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YOUR GROUP LIFE INSURANCE PLAN West Kern Community (Taft College)

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Standard Insurance Company
Group Life and Accidental Death & Dismemberment (AD&D) Insurance
YOUR GROUP
LIFE INSURANCE
PLAN
West Kern Community College
Active Employees
(other than Confidential and
Management)
2
Your employer provides you with an option for a Group Term Life
Insurance plan that offers a basic level of nancial security for your
loved ones. This coverage is offered through Standard Insurance
Company (The Standard), which has more than 100 years of
experience helping customers achieve nancial well-being and
peace of mind. In addition, you may have the option of purchasing
Supplemental Life Insurance for yourself, your spouse/domestic
partner, and/or your children. See Page 3 of this booklet for your
coverage options.
The Protection You
Need From A Partner
You Can Trust
Your Life Insurance plan features
Additional plan features included at no
additional cost
• Accidental Death & Dismemberment (AD&D) Insurance is
included with your Basic Life Insurance plan.
• Accelerated Benefit allows you to receive up to 80% of the
amount of Life Insurance in force when you provide satisfactory
proof to The Standard that, while insured, you have been
diagnosed as terminally ill with a life expectancy of less than 12
months. The amount paid under the accelerated benefit reduces
the amount of Life Insurance paid upon your death.
• Qualified Disability Benefit allows you to receive up to 60%
of the amount of Life Insurance in force when you provide
satisfactory proof to The Standard that, while insured, you are
unable to perform two or more activities of daily living (bathing,
continence, dressing, eating, toileting, transferring) without
hands-on or standby assistance. The amount paid under the
qualified disability benefit reduces the amount of Life Insurance
paid upon your death.
• Travel Assistance provides insured employees and their
families access to a comprehensive range of professional,
24-hour medical, legal and trip assistance information, as well
as referral and coordination services. This worldwide assistance
service is available to plan participants whenever they are
traveling 100 miles or more from home or when traveling in a
foreign country for trips up to 180 days
1
.
1
Travel assistance is provided by UnitedHealthcare Global, which is not afliated
with Standard Insurance Company. Consult the UnitedHealthcare Global Travel
Assistance program description for complete terms, conditions and limitations. For
a copy of the program description call The Standard at 800.522.0406.
• Basic Life and Dependent Life Insurance coverage.
• Options for you to purchase additional coverage to meet your
specific needs.
3
Life Insurance Coverage Highlights
Eligibility
You are eligible to participate in this plan if you are:
Basic Life and AD&D
Insurance
Dependents Life and
AD&D Insurance
Supplemental Life and
AD&D Insurance
The amount of your Supplemental Life Insurance, if elected, equals the amount
of your Basic Life Insurance
The amount of your Supplemental Plus Life and AD&D Insurance, if elected, is
is equal to the amount of Supplemental Life and AD&D Insurance. Supplemental
Plus Insurance ends at age 65.
Proof of Good Health
Satisfactory proof of good health is required in all of the following instances
2
:
• If you apply for Supplemental and Supplemental Plus Life Insurance more
than 120 days after you become eligible under your employer’s Group Life
Insurance plan, or your fail to make the required premium contribution by the
third month following the date you apply.
• To become insured for any amount greater than the amount for which you or
your dependent was insured under the prior plan, if you or your dependent
was insured under the prior plan.
• For any combination of Supplemental Life Insurance and/or Supplemental
Plus Life Insurance in excess of the guarantee issue amount of $100,000.
• For any increase in Supplemental Life Insurance and Supplemental Plus Life
Insurance
• For reinstatements, if required.
2 Satisfactory proof of good health will not be required for active participants to become insured for amounts of Supplemental Life Insurance, and/or
Dependents Life Insurance, not to exceed the guarantee issue amount, for which you apply within 31 days following a qualifying family status change and for
which you make the required premium contribution by the third month following the date you apply.
Participant’s Age at Death
Under 25
25 through 29
30 through 34
35 through 39
40 through 44
45 through 49
50 through 54
55 through 59
60 through 64
65 through 69
70 or over
$136,800
$120,000
$103,200
$88,200
$70,200
$52,800
$34,200
$27,600
$23,400
$14,400
$8,400
Benet AmountParticipant’s Age at Death Benet Amount
Supplemental Plus Life
and AD&D Insurance
West Kern Community College - Active Employees (other than Condential and
Management)
• An active employee of West Kern Community College who is working at
least 20 scheduled hours a week and for whom West Kern Community
College has negotiated to provide coverage under the Group Policy.
