Table of Contents

Frequently Asked Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Pre-Tax Benets
Flexible Benet Administrators Medical Reimbursement Account . . . . . . . . . . . . . . . . . 5
The Benets Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Flexible Benet Administrators Dependent Care Reimbursement Account . . . . . . . . . 15
Ameritas Dental Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Ameritas Dental PPO Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Ameritas Dental PPO FAQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Ameritas VSP Vision Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Aac Accident Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Allstate Benets Cancer Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Aac Critical Illness Plan (cancer optional) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Aac Hospital Indemnity Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

After-Tax Benets
AUL Short-Term Disability Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
AUL Long-Term Disability Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Reliance Standard Term Life Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Boston Mutual Whole Life Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

For Your Reference

Continuing Benets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Contact Information for Questions and Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

* * * * * * * * NOTICE * * * * * * * *
The products described in this booklet are part of a Cafeteria Benets
Plan arranged by Mark III Brokerage for eligible Pitt County Schools
employees. The Cafeteria Benets Plan allows you to pay for certain
insurance premiums before taxes are taken out of your paycheck. Paying
for benets in this method reduces your taxes and increases your take
home pay.
The Plan Year is April 1, 2015 through March 31, 2016.
All products described in this booklet are deducted on a pre-tax basis
EXCEPT:
AUL Short-Term Disability
AUL Long-Term Disability
Reliance Standard Term Life
Boston Mutual Whole Life
If you wish to add or make changes to your insurance coverage(s), please
consult a Benets Representative during your scheduled enrollment
period. You will not be able to make any changes once the enrollment
period is over unless you experience a qualied event outlined by the IRS
(i.e., marriage, divorce, birth of a child, etc.) If you should experience a
qualied event, you have 30 days from the date of the event to make any
changes.

This booklet highlights the benets offered through your employer for the current plan
year. This is not an Insurance Contract and only the actual policy provisions will prevail.
All information in this booklet including premiums are subject to change. All policy
descriptions are for informational purposes only. Please read your certicate for each
product for the exact terms and conditions.

Plan Arranged By:

Frequently Asked Questions

What is a Flexible Benets Plan?
A Flexible Benets Plan allows employees to select various employee benets to match their specic
needs. Under IRS Code Section 125, certain insurance premiums can be payroll deducted on a
pre-tax basis.
How does a Flexible Benets Plan help employees save money?
By electing to pay for qualied insurance premiums on a pre-tax basis, dollars are deducted for these
elections and taxable payroll is reduced before state, federal and FICA withholding are taken out. In the
example below, the employee is saving $120 per month, or $1,440 per year.
With Plan

Without Plan

$3000

$3000

Flexible Spending Account (FSA)

$250

Qualied Insurance Premiums

$150

Taxable Income

$2600

$3000

Taxes (30%)

$780

$900

Net Take Home Pay

$1820

$2100

Less FSA &

Insurance Premiums

$400

Net After Expenses

$1820

$1700

Salary (monthly)
Less Pre-Taxed Dollars:

Less:

Which taxable income is reduced and will these be taxable at a later date?
Premiums and money set aside for your FSA are subtracted from your pay check prior to ANY taxes
being taken out. As long as you use your FSA money for qualied expenses, you will not be taxed on
these funds.
Who is considered a dependent?
A dependent is considered to be anyone you claim on your taxes as a dependent. Your dependent
however, does not to have to be enrolled in your medical plan to be considered a dependent.
How do I enroll in the Flexible Benets Plan?
Enrollment is held on an annual basis. During enrollment, employees can meet with a Benets
Representative to review current benet elections and make changes to their benets for the upcoming
plan year. Any changes made during the enrollment period will become effective April 1st of the upcoming
year.
Can I make changes to my benets during the Plan Year?
Generally you cannot change the elections you have made after the beginning of the Plan Year. However,
there are certain limited situations when you can change your elections. You are permitted to change
elections if you have a change in status and you make an election change that is consistent with the
change in status. If you need to make a change to your benets due to a change in status, you have
30 days from the date of status change to make appropriate changes. Currently, Federal law considers
3

the following events to be changes in status:

Marriage, divorce, death of a spouse, legal separation, or annulment
Change in the number of dependents, including birth, adoption, placement for adoption, or death of
a dependent
Any of the following events for you, your spouse, or dependent: Termination or commencement
of employment, a strike or lockout, commencement or return from an unpaid leave of absence, a
change in worksite, or any other change in employment status that affects eligibility for benets
One of your dependents satises or ceases to satisfy the requirements for coverage due to change
in age, student status, or any similar circumstance
A change in place of residence of you, your spouse, or your dependent. This applies ONLY to
Dependent Care and ONLY if that change in residence results in a change of dependent care
service provider and its cost
For additional details, please see Changes in Your Election on pages 12-13.
What do I need to do if I terminate employment with the School System?
Please Continuing Your Benets on page 69.
Where do I get a claim form?
To download a claim form for any of your benets, please visit www.markiiibrokerage.com/pcsnc
What is the maximum amount of money I can elect or contribute annually to my Medical
Reimbursement Account?
The maximum amount that you can contribute is $2,550.
Can I change my contribution amounts to my Medical or Dependent Reimbursement Accounts
if I nd that I am contributing too much or too little?
No, you can only change your contribution amount if you experience a qualifying event. Please see
pages 12-13.
Can I view my Medical Reimbursement Account online?
Yes, please see page 18 for instructions.
Do I have to re-elect my annual contribution for my Medical Reimbursement and Dependent
Care Accounts each year?
Yes, you must re-elect the Medical and/or Dependent Care Reimbursement Accounts each year. These
accounts DO NOT automatically carry-over to the next year. If you do not re-elect the benet(s), you
will not have the plan on April 1st. Please see a Mark III Representative during the annual enrollment
to re-elect your contribution.
Can I use my contributions outside of the current plan year?
Medical & Dependent Care expenses must be incurred during the plan year to be eligible for
reimbursement. You have a 90-day run-out period after the plan year has ended to remit receipts.
You also have a 2 1/2 month grace period which means you can continue to spend your current
account funds during the grace period after the end of your plan year. Please see page 12 for further
information.
Can I still purchase Over-the-Counter products using my Medical Reimbursement Account
contributions?
No, please be advised that recent Senate legislation has stated that effective January 1, 2011, participants
are required to have a prescription for Over-the-Counter (OTC) products to be eligible under their
Medical Reimbursement Account plan. Therefore a prescription or letter of medical necessity will be
required after January 1, 2011 for OTC items.
4

