This disability plan is specifically designed for IBEW Local 134 members to help them protect their income and assets in the event of a disability or illness. Since January 1, 2003 IBEW Local 134 brothers and sisters have received over $1,758,990 in benefits from this program which has helped them keep their bills paid during periods of disability or illness.

If you became disabled or ill, could you...

• Cover the loss of your income for at least 55 days? According to MetLife Employee Benefits Trend Research, the average length of a short term disability claim in 2004 was 55 days.
• Cover the unexpected loss of your income in addition to a likely increase in medical expenses including office visit and prescription copays, deductibles and/or coinsurance? Your medical expenses are likely to go up when you become disabled. Are you prepared for reduced income and increased expenses?
• Rely on Social Security income in the event of a disability or illness? Not necessarily. According to the Social Security Disability Web Site, the average disability amount paid to individuals without qualifying dependents in 2003 was only $833 and 60% of Social Security disability claims are denied on first review.

Do not underestimate the importance of disability income insurance. Take advantage of the program designed specifically for the brothers and sisters of IBEW Local 134 and protect your most valuable asset, your paycheck.

• As a plan participant, I agree to notify Group Benefit Associates:

  • Within 60 days of any layoff and again within 60 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

  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 Reliance Standard to bring you this program. Reliance Standard 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: 30 day non-occupational accidental injury, 30 day non-occupational sickness or pregnancy.
• Benefit Amount: $250 per week
• Benefit Period: 22 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: $5,000 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.
• Survivor Benefits: In the event of your death, three times your net disability payment is payable to your spouse or children under age 25.

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	=	____.__
		Monthly Earnings

*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

15-24	$0.28
25-29	$0.35
30-34	$0.40
35-39	$0.47
40-44	$0.65
45-49	$1.48
50-54	$2.51
55-59	$3.58
60+	$3.14

Divide by 100 for your cost: ($/100)= $_______._____ LTD Cost

Add the short-term disability premium to determine your total monthly premium: $+$25.89= $_______._____ Total Premium

*Rates valid for the period of September 1, 2010.

*Your age bracket will be redetermined on the first of the month following your birthday. 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 e-mail within 30 days of the requested termination date. Terminations can only be processed on the first of the month, mid-month terminations are not allowable.

Premium Payments & Grace Periods: Premium must be paid via automatic ACH bank drafts of by credit card (Visa or Mastercard). Drafts occur on the 20th of the month for the following month (example, October 20th for November's coverage). If the 20th falls on a weekend or holiday, the draft occurs on the next business day. If a payment is declined or returned, a notice will be sent to your last known address. If payment is not received by the end of the month of which premium was returned, your policy will be canceled (example, the payment drafted on October 20th for November's coverage is declined. A notice will be sent and payment must be received by November 30 to avoid a lapse in coverage).

The following PDF documents are provided for your reference:

• Summary of Benefits
• New Member Enrollment Form
• Disability Policy Change Form
• Short Term Disability Claim Form
• Long Term Disability Claim Form
• Late Applicant Evidence of Insurability

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 Reliance Standard 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. Reliance Standard can be reached directly at:

Claims Department: 800-351-7500 phone/ 267-256-3519 fax

Premium billing questions are handled by Group Benefit Associates at 800-450-1271.