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- Forms and Documents
This disability plan is specifically designed for IUOE Local 399 members to help them protect their income and assets in the event of a disability.
Some Questions to Think About
- Could you afford to take a six-month vacation? If you can’t, do you think you could afford living through a six-month illness or injury?
- How would you and your family pay your bills without your income?
- How long would your savings last if you were unable to work because of an illness or accident and your income stopped?
- If you were sick or injured in an accident today, would your family’s standard of living be affected?
- What impact would a long-term illness or injury have on your ability to save for retirement?
- Within 60 days of any layoff and again within 60 days of my subsequent return to work
- Immediately when my bank account changes for the purpose of premium collection
- Immediately when my wage rate changes
- Within 1 year of my date of disability if I become disabled
I understand that failure to notify Group Benefit Associates in a timely manner of any of the above listed changes can affect my participation in the plan or the benefits I am eligible to receive under the plan.
Group Benefit Associates has teamed together with Hartford Life and Accident Insurance Company to bring you this program. The Hartford is the insurance carrier for the policy and processes all claims and Group Benefit Associates is the TPA (third-party administrator) responsible for premium collection and remittance.
Short Term Disability (STD)
- Benefit Begins: 15th day non-occupational accidental injury, 15th day non-occupational sickness or pregnancy.
- Benefit Amount: $250 per week
- Benefit Period: 24 weeks
During the first 12 months of coverage, no STD benefits will be paid for a disability that is due to a pre-existing condition. A pre-existing condition is an injury or sickness for which you received medical treatment, consultation, diagnostic measures, prescribed drugs or medicines, or for which you followed treatment recommendations during the three months prior to your effective date of coverage. This provision also applies if you did not consult a physician when an ordinarily prudent person would have. Exclusions may vary by state.
Long Term Disability (LTD)
- Benefit Begins: 180 days following non-occupational accidental injury, sickness or pregnancy
- Benefit Amount: 60% of monthly covered earnings
- Maximum Benefit: $4,500 per month less deductible sources of income and disability earnings.
- Minimum Benefit: $100 per month
- Benefit Period: Up to 5 years
- Limited Pay Periods:Disabilities due to mental illness and disabilities primarily based on self-reported symptoms are limited to 24 months of benefits during your lifetime.
Please follow the steps below to calculate your monthly premium:
Calculating your monthly long-term disability (LTD) cost:
|Enter your hourly wage rate||
|Multiply by 2080||
|Divide by 12||
*If your monthly earnings exceed $7,500 (maximum monthly covered earnings) then use $7,500 as your monthly earnings to calculate your premium.
Multiply your monthly earnings by the rate for your age x your rate=$_______._____
|Age as of Jan. 1st of this year||Rate per $100 of pre-disability earnings|
Divide by 100 for your cost= $_______._____ LTD Cost
Add the short-term disability premium to determine your total monthly premium
+$15.25= $_______._____ Total Premium
**Please note that if you fall into a new age bracket as indicated above, your premium will increase. You will also experience a premium change if you have experienced a change in your pay rate.
Termination Requests: Termination requests must be received in writing by mail, fax or email within the same month of the requested termination date. Terminations can only be processed on the last day of the month, mid-month terminations are not allowable.
Premium Payments: Premiums for this program are collected in advance of the month that they are due. All premiums are collected automatically either from a Visa, Master Card or checking account. Collection occurs on the 15th of the month for the following month (example, October 15th for November's coverage). If the 15th falls on a weekend or holiday, the collection occurs on the next business day. If a payment is declined or returned, a notice will be sent to your last known address.
- If you have been a member of IUOE Local 399 for longer than 90 days, you are considered a late applicant and must complete a medical questionnaire and receive approval from the insurance company. Download the. Fax or mail your completed enrollment form to Group Benefit Associates.
- If you joined IUOE Local 399 within the last 90 days, you are within your open enrollment window and can join with no medical questionnaire. If you elect not to enroll within your open enrollment period, you will have to complete a medical questionnaire and receive approval from the insurance company to join the plan in the future. Click , or download the then fax or mail your completed enrollment form to Group Benefit Associates. ,
Once your application is received and processed you will receive a confirmation letter via US mail indicating your effective date, insured earnings and monthly premium. If you are a late applicant, please expect a delay in the processing of your enrollment form as the insurance company requires at least 1-2 weeks to review your medical questionnaire and make a determination.
- Summary of Benefits
- Late Applicant Enrollment Form
- New Member Enrollment Form
- Disability Policy Change Form
The disability income insurance claim form is composed of three separate sections that need to be completed by you, your physician and your employer.
- Employee Section: Please be sure to complete this part clearly and sign where indicated.
- Physician Section: Please have the physician that disabled you complete this part. If you have seen additional physicians, please also include their names, addresses, phone numbers and fax numbers on a separate sheet of paper.
- Employer Section: Even though your policy is purchased through the union, your benefit is based on the income you receive from your particular employer. Your employer assumes no liability or responsibility for your claim by completing this form for you.
Failure to provide proper information and documentation will delay your claim so it is very important the claim form is complete and clear. Once complete, forward the form to our office by mail or fax.
How Your Claim Will Be Handled:
Once received by Group Benefit Associates, we will begin waiving your premium as of the date of your disability. The processing of your claim will be handled by The Hartford and therefore you may inquire with them regarding the status of your claim. Please note that Group Benefit Associates does not have access to information regarding claims determination or benefit payments. However, the assistance of our office can be requested if you encounter difficulty in getting your claim processed.
The Hartford Claims Customer Support:
Premium billing questions are handled by Group Benefit Associates at 800-450-1271.