Flexible Benet Administrators

Medical Reimbursement Account
Plan Year: April 1, 2015 - March 31, 2016
Medical Reimbursement Account Maximum (Flexible Benet Plan) - $2,550.00
Medical Reimbursement Account Minimum (Flexible Benet Plan) - $0
Eligibility: Full-time employees and part-time employees, who are considered permanent,
working at least 20 hours or more per week are eligible to participate in the plan on the rst
day of the month following their date of hire.
Waiting Period: First day of the month after hire date
Run Off Period: 90 days following the end of the plan year to le for services rendered during
the plan year.
2 1/2 month Grace Period: You can continue to spend your current account funds during the
grace period after the end of your plan year.
FLEXIBLE BENEFIT PLAN: THE BETTER YOU PLAN, THE MORE YOU SAVE!
Its more than a slogan. The Flexible Benet Plan is a real solution to issues facing all of us. Simply stated,
by taking advantage of tax laws, the Flexible Benet Plan works with your benets to save you money.
Your insurance programs are designed to help you and your family become nancially secure as well
as to protect you against the high cost of medical care including catastrophic events. However, almost
everyone has a number of necessary, predictable expenses that are not covered by your insurance
programs. The Flexible Benet Plan will help you pay for these predictable expenses. The Flexible
Benet Plan offers a unique way to help pay for some of your health care expenses.
The Flexible Benet Plan offers a unique way to help pay for some of your health care expenses and
dependent care expenses.
The key to the Flexible Benet Plan is that your eligible expenses are paid for with tax free dollars. You
will not pay any federal, state or social security taxes on funds placed in the Plan. You will save between,
approximately, $27.65 and $37.65 on every $100 you place in the plan. The amount of your savings will
depend on your federal tax bracket.
Using the Flexible Benet Plan can save you a signicant amount of money each year, however, it is
important that you understand how the plan works and how you can make the most of the advantages
the Flexible Benet Plan offers.
This chapter will help you understand the Flexible Benet Plan. The chapter covers how the plan works,
describes the categories of the plan, explains the rules governing the plan, the reimbursement process
and how you can elect to participate in the Flexible Benet Plan. Prior to electing to participate in the
Flexible Benet Plan, it is important that you read and understand the Rules and Regulations section
of this handbook.
After you read this material, if you have any questions please feel free to contact Flexible Benet
Administrators, Inc. at 1.757.340.4567 or 1.800.437.3539.
FLEX NOTE: FLEX is authorized by Section 125 of the Internal Revenue Code

HEALTH CARE REIMBURSEMENT ACCOUNT

The Health Care Reimbursement Account allows you to pay for your uninsured medical expenses with
pre-tax dollars. With this account, you can pay for your out of pocket medical expenses for yourself,
your spouse and all of your dependents for medical services that are incurred during your Plan Year.
The maximum you may place in this account for the Plan Year is $2,550.
EXAMPLES OF ELIGIBLE HEALTH CARE EXPENSES
FEES/CO-PAYS/DEDUCTIBLES
Acupuncture
Laser Eye Surgery
Sterilization Fee
Ambulance hire
Nursing
Surgery
Anesthetist
Obstetrician
X-Rays
Chiropractor
Physician
Wheel Chair
Erectile dysfunction medication
Prescription Eye glasses/ Contact lenses
Dental Fees
Psychiatrist
Diagnostic
Psychologist
Eye Exams
Laboratory
Hospital
OTHER ELIGIBLE EXPENSES:
Prescription drugs
Diabetic supplies
Articial limbs & breasts
Routine Physicals
(only if reconstructive)
Condoms
Birth control pills, patches
Dentures
(e.g. Norplant)
Oxygen
Orthopedic shoes/inserts
Physical Therapy
Incontinence supplies
Fertility Treatments
Carpal tunnel wrist supports
Hearing aids and batteries
Vaccinations & Immunizations
Reading glasses
Elastic hose
Medical equipment
(medically prescribed)
Pedialyte for dehydration
Contact lens supplies
Therapeutic care for drug and alcohol addiction
Take-home screening kits (HIV, colon cancer)
At home pregnancy test kits
Mileage, parking and tolls ( you may be reimbursed $.23* a mile for 2015 plus parking and tolls when
medical reasons make it necessary to travel)
Tuition fees for medical care (if the college furnishes a breakdown of medical charges)
Orthodontic expenses (not for cosmetic purposes)
The above list is compiled from IRS publication 502. If you are unsure that your expected medical expense will be eligible
under tax code regulations, please call Flexible Benet Administrators at 757.340.4567 or 800.437.FLEX before making
your election for the Plan Year. IRS publication 502 can be ordered by calling the IRS at 800.829.3676.
* Mileage reimbursement rate is based on IRS regulation and subject to change.