$1,500
4
3 Frequency of required premium payments (monthly, tenthly, etc.) is determined by your employer.
4 Participants in the California Teachers Association Voluntary Life and AD&D Insurance plan may have no more than a combined total of $500,000 of
Life Insurance, and no more than a combined total of $500,000 of AD&D Insurance with The Standard.
5 If your district provides a dened contribution plan, a portion of your Life Insurance premium may not be covered by your district, depending on the
structure of your dened contribution plan. Consult your benets administrator to determine what portion, if any, of your Life Insurance premium you
would be required to contribute.
Costs
Coverage Benet Amount
$0 (Premium fully paid by your employer)
Basic Life and AD&D
Insurance
Dependents Life
and AD&D Insurance
Supplemental Plus
Life and AD&D
Insurance
4
Supplemental Life
and AD&D Insurance
4
Varies based on age at death
(see Page 3)
Varies based on age at death
(see Page 3)
Varies based on age at death
(see Page 3)
$1,500
$0 (Premium fully paid by your employer)
5
$10.80
$10.80
Tenthly Rate
3
Life Enrollment
for CEIP-Endorsed Plans
Standard Insurance Company
CTA Benets and Services
PO Box 4744 Portland OR 97208
Tel & TTY 800.522.0406 Fax 888.414.0393
Sign and date the completed form and return it to your Employer. If you have questions about completing this form please
contact your Employer.
I wish to make the choices indicated on this form. If electing coverage, I authorize my Employer to deduct premiums from my wages to cover my
cost of insurance. I understand that my Employer may provide updated payroll information to The Standard either periodically or at The Standard’s
request to ensure proper premium deductions are being made for my coverage. I understand that my premium deduction amount will change if my
coverage or costs change. This authorization will remain in effect until cancelled by me or by The Standard.
Signature ____________________________________________________________________________ Date ___________________________________________
Refer to the enrollment materials provided or your benets administrator when completing the following and mark the coverages you wish to
elect. Coverage options may be subject to Evidence Of Insurability requirements (proof of good health).
Coverages
Signature Required
Primary
Primary
Contingent
Contingent
FULL NAME*
ADDRESS
DATE OF BIRTH* SOCIAL SECURITY NO.
RELATIONSHIP*
% OF BENEFIT*
TOTAL 100%
TOTAL 100%
Unless otherwise specied on a separate sheet of paper, this designation applies to coverage available through your CEIP-endorsed plans,
if any, including Life Insurance and Accidental Death and Dismemberment (AD&D) Insurance associated with your Life Insurance.
Designations are not valid unless signed, dated and delivered to The Standard at the address above during your lifetime. See page 2
for further information.
MAILING ADDRESS CITY STATE ZIP
SCHOOL DISTRICT Please do not abbreviate.
FIRST NAME MIDDLE INITIAL LAST NAME
PHONE DATE OF BIRTH GENDER GROSS ANNUAL SALARY
$ ______________
Male Female
PARTICIPANT ID
POLICY NO.
Employee Information
DATE FIRST WORKED (CURRENT SCHOOL DISTRICT) ELIGIBILITY DATE HOURS WORKED PER WEEK
BILLING CLASS
TYPE OF EMPLOYEE
Certicated
Classied
Board Member
Management / Condential Other
ARE YOU SELECTING COVERAGE DUE TO A QUALIFYING FAMILY STATUS CHANGE WITHIN THE LAST 31 DAYS?
Yes
No Effective Date _______________________________ Type _________________________________________
Basic Benets
Electable Benets (Contributory) - Each of the contributory life insurance coverages listed below has a matching Accidental Death &
Dismemberment (AD&D) benet.
Beneciary Designations * Required elds.
