C. Voluntary Disability Insurance Monthly premium is calculated on a percentage of your basic monthly salary. A late enrollment penalty will apply if you choose to enroll in coverage at a later date or allow coverage to lapse. Voluntary Term Disability Enroll For Coverage Decline Coverage Short Term Disability plans pay weekly benefits with coverage dates ending after 60 or 90 days depending upon plan enrollment. Voluntary Long Term Disability Enroll For Coverage Decline Coverage Long Term Disability plans pay monthly benefits with benefits starting after 60 or 90 day waiting periods depending upon plan enrollment. D. Voluntary Long Term Care Insurance Employee Long Term Care enrollment as a newly eligible employee has guarantee issue* amounts of up to $6,000 in monthly benefit, professional home care option for 3 or 6 year duration without having to submit medical history for enrollment approval. Enrollment requests for unlimited duration, amount over $6,000, home care, and 5% simple inflation options, enrollment after first eligible or a future date, and Spouse/Domestic Partner Long Term Care will require the UNUM medical history statement to be filled out and submitted to UNUM. You can find a link to UNUM forms on the OEBB website: * You are required to submit a medical history statement on any coverage amount that is not guarantee issue or if you are requesting a change in enrollment coverage. Employee Long Term Care* Request Coverage Change Coverage Decline Coverage Plan Option Coverage Amount Duration Professional Home Care Professional Home Care 5% Inflation $2,000 $5,000 $8,000 3 – Total Home Care Total Home Care $3,000 $6,000 $9,000 6 Years $4,000 $7,000 Unlimited Spouse/Domestic Partner Long Term Care* Request Coverage Change Coverage Decline Coverage Plan Option Coverage Amount Duration Professional Home Care Professional Home Care 5% Inflation $2,000 $5,000 $8,000 3 – Total Home Care Total Home Care $3,000 $6,000 $9,000 6 $4,000 $7,000 Unlimited 7. Beneficiary Designation The Standard Order of Survivorship (If you have a Domestic Partner, an Affidavit* must be on file for distribution.) I To designate the following as beneficiary (Attach additional sheets if necessary.) Total of primary percentages must = 100% Total of contingent percentages must = 100% Name Address City State Zip Relationship Primary or Contingent Whole % OR Name Address City State Zip Relationship Primary or Contingent % OR Name Address City State Zip Relationship Primary or Contingent Whole % OR
C. Voluntary Disability Insurance Monthly premium is calculated on a percentage of your basic monthly salary. A late enrollment penalty will apply if you choose to enroll in coverage at a later date or allow coverage to lapse. Voluntary Term Disability Enroll For Coverage Decline Coverage Short Term Disability plans pay weekly benefits with coverage dates ending after 60 or 90 days depending upon plan enrollment. Voluntary Long Term Disability Enroll For Coverage Decline Coverage Long Term Disability plans pay monthly benefits with benefits starting after 60 or 90 day waiting periods depending upon plan enrollment. D. Voluntary Long Term Care Insurance Employee Long Term Care enrollment as a newly eligible employee has guarantee issue* amounts of up to $6,000 in monthly benefit, professional home care option for 3 or 6 year duration without having to submit medical history for enrollment approval. Enrollment requests for unlimited duration, amount over $6,000, home care, and 5% simple inflation options, enrollment after first eligible or a future date, and Spouse/Domestic Partner Long Term Care will require the UNUM medical history statement to be filled out and submitted to UNUM. You can find a link to UNUM forms on the OEBB website: * You are required to submit a medical history statement on any coverage amount that is not guarantee issue or if you are requesting a change in enrollment coverage. Employee Long Term Care* Request Coverage Change Coverage Decline Coverage Plan Option Coverage Amount Duration Professional Home Care Total Home Care Professional Home Care – 5% Inflation Total Home Care $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 3 6 Years Unlimited Spouse/Domestic Partner Long Term Care* Request Coverage Change Coverage Decline Coverage Plan Option Coverage Amount Duration Professional Home Care Total Home Care Professional Home Care – 5% Inflation Total Home Care $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 3 6 Unlimited 7. Beneficiary Designation I The Standard Order of Survivorship (If you have a Domestic Partner, an Affidavit* must be on file for distribution.) To designate the following as beneficiary (Attach additional sheets if necessary.) Total of primary percentages must = 100% Total of contingent percentages must = 100% Name Address City State Zip Relationship Primary or Contingent OR Whole % Name Address City State Zip Relationship Primary or Contingent OR % Name Address City State Zip Relationship Primary or Contingent OR Whole %
2017-18%20OEBB%20Midyear%20Change%20Form.docx