NOTE: ORTHODONTIC TREATMENT IS REIMBURSED ACCORDING TO YOUR PAYMENT PLAN

WITH THE ORTHODONTIST. FOR EXAMPLE: If your payment plan is set up to pay $100 a month for
the orthodontic treatment, you can be reimbursed $100 a month for the payments that become due
during the Plan Year.
OVER-THE-COUNTER DRUGS
Please be advised that Senate legislation has stated that effective January 1, 2011, participants are
required to have a prescription for Over-the-Counter (OTC) products to be eligible under their FSA
plan. Therefore a prescription or letter of medical necessity will be required after January 1, 2011 for
OTC items.
OVER -THE-COUNTER EXPENSES
Examples of eligible medications and drugs that
prescription or letter of medical necessity:
Antacids

Pain relievers/aspirin

Ointments & creams for joint pain

First aid creams (Bactine, diaper rash)

Allergy & sinus medication

may be purchased in reasonable quantities with a

Cough & cold medications
Laxatives
Anti-diarrhea medicine
Bug-bite medication

OVER-THE-COUNTER EXPENSES THAT ARE NOT ELIGIBLE

The following examples are OTC items that are not eligible and will not be reimbursed under any
circumstances because the items are considered dietary supplements, toiletries, cosmetic or personal
use items:
Multi/Daily Vitamins
Herbal/natural supplements
Weight loss products/foods
Acne creams/face cleanser
Face cream/moisteners
Medicated shampoo/soaps
Mouthwash/toothpaste
Toothbrushes (even if dentist recommends a special one)
Feminine hygiene products
Eye/facial makeup/preparations
Deodorant
Rogaine
Chapstick
Suntan Lotion
DUAL PURPOSE DRUGS & ITEMS
EXPENSES THAT NEED DOCUMENTATION FROM YOUR PHYSICIAN TO BE ELIGIBLE THROUGH
THE HEALTH CARE ACCOUNT
The following items are examples of products that are considered as having both a medical purpose
and a general health, personal/cosmetic purpose and require a medical practitioners note stating the
name of the patient, the specic medical condition for which the OTC is recommended, the time frame
of the treatment and that the treatment is not cosmetic:
Weight-loss drugs (to treat obesity)
Nasal sprays for snoring
Pills for lactose intolerance
Fiber supplements (to treat a medical condition for a limited time)
OTC Hormone therapy (to treat menopausal symptoms)
St. Johns Wort (for depression)
EXPENSES FOR IMPROVEMENT OF GENERAL HEALTH are not eligible for reimbursement even if
a doctor prescribes the program. However, if the program is prescribed for a specic medical condition
(e.g. Obesity, Emphysema), then the expense would be eligible. We must have a letter from your doctor
on le for each Plan Year stating specically what illness or disease is being treated or prevented and
the length of time you will be required to use this treatment in order to reimburse for any of these types
7

of expenses.
Health Club Dues
Weight Loss Programs
Exercise equipment

Exercise classes
Wigs

NOTE: For Weight Loss Programs, only the cost of the program is an eligible expense. Any cost for
food or food supplements is not an eligible expense.
COSMETIC expenses, prescriptions and treatments are not eligible. This applies to any procedure
that is directed at improving the patients appearance and does not meaningfully promote the proper
function of the body or prevent or treat an illness or disease. If cosmetic treatment is necessary to
correct a deformity or abnormality, a personal injury or a disguring disease, it must meet IRS eligibility
guidelines outlined in IRS publication 502 and will require a physicians letter of medical necessity.
OTHER EXPENSES THAT ARE NOT ELIGIBLE FOR REIMBURSEMENT THROUGH THE HEALTH
CARE ACCOUNT
ESTIMATES for medical expenses that have not been rendered cannot be reimbursed. Medical services
do not have to be paid for, however, the services must have been rendered during the Plan Year, to be
eligible for reimbursement.
PREMIUM EXPENSES for any insurance policies are not eligible for reimbursement through the Health
Care Account. This includes contact lens insurance.
EXPENSES PAID BY AN INSURANCE COMPANY are not eligible for reimbursement through the
Health Care Account. Only the portion you have to pay out of your pocket for your medical expenses
is eligible for reimbursement.

Claims Submission
OBTAINING A REIMBURSEMENT FROM YOUR HEALTH CARE ACCOUNT
To obtain a reimbursement from your Health Care Account, you must complete a Claim Form. This form
is available from your employer's website. You must attach a receipt or bill from the service provider
which includes all the pertinent information regarding the expense:
Date of service
Providers name
Patients name
Nature of the expense
Amount charged
Amount covered by insurance (if applicable)
Cash register receipts, credit card receipts and canceled checks alone are not eligible forms of
documentation for medical expenses. These items are not considered third party receipts because
they only reect that payment has been made and do not provide the required information listed above.
Prescription documentation must include the name of the prescribed medication.
OBTAINING A REIMBURSEMENT FOR OVER-THE-COUNTER ITEMS
For the purchase of over-the-counter medications, with a prescription or letter of medical
necessity, cash register receipts will be accepted as documentation if the receipt is detailed and
indicates the name of the service provider, the date of the purchase, the amount of the purchase
and the name of the product purchased. You must also send in a copy of the prescription or
letter of medical necessity signed by a physician, along with your claim form. If the receipt does
8

not specically reect the name of the product we cannot accept the claim for reimbursement of that
item. The name of the patient does not have to be on the receipt, however, the name of the patient must
be listed on the claim form.
NOTE: In order to be eligible for reimbursement through the Health Care Account, the medical expense
must be incurred during the Plan Year. IRS denes incurred as when the medical care is provided (or
date of service), not when you are formally billed, charged for, or pay for the care. FOR EXAMPLE: If
you go to the doctor on March 26th and your Plan Year begins on April 1st, this expense is not eligible
in the new Plan Year. Even if you pay for this expense after April 1st, the date of service was before
the Plan Year began and therefore is not eligible.
THE HEALTH CARE ACCOUNT IS A PRE-FUNDED ACCOUNT
This means that you can submit a claim for medical expenses in excess of your account balance. You
will be reimbursed your total eligible expense up to your annual election. The funds that you are prefunded will be recovered as deductions continue to be deposited into your account throughout the Plan
Year.