SI 7533-CTAdp2_503176_Class 2 (5/18)
West Kern Community College
503176
Class 2
Supplemental Life Insurance
Supplemental Plus Life Insurance
=
Basic Life Insurance with matching Accidental Death & Dismemberment (AD&D) benet - Varies based on age at death
=
Basic Dependents Life and AD&D Insurance - $1,500
Reset
Print Enrollment Form
6
Immediate Needs
Medical and hospital expenses $ ______________ $ ______________
Funeral/burial expenses ______________ ______________
Loans/debts requiring payment upon death ______________ ______________
Taxes
Federal and state income taxes ______________ ______________
Property taxes ______________ ______________
Federal and state estate taxes ______________ ______________
Long Term Needs
Mortgage balance $ ______________ $ ______________
Other debts (credit cards, car & student loans, etc.) ______________ ______________
Educational/vocational fund ______________ ______________
Emergency fund for unforeseen expenses ______________ ______________
Income Replacement
Consider the annual income needed to provide
for everyday expenses like food, clothing and fuel,
and multiply by the number of years that income is
needed. $ ______________ $ ______________
Total Income Needs
Add all of the above. $ ______________ $ ______________
Available Resources
Existing Life Insurance coverage $ ______________ $ ______________
Other assets such as 401(k), stocks, bonds, etc. ______________ ______________
Total Available Resources
Add all of your available resources. $ ______________ $ ______________
Additional Life Insurance Needed
Subtract the amount of your total available
resources from your total income needs. $ ______________ $ ______________
Life Insurance Worksheet You Your Spouse/
Domestic Partner
Beneciary Information
• Your designation revokes all prior designations.
• Benets are payable to a contingent beneciary only if you are not survived by one or more primary beneciaries.
• If you name two or more beneciaries in a class (primary or contingent), two or more surviving beneciaries will share
equally, unless you provide for unequal shares. If you complete the “% of Benet” box(es), the amounts should add
up to 100% for each class (primary or contingent). For example, “Primary - John Q. Doe, 60%; Jane Q. Doe, 40%.”
• If a minor (a person not of legal age) or your estate is the beneciary, it may be necessary to have a guardian or
a legal representative appointed by the court before any death benet can be paid. If the beneciary is a trust or
trustee, the written trust must be identied in the beneciary designation. For example, “Dorothy Q. Smith, Trustee
under the trust agreement dated mm/dd/yyyy.”
• A power of attorney must grant specic authority, by the terms of the document or applicable law, to make or
change a beneciary designation. If you have questions, consult your legal advisor.
• Spouse and/or Dependents Insurance, if any, is payable to you, if living, or as provided under the Group Policy.
How much coverage do I need?
Use the worksheet below to calculate the amount of Life Insurance you may need. Once you determine how much
coverage you need, complete the enrollment form in this booklet and submit it to your human resources department.
7
Answers to Common Questions
How are benets paid?
For amounts of less than $25,000, The Standard issues a check to each
designated beneciary. The Standard pays amounts of $25,000 or more
to each designated beneciary by depositing funds into a convenient,
no fee, interest-bearing draft account called Standard Secure Access.
With Standard Secure Access, each beneciary receives a personalized
checkbook and has complete control of the account. Beneciaries can
write checks as needed or for the full amount. This arrangement allows
beneciaries to earn interest on their benets while they take time to
consider nancial decisions.
How do I apply?
Complete the enclosed enrollment form and give it to your
When does my Life Insurance
become effective?
If proof of good health is not required:
Subject to the active work requirement, Contributory Life Insurance and
Contributory Dependent Life Insurance not subject to satisfactory proof
of good health becomes effective on the later of the date you become
eligible, or the rst day of the calendar month following the date you
apply, provided the required premium contribution has been made for that
month.
If you are required to provide proof of good health:
Subject to the active work requirement, Contributory Life Insurance and
Contributory Dependent Life Insurance subject to satisfactory proof of
good health becomes effective on the rst day of the calendar month
following the date we approve your Medical History Statement, provided
the required premium contribution has been made for that month.
If my Life Insurance ends or is
reduced, can I convert to an
individual policy?
If your Life Insurance from The Standard ends or is reduced for any
reason other than failure to pay premiums, you may be able to convert
the terminated coverage to certain types of individual Life Insurance
policies without providing proof of good health. You must apply for
conversion and pay the required premium within 31 days after group
coverage ends or is reduced. AD&D Insurance may not be converted
under this provision.
