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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?
- This plan is specifically designed to benefit the members of IUOE Local 399. As a current member, you are eligible to enroll in this group coverage.
If you joined IUOE Local 399 within the last 90 days, you are within your open enrollment period and can join with no personal health statement.
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 Late Applicant Enrollment Health Statement. You can expect the insurance carrier to make a determination within 14 business days. You will receive a letter from the insurance carrier to advise if your enrollment has been accepted.
As a plan participant, you must notify Group Benefit Associates:
Within 30 days of any layoff and again within 30 days of my subsequent return to work
Immediately when my bank account or credit card information 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
Within 30 days if I withdraw from the Union
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 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.
Cancellation Requests: Cancellation requests must be received in writing by mail, fax, or e-mail. Cancellations will become effective on the last day of the month in which they are received.
Premium Waived if Disabled: Premium will not need to be paid if you are receiving benefits. Please contact us within 30 days of your disability so that we may waive your premium while you are not working.
Premium Payments: Your initial premium due will be collected within 5 business days of your enrollment. Subsequent premiums will be collected automatically from a Visa, MasterCard or direct debit from a checking account on the 15th of each month. If the 15th falls on a weekend or holiday, the charge will occur on the next business day.
- 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 Late Applicant Enrollment Health Statement. You can expect the insurance carrier to make a determination within 14 business days. You will receive a letter from the insurance carrier to advise if your enrollment has been accepted.
- 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.