Benets Card
The Benets Card system allows you to pay for eligible pre-tax account expenses electronically at
approved service providers and merchants. The Benets Card provides you with instant access to your
pre-funded Health Care Reimbursement Account for many common regular eligible expenses. You may
also enjoy the convenience of paying for your childcare expenses (up to your account balance at the
time of the swipe) with the Benets Card.
In order for you to get the most benet from your Plan, we want to remind you of a few things concerning
the Benets Card.
The Benets Card works just like a debit card, only your bank account consists of the funds you elected
to set aside in your pre-tax account(s). The card is not eligible for use at ATMs or other unqualied
merchant locations. The card will be denied at the point of sale when a transaction at an ineligible
location is attempted. If an eligible provider does not accept MasterCard, you must le a paper claim.
When using the card at a self-service merchant terminal, you may select the credit or debit option (with
your PIN).
How To Receive Your PIN:
The most cost effective way to provide a cardholder their PIN is to use the e-PIN delivery functionality.
e-PIN delivery provides a simple and secure way for participants to view their PIN on the FBA WealthCare
Portal. The FBA WealthCare Portal My Cards page provides a View PIN button next to each card
number. Upon clicking View PIN, FBA WealthCare Portal pops-up a new window containing the cards
four digit PIN.
Detailed information will also be available on our website at www.mywealthcareonline.com/fba .
Your card will be mailed to your home address via rst class mail. Please allow up to two weeks for
delivery of your card. If you do not receive your card two weeks after the start of your Plan Year, contact
Flexible Benet Administrators, Inc. so that a replacement card may be ordered. Any eligible expense
incurred during that time may be reimbursed by mailing, faxing or emailing a claim form and proper
documentation to Flexible Benet Administrators, Inc., following the customary claims ling procedure
and cutoff times.
When you receive your card, sign the back of the card prior to using it. Your card is activated upon the
rst swipe of your card.
9

Continue to save all receipts. Flexible Benet Administrators, Inc. may request them to verify expense
eligibility.
Flexible Benet Administrators, Inc. will notify you by mail or e-mail if you incur an expense with the card
that is or appears to be ineligible. Upon this notice you must send Flexible Benet Administrators, Inc. a
Transaction Substantiation Form with the corresponding itemized documentation within 40 days of the
transaction; you may download and print a Transaction Substantiation Form from our website. If you do
not send in those required items, your card will be deactivated until the documentation is received.
Your transaction will be denied for any amount greater than your health care reimbursement account
annual election or your dependent care reimbursement account posted balance at the time of the swipe.
You should notify Flexible Benet Administrators, Inc. immediately if your card is lost or stolen to
deactivate the card. If your employment is terminated, your card will be permanently deactivated.
You may monitor your account balance, transaction history or print a statement at any time, night or day
on the Benets Card website: www.mywealthcareonline.com/fba.
Additional information regarding the Benets Card is available on our website: www.ex-admin.com
You may also download the Transaction Substantiation Form from our website under Participants;
Forms.

Attention: Benets Card Participant

Subject: Benets Card Use
In light of IRS Rulings on Benets Card use, it is important that you make yourself familiar with the
cardholder agreement that accompanies your Benets Card. Flexible Benet Administrators, Inc.
strongly suggests reviewing this document and making yourself and any dependent cardholders in your
household aware of the terms.
Please be aware that upon receipt and signing of your Benets Card, you as the cardholder and
employee participant of the Plan are ultimately responsible for using the card for eligible expenses. This
also applies to any dependent that has use of the Benets Card. By signing the back of the card, the
employee/dependent is agreeing to the terms and conditions of this agreement.
As in the past, your responsibility as a participant in a tax-free plan is to use the card for eligible expenses
ONLY (such as prescriptions, eyeglasses and medical co-pays, etc.) As with paper claim submission,
cosmetic prescriptions and procedures as well as over the counter medications and products are not
eligible for reimbursement. Please remember that each time you use your card you are certifying that
the expense is eligible. If you have any doubt as to whether an expense is eligible, you should refer to
your employee handbook, IRS Publication 502 or call our ofce to speak with one of our administrators.
It is also your responsibility to acquire all documentation such as receipts, EOBs, etc. for the Plan Years
expenses and to retain the documentation for the entire Plan Year. If you are aware that you have paid for
an expense with the card that is ineligible it is your responsibility to notify Flexible Benet Administrators,
Inc. immediately. You will need to submit a paper claim form with substantiating documentation along
with repayment for the amount of the ineligible expense.
Flexible Benet Administrators, Inc. may request documentation to substantiate your Benets Card
transactions to determine eligibility of the expense. In the event that your documentation shows ineligible
expenses were paid with your Benets Card, Flexible Benet Administrators, Inc. will request that you
re-pay the amount of the ineligible expense. If the payment is not received in the allotted time frame your
card will be deactivated. Also, Flexible Benet Administrators, Inc. may offset future claims and notify
your employer. IRS rulings allow your employer to withhold this amount from your wages if necessary.
10

The Benets Card is NOT PAPERLESS, just less paper and is a great convenience for the participants
in the Plan, if used properly.
PLEASE NOTE: Eligible items purchased at participating Inventory Information Approval System (IIAS)
merchants will be automatically approved! When purchasing prescriptions and/or over-the-counter FSAeligible items, the merchants IIAS will verify the items and automatically approve the transaction with
no follow-up request. The Benets Card is not accepted at merchants who have not implemented IIAS.
Please visit www.sig-is.org and select IIAS Merchants List for the most recent list of IIAS merchants.

