last day yu are in active emplyment unless cntinued due t a cvered leave f absence r due t an injury r sickness, as described in the certificate f cverage; Fr dependent s cverage, the date f yur death. In additin, cverage fr any ne dependent will end n the earliest f: The date yur cverage under a plan ends; The date yur dependent ceases t be an eligible dependent; Fr a spuse, the date f divrce r annulment. Unum will prvide cverage fr a payable claim which ccurs while yu and yur dependents are cvered under the plicy r plan. Emplyee: Insurance cverage will be delayed if yu are nt in active emplyment because f an injury, sickness, temprary layff, r leave f absence n the date that insurance wuld therwise becme effective.
Changes t Cverage Dependent: Insurance cverage will be delayed if that dependent is ttally disabled n the date that insurance wuld therwise be effective. Ttally disabled means that, as a result f an injury, a sickness r a disrder, yur dependent is cnfined in a hspital r similar institutin; is unable t perfrm tw r mre activities f daily living (ADLs) because f a physical r mental incapacity resulting frm an injury r a sickness; is cgnitively impaired; is receiving r is entitled t receive any disability incme frm any surce due t any sickness r injury; is receiving chemtherapy radiatin therapy r dialysis treatment; r has a life threatening cnditin. Each year yu and yur spuse will be given the pprtunity t change yur Life cverage and AD&D cverage. Any increase in Life cverage will require evidence f insurability. The suicide exclusin will apply t any increase in cverage. AD&D cverage des nt require evidence f insurability fr increase amunts. This plan highlight is a summary prvided t help yu understand yur insurance cverage frm Unum. Sme prvisins may vary r nt be available in all states. Please refer t yur certificate bklet fr yur cmplete plan descriptin. If the terms f this plan highlight summary r yur certificate differ frm yur plicy, the plicy will gvern. Fr cmplete details f cverage, please refer t plicy frm number C.FP-1, et al. Life Planning is prvided by Ceridian Incrprated. The services are subject t availability and may be withdrawn by Unum withut prir ntice. Underwritten by: Unum Life Insurance Cmpany f America, 2211 Cngress Street, Prtland, Maine 04122, www.unum.cm Unum is a registered trademark and marketing brand f Unum Grup and its insuring subsidiaries. 2007 Unum Grup. All rights reserved.