May I buy group Life Insurance
after I leave my employer?
If your insurance ends because your employment terminates or your
occupation changes so that you are no longer eligible under the
group policy, you may be eligible to buy group Life Insurance from
The Standard through the portability provision, assuming you meet
the eligibility requirements.
What if I have additional
questions?
If you have any additional questions, please contact
your human resources representative.
your human resources representative.
Please see your human resources
representative for additional information.
Standard Insurance Company
1100 SW Sixth Avenue
Portland OR 97204
www.standard.com
GP 190-Life/S399/CTA.1
Life Insurance Terms and
Exclusions
Life Insurance active work requirement
All coverage is subject to an active work requirement. Active work
means performing the material duties of your own occupation at
your employer’s usual place of business. You must be capable of
active work on the scheduled effective date of your insurance or
an increase in your insurance or your insurance or increase will not
become effective as scheduled. If you are incapable of active work
on the scheduled effective date of insurance due to physical disease,
injury, pregnancy or mental disorder, your insurance or increase in
insurance (including Dependents Life Insurance) will not become
effective until after you complete one full day of active work as an
eligible participant.
Life Insurance termination provisions
Life Insurance will automatically end on the earliest of the following:
• The date the last period ends for which a premium was paid for
your Life Insurance (except if premiums are waived while totally
disabled)
• The date the group policy terminates
• The date your employer’s participation under the group policy is
terminated
• The date your employment terminates, unless otherwise stated
in the group policy
• For Supplemental Plus Life Insurance, the earlier of a) the date
you reach age 65 and b) the date of your retirement
• The rst day of the calendar month following the date you
cease to be a participant; however, insurance may continue
with premium payments for limited periods under certain
circumstances
Dependents Life Insurance termination provisions
Dependents Life Insurance (if applicable) will automatically end on
the earliest of the following:
• Two years after the date you die (however, coverage will not
be continued beyond the date your surviving spouse/domestic
partner remarries or enters a domestic partner relationship)
• The date your Life Insurance ends under the group policy
• The date the group policy or Dependents Life Insurance
terminates
• The date the last period ends for which a premium was paid for
your Dependents Life Insurance
• When the dependent ceases to be an eligible dependent
• For your spouse/domestic partner, the date of your divorce or
termination of your domestic partner relationship
• For a child who is disabled, 90 days after we mail you a request
for proof of disability, if proof is not given
Accidental Death and Dismemberment (AD&D)
exclusions and limitations
Losses must be caused solely and directly by the accident. No AD&D
Insurance benet is payable if the accident or loss is caused or
contributed to by war or act of war (including declared or undeclared
war, whether civil or international, and any substantial armed
conict between organized forces of a military nature); suicide
or other intentionally self-inicted injury, while sane or insane;
committing or attempting to commit an assault or felony; physical
disease (including but not limited to heart attack or stroke); mental
disorder or pregnancy, bacterial infections (except infections which
occur with and through a cut or wound at the time of the accident);
medical or surgical treatment for any of the above (except surgical
treatment required by the accident and performed within 90 days
after the accident). AD&D benets are not payable for losses
occuring more than 365 days after the accident.
AD&D termination provisions
AD&D Insurance for you automatically ends on the earliest of the
following:
• The date your Group Life Insurance ends
• The date the last period ends for which a premium was paid for
your AD&D Insurance
• The date your Waiver of Premium begins
• The date AD&D Insurance terminates under the Group Policy
• The date you retire
Dependents AD&D termination provisions
Dependents AD&D Insurance (if applicable) ends automatically on
the earliest of the following:
• The date your Dependents Life Insurance ends
• The date Dependents AD&D Insurance terminates under the
Group Policy
• The date the last period ends for which a premium was paid for
your Dependents AD&D Insurance
• For your spouse/domestic partner, the date of your divorce or
termination of your domestic partner relationship
• For any dependent, the date the dependent ceases to be a
dependent
• For a child who is disabled, 90 days after we mail you a request
for proof of disability, if proof is not given
• The date your Waiver of Premium begins
• The date you retire
The information in this booklet is subject to all of the terms and provisions of the group policy.
SI 14046-503176_Class 2 (5/18)
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YOUR GROUP LIFE INSURANCE PLAN West Kern Community (Taft College)

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