RULES AND REGULATIONS

CLAIM FILING DATES
All claims received in the ofce of Flexible Benet Administrators, Inc. will be processed within one
week via check.
COMMON ERRORS TO AVOID WHEN FILING CLAIMS
The claim form is not signed
Canceled checks, cash register receipts or credit card receipts are sent in place of receipts or bills from
the provider of service
Cash register receipts for OTC item(s) do not indicate the specic name of the product(s) purchased
Claim form has not been completed
Insufcient postage on envelope
Previous balance statements or payment on account receipts submitted in place of actual date of
service itemized bills or receipts
Your claim form may be returned to you or delayed in processing for improper or insufcient documentation.
If you have questions about your claims, you may contact Flexible Benet Administrators, Inc. at
(757) 340-4567 or (800) 437-FLEX, from 8:30 a.m. to 5:00 p.m, Monday through Friday.
REIMBURSING THE PROVIDER OF SERVICE
All reimbursements will be sent to you directly. After receiving payment from your account, you are
responsible for paying your providers.
ELIGIBLE DEPENDENTS
An individual is considered to be a dependent if he or she is a qualifying child or qualifying relative of
the taxpayer. The following qualifying criteria now apply. To be a dependent child: the individual is
a child to the participant, and the individual doesnt turn 27, regardless of any other status by the end
of the taxable year.
In addition, the following qualifying criteria apply to be a dependent relative: the individual has a
specic family type relationship to the taxpayer, the individual is not a qualifying child of any other
taxpayer, the individual receives more than half of his or her support from the taxpayer, and the
individuals annual gross income is less than the Section 151 limit ($4,000 for 2015; this criteria does
not apply to health plans).
GRACE PERIOD FOR INCURRING EXPENSES
To help participants avoid forfeiting funds, the IRS offers a 2 month 15 day grace period. This means
you have an additional 2 months & 15 days after the end of your Plan Year to incur expenses in your
Dependent Care Reimbursement Account and HealthCare Reimbursement Account. For the Plan Year
04/01/15-3/31/16, you may be reimbursed for expenses that were incurred 04/01/15-06/15/16.
11

**When estimating your expenses and calculating your annual election, do not include expenses
that will be incurred during the grace period; this is offered for participants that overestimated
expenses incurred during the Plan Year to help eliminate forfeiture of funds.**
RUNOFF PERIOD FOR FILING CLAIMS
You have the entire Plan Year plus 90 days to le all claims that were incurred during the Plan Year and
during the 2 month & 15 day extension. All claims must be received in the ofce of Flexible Benet Plan
Administrators Inc. by 5:00 p.m. on the 90th day, following the end of your Plan Year. Therefore, for the
Plan Year 04/01/15-3/31/16, all claims must be in our ofce by 5:00 p.m. on June 29, 2016. If claims are
not received during this time frame for expenses incurred during the Plan Year, your remaining funds
will be forfeited. (Remember 90 days does not mean 3 months and received in the ofce does not
mean the day it was postmarked). Please, do not delay, complete your claims early.
EFFECT ON BENEFITS CARD PARTICIPANTS
Any participant using the Benets Card should note that card swipes during the 2 month 15 day grace
period (April 1, 2016 June 15, 2016) are recognized by our administrative software system. These
swipes will be applied to your leftover 2015 balance, if applicable, until those funds are exhausted.
Once your 2015 account is depleted, any other card swipes within the grace period will be applied to
your 2016 balance.
FORFEITING FUNDS
Any money you do not use from a reimbursement account for expenses incurred during a Plan Year and
the 2 month 15 day extension will be forfeited. The forfeited funds will be returned to your employer to
offset the cost of the program. If you plan carefully, you can avoid being affected by this IRS restriction.
CHANGES IN YOUR ELECTION
No, generally you cannot change the elections you have made after the beginning of the PLAN YEAR.
However, there are certain limited situations when you can change your elections. You are permitted to
change elections if you have a change in status and you make an election change that is consistent
with the change in status. Currently, Federal law considers the following events to be changes in
status:
Marriage, divorce, death of a spouse, legal separation or annulment;
Change in the number of dependents, including birth, adoption, placement for adoption, or death of a
dependent;
Any of the following events for you, your spouse or dependent: Termination or commencement of
employment, a strike or lockout, commencement or return from an unpaid leave of absence, a change
in worksite, or any other change in employment status that affects eligibility for benets;
One of your dependents satises or ceases to satisfy the requirements for coverage due to change in
age, student status, or any similar circumstance; and
A change in place of residence of you, your spouse, or your dependent. This applies ONLY to Dependent
Care and ONLY if that change in residence results in a change of dependent care service provider and
its cost.
In addition, if you are participating in the Dependent Care Reimbursement Account, then there is a
change in status if your dependent no longer meets the qualications to be eligible for dependent
care.
You may not change your election under the Dependent Care Reimbursement Account if the cost
change is imposed by a dependent care provider who is your relative.
12

To make a change in your elections, a STATUS CHANGE FORM must be completed within 30 days
of the event. Flexible Benet Administrators, Inc. or your benets contact person will determine if your
requests for an election change meets IRS Regulations.
TRANSFERRING FUNDS BETWEEN ACCOUNTS
IRS regulations do not allow money to be transferred between reimbursement accounts. If you elect
funds to be placed in your Health Care Account, you must submit eligible medical expenses to be
reimbursed from these funds. This IRS regulation also applies to the Dependent Care Account.
TERMINATION OF EMPLOYMENT
If you have funds in your Health Care Account and you submit receipts for expenses incurred prior to
your termination, you can be reimbursed for funds remaining in your account up to your annual election.
However, if you have money left in your Health Care Account and do not have receipts for expenses
incurred prior to your termination, you cannot be reimbursed for the money remaining in your account
unless you elect to participate in the federal program, COBRA. If you elect to participate in COBRA,
you will need to continue to set aside dollars on an after tax basis to be deposited into your Health
Care account. You can receive information concerning this program from the contact person in your
company.
Your Dependent Care Account functions differently. If you have funds remaining in these accounts, this
money will be reimbursed to you if appropriate receipts are submitted. You can receive reimbursement
for expenses incurred during the Plan Year if receipts are submitted within the Plan Year and before the
end of the 90 day grace period following the Plan Year end.
EFFECT ON SOCIAL SECURITY BENEFITS
As you are not paying social security tax on the portion of your income that has been placed in the Plan,
your social security benets may be slightly reduced. We suggest putting part of your tax savings into
your Employers Retirement Program or some other savings vehicle.
ACCOUNT BALANCES
You may call Flexible Benet Administrators, Inc. at 1.757.340.4567 or 1.800.437.3539 from 8:30
a.m. to 5:00 p.m., Monday through Friday, to check your account balance. You may also access your
personal account information at your convenience via our secure website: www.mywealthcareonline.
com/fba. Each reimbursement check stub will show your contributions, request for reimbursements, and
disbursements. It will also show your annual election and the balance to request by the end of the Plan Year.
A reminder letter will be sent two months prior to the end of the Plan Year if you have funds left in your accounts.
ESTIMATING YOUR EXPENSES
This worksheet will help you determine your annual expenses for your Health Care Reimbursement
account. Good planning and careful estimating is the best way to take full advantage of your Flexible
Benet Plan.

13

ESTIMATING YOUR QUALIFYING HEALTH CARE EXPENSES

Medical deductibles
Medical co-payments
Prescription drugs

_______________
_______________
_______________

Vision Exams, Glasses, Contacts _______________

Dental/Orthodontia
Routine exams and physicals
Over-the-counter expenses

_______________
_______________
_______________

TOTAL ESTIMATED MEDICAL

EXPENSES FOR THE PLAN YEAR
(Max. $2,500)
_______________

14

Flexible Benet Administrators Dependent Care

Reimbursement Account
Plan Year: April 1, 2015 - March 31, 2016
Dependent Care Reimbursement Account Maximum: $5,000
Dependent Care Reimbursement Account Minimum: $0

Debit card CAN be used with the Dependent Care account

The Dependent Care Reimbursement Account allows you to pay for day care expenses for your
dependents with tax-free dollars.
ELIGIBLE DEPENDENT
A child under 13 who qualies as a dependent on your Federal Income Taxes
Any other dependents, including a disabled spouse, disabled children over age 13 and elderly
parents, who depend on you for nancial support, qualify as dependents for tax purposes, and are
incapable of self care
Please refer to Rules and Regulations: Eligible Dependents for the latest denition of a dependent,
as revised under Section 152 of the Code by the Working Families Tax Relief Act of 2005 (WFTRA)
ELIGIBLE DEPENDENT CARE EXPENSES
For dependent care expenses to be eligible for reimbursement, you must be working during the time
your eligible dependents are receiving care. If you are married, your spouse must be:
Working at the time the day care services are provided;
A full-time student for at least ve months during the year; or
Mentally or physically disabled and unable to provide care for him or herself
EXPENSES FOR KINDERGARTEN are not eligible for reimbursement since they are generally for
education, and not for custodial care. In order for an expense to be eligible for reimbursement from the
Dependent Care Reimbursement Account, the primary purpose for the care of the qualifying individual
must be to assure the individuals well-being and protection. Dependent care must still be primarily for
custodial care, not education, in order to qualify as an eligible employment-related expense from the
Dependent Care Reimbursement Account.
EXAMPLES OF DEPENDENT CARE EXPENSES
Babysitters or Nannies that claim the child care as income on their taxes
Licensed day care centers
Private Preschool
Before and after school care
Day care for an elderly or disabled dependent
EXPENSES THAT WOULD NOT BE ELIGIBLE THROUGH THE DEPENDENT CARE ACCOUNT
Kindergarten (kindergarten & above is considered an educational expense)
Days you or your spouse are not working including sick leave, vacation days, and maternity leave
Transportation, books, clothing, or entertainment (Note: These expenses will be covered if provided by
the nursery school or day care center as part of its preschool care services. If these types of expenses
are billed separately, they are not an eligible expense.)
Care provider may not be a child of yours under the age of 19 or anyone you claim as a dependent for
federal income tax purposes.
Babysitting for social events
15

 OVERNIGHT CAMP: Overnight camp is not an eligible expense, only DAY CAMPS are eligible.
Remember that this account is set-up so that you and your spouse are able to go to work and Overnight
camp is 24-hour care.
ANNUAL MAXIMUM FOR THE DEPENDENT CARE REIMBURSEMENT ACCOUNT
Must Not Exceed The Lesser Of:
$5,000 for one or more children ($2,500 if you are a married individual ling a separate tax return);
Your wages or salary for the Plan Year; or
The wages or salary of your spouse
If your spouse is either a full time student or is incapable of taking care of himself or herself then he or
she is deemed to have monthly earnings of $250 if there is one (1) child or dependent, and $500 if there
are two (2) or more children or dependents.
USING THE DEPENDENT CARE REIMBURSEMENT ACCOUNT
VERSUS
FILING FOR A TAX CREDIT ON YOUR TAXES
Under current IRS regulations, you may be eligible to receive a tax credit for dependent care costs.
You may claim a credit for dependent care, up to $3,000 for one child and $6,000 for two or more
children, on your income taxes through the child care tax credit. However, through the Dependent Care
Reimbursement Account you may set aside up to $5,000 per year, for one or more children, if you are
married and ling a joint tax return or if you are a single parent. If you are married and ling separate
tax returns, you may set aside only $2,500.
Typically, more money is saved by paying for dependent care through the FSA Dependent Care
Reimbursement Account than by taking the dependent care credit on your tax return. This is because
the total for federal, state, and FICA savings usually exceeds the dependent care credit. At taxable
incomes greater than $14,000, participants will probably benet more from taking reimbursement from
the Flexible Benet Plan. These assumptions are based on the inclusion of your state income tax.
You can also le for the tax credit while participating in the Dependent Reimbursement Care
Account. If the amount you have placed through the reimbursement account does not meet the
maximum allowed by the IRS, you can claim the difference between your Dependent Care deductions
and the IRS maximum allowable expenses for the tax credit. You can claim a tax credit for any additional
dependent care expenses incurred over the $5,000 maximum FSA limit up to the $6,000 child care tax
credit limit on your taxes. You cannot claim the tax credit for any dependent care expenses paid from
the Dependent Care Reimbursement Account. It is your responsibility to report the Dependent Care
amount on your tax form 2441. The amount is listed on your W-2 under Dependent Care Benet for the
tax year. If you are not sure about the eligibility of an expense, phone Flexible Benets Administrators at
(757) 340-4567 or (800) 437-FLEX or refer to IRS Publication 503: Dependent Care Expenses. This
publication can be ordered by calling the IRS at (800) 829-3676.
OBTAINING A REIMBURSEMENT FROM YOUR DEPENDENT CARE REIMBURSEMENT ACCOUNT
To obtain a reimbursement from your Dependent Care Reimbursement Account you must complete a
Claim Form. This claim form is available from your employer (See sample Claim Form at the end of this
summary). You must attach a receipt from the service provider which includes all of the following:
Name of dependent receiving care
Date(s) care was provided (must match Claim Form)
Name of service provider
16

 Social Security or Tax I.D. number of the provider

Amount of the charge
NOTE: Dependent care expenses can only be reimbursed after the care is provided. This means that
advance payments of dependent care expenses cannot be made. FOR EXAMPLE: If you pay for
a summer day camp for your child in May but the camp is the rst week in July, we cannot reimburse
you for this expense until July when the service is provided.
THE DEPENDENT CARE REIMBURSEMENT ACCOUNT IS NOT A PRE-FUNDED ACCOUNT
This means that you will only be reimbursed up to your account balance at the time you submit your
claim. If your claim is for more than your account balance, the unreimbursed portion of your claim
will be tracked by Flexible Benet Administrators. You will be automatically reimbursed as additional
deductions are taken and deposited into your account, until your entire claim is paid out.
ESTIMATING YOUR EXPENSES
This worksheet will help you determine your annual expenses for the Dependent Care Reimbursement
account. Good planning and careful estimating is the best way to take full advantage of your Flexible
Benet Plan.

ESTIMATING YOUR DEPENDENT CARE EXPENSES

Child day care expenses
Pre-School expenses
Summer Day Camp expenses
Adult day care expenses
Other eligible expenses

_______________
_______________
_______________
_______________
_______________

TOTAL ESTIMATED DEPENDENT CARE

EXPENSES FOR THE PLAN YEAR
_______________
(Max. $5,000)

17

Accessing Your Flex Account Online

GET CONNECTED WITH YOUR ACCOUNTWHEREVER, WHENEVER.
Introducing... our convenient participant website! With the online WealthCare Portal you can
view your account status, submit claims and report your benets card lost/stolen right from
your computer.
FOLLOW THE SIMPLE STEPS OUTLINED BELOW TO ESTABLISH YOUR SECURE USER
ACCOUNT.
Get started by visiting www.mywealthcareonline.com/fba/ and click the new user link.
You will be directed to the registration page.
Follow the prompts to create your account.
Name
Email Address
Employee ID (Your SSN no spaces or dashes)
Employer ID (FBAPITT or your benet card number)
Once completed please proceed to your account.
CLICK AND SUBMIT WITH ONLINE CLAIMSITS THAT EASY
Get started by visiting www.mywealthcareonline.com/fba and click the participant account log-in
link.
Log into your account with your username and password.
Click on My Account and click Reimbursement Request. Follow the prompts to submit your claim..
Complete online claim form
Upload your supporting documentation
Click Submit
Once completed your claim will be posted immediately to your account and will be reviewed within
2-3 business days.
ADMINISTERED BY FLEXIBLE BENEFIT ADMINISTRATORS, INC.
509 VIKING DRIVE, SUITE F
P.O. BOX 8188
VIRGINIA BEACH, VA 23450
1.757.340.4567 or 800.437.FLEX
FAX: 757.431.1155
FlexDivision@ex-admin.com
www.mywealthcareonline.com/fba

18

Ameritas Dental Plan

CALENDAR YEAR DEDUCTIBLE
$25.00 per individual for Type 2 - Basic Procedures and Type 3 - Major Procedures (3 times family limit).
After the date that 3 covered family members have each satised their individual deductible the entire
deductible or any remaining portion of the deductible for any family member will be waived for the rest
of that calendar year.
TYPE I- PREVENTIVE AND DIAGNOSTIC
Type I benets are payable at 100% U&C*.
Routine Exam (Two per calendar year)
Bitewing X-rays (Two per calendar year)
Space Maintainers

No deductible applies.
Cleanings (Two per calendar year)
Full Mouth/Panoramic X-rays (One in three years)
Fluoride for Children 19 and under
(One per calendar year)

TYPE II- BASIC PROCEDURES

Type II benets are payable 80% U&C. $25.00 deductible applies.
Restorative Composites
General Anesthesia
Repair of Bridgework/Denture
Simple Extractions
Restorative Amalgams
Complex Extractions
Oral Surgery
Sealants (age 16 and under)
TYPE III - MAJOR PROCEDURES
Type III Benets are payable at 50% U&C*. $25.00 deductible applies.
Inlays
Crowns (One in Five years per tooth)
Onlays
Dentures
Endodontics
Periodontics
ORTHODONTIA (For Children Only)
Paid at 50% U&C* with a $1,250 lifetime maximum per person.
No deductible applies
ANNUAL MAXIMUM BENEFIT
Type I, II and Type III Procedures: $1,250 per calendar year, per person.
ANNUAL MAXIMUM CARRYOVER
1. Visit a dentist between January 1 and December 31 of each year.
2. Submit a claim for a covered procedure prior to March 1 of the following year.
3. Total dental benets paid for the calendar year must be less than $500.00.
If you meet all 3 requirements then you will be eligible for the Annual Maximum Carryover
benet. This benet will provide you with an additional $250 towards your annual dental
maximum for the following year. In future years, if you continue to meet these requirements
you will continue to see an increase in your annual maximum by $250 until you have reached
an annual maximum carryover limit of $1,000. This benet allows you to accumulate up to
a $2,250 annual dental maximum.
*Percentage based on Usual and Customary charges.

19

LATE ENTRANT PROVISION

There is a 12 month waiting period on all procedures (except cleanings, exams, and uoride
treatments) for employees and/or dependents who do not enroll within 31 days of becoming
eligible for coverage. This provision is waived for employees who enrolled during the initial
enrollment period. The initial enrollment period includes when the plan was rst offered through
Mark III, employees date of hire, and qualifying events. The initial enrollment period DOES NOT
INCLUDE each annual enrollment period.
DENTAL EXCLUSIONS (DEFERMENT PERIOD)
During the rst 36 months following your or your dependents Dental Coverage Effective Date, the
initial placement of dentures, partial dentures, or bridges, if it includes the replacement of teeth all
of which are missing prior to the effective date. (For currently covered insureds, Ameritas will use
the employees Date of Hire to determine the 36 month period.) This exclusion will not apply if the
prosthesis replaces a sound natural tooth which is extracted while the patient is insured under this
Dental Coverage and which is replaced within 12 months of the extraction. During the rst 36 months
of coverage, the replacement of bridges, partial dentures, dentures, inlays or crowns is excluded.
EXCEPTIONS to this exclusion will be made if the replacement is made necessary by: a) accidental
bodily injury to sound natural teeth (chewing injuries are not considered accidental bodily injuries), or
b) the extraction of a sound natural tooth provided the replacement is completed within 12 months
of the date of the injury or extraction.
ELIGIBLE EMPLOYEES
You are eligible for insurance if you are a full-time employee working at least 30 hours per week
or as a permanent part-time employee working at least 20 hours per week.
NOTE: Please inquire with your Benets Department if you are unclear if you qualify for
dental coverage.
ELIGIBLE DEPENDENTS
Provides Coverage On:
Your Spouse
Children up to age 26 regardless of student status
PREDETERMINATION OF BENEFITS
A treatment plan MAY be led if a proposed course of treatment will exceed $200.00. With this information,
Ameritas can determine the benets payable under this policy prior to the work actually being done. It
will give the insured the amount payable, along with an idea of the out of pocket expense.
COORDINATION OF BENEFITS
If you or any of your dependents incur charges which are covered by any other group plan, the
benets of this plan will be coordinated with the benets of the other plan so that the total benets
received are not greater than the charges incurred.
CERTIFICATE OF INSURANCE
This is a summary of coverage and is not a binding contract. A certicate of coverage will be made
available to you shortly which describes the benets in greater detail. Should there be differences
between this summary and the contract, the contract will govern.
SECTION 125
This policy is provided as part of the Policyholders Section 125 Plan. Each member has the option
under the Section 125 Plan of participating or not participating in this policy. A member may change
20

their election only during an annual election period, except for a change in family status. Examples
of such events would be marriage, divorce, birth of a child, death of a spouse or child or termination
of employment. Please see your plan administrator for details.
LIMITATIONS/EXCLUSIONS (This is not a complete list)
For any treatment which is for cosmetic purposes. Facings on crowns or pontics behind the 2nd
bicuspid are considered cosmetic.
Charges incurred prior to the date the individual became insured under this plan, or following the
date of termination of coverage.
Services which are not recommended by a dentist or which are not required for necessary care
and treatment.
Expenses incurred to replace lost or stolen appliances.
Expenses incurred by an insured because of a sickness for which he/she is eligible for benets
under Workers Compensation Act or similar laws.
ORTHODONTIA LIMITATIONS (This is not a complete list)
No benet is payable for expenses incurred:
In connection with a Treatment Program which was begun before the individual became insured
for orthodontic benets.
During any quarter of a Treatment Program if the individual was not continuously insured for
orthodontic benets for the entire quarter.
After the individuals insurance for orthodontic benets terminates.
AMERITAS MANAGED CARE PRODUCTS
Employers achieve a balance between cost efciency and employee choice.
Plan members are free to receive care from any dentist they choose. Their out-of-pocket expenses
are generally lower when using PPO dentist who have agreed to provide dental care at contracted fees.
Over 70,000 PPO provider access points are available nationwide.
PPO network dentists must meet our credentialing and quality assurance
evaluation requirements.
This is only a partial description of the dental benets available under this policy. Consult your
certicate booklet for details.

21

Ameritas Dental Plan Monthly Rates

Employee Only

$34.36

Employee + Spouse

$67.98

Employee + Children

$73.70

Employee + Family

$111.12

NOTE: You are required to pay for the dental plan with pre-tax dollars. No changes are allowed
during the 12 month plan year unless there is a change in family status (qualifying event).

If you have any questions about PPO or the plan, please call:
Ameritas Group Claims Department at 800-487-5553
Or, visit the Ameritas website at:
www.AmeritasGroup.com

This plan is underwritten by Ameritas Life Insurance Corporation

22

Ameritas Dental PPO Plan

To access the full value of the PPO Plan, you are strongly encouraged to utilize In-Network
providers. If you are not planning to utilize an In-Network Provider, do not enroll in the PPO
Plan or your Out-of-Network benets will be signicantly reduced.
CALENDAR YEAR DEDUCTIBLE
$25.00 per individual for Type 2 - Basic Procedures and Type 3 - Major Procedures (3 times family limit).
After the date that 3 covered family members have each satised their individual deductible the entire
deductible or any remaining portion of the deductible for any family member will be waived for the rest of
that calendar year.
TYPE I- PREVENTIVE AND DIAGNOSTIC
Type I benets are payable at 100% MAC* No deductible applies.
Routine Exam (Two per calendar year)
Cleanings (Two per calendar year)
Bitewing X-rays (Two per calendar year)
Full Mouth/Panoramic X-rays (One in three years)
Space Maintainers
Fluoride for Children 19 and under
(One per calendar year)
TYPE II- BASIC PROCEDURES
Type II benets are payable 80% MAC* $25.00 deductible applies.
Restorative Composites
General Anesthesia
Repair of Bridgework/Denture
Simple Extractions
Restorative Amalgams
Complex Extractions
Oral Surgery
Sealants (age 16 and under)
TYPE III - MAJOR PROCEDURES
Type III Benets are payable at 50% MAC*. $25.00 deductible applies.
Inlays
Crowns (One in Five years per tooth)
Onlays
Dentures
Endodontics
Periodontics
ORTHODONTIA (For Children Only)
Paid at 50% MAC* with a $1,250 lifetime maximum per person.
No deductible applies
ANNUAL MAXIMUM BENEFIT
Type I, II and Type III Procedures: $1,250 per calendar year, per person. Benets will be payable
when a Covered Expense is incurred. The Covered Expenses for a program are based on the estimated
cost of the insureds program. They are pro-rated by quarter (three month periods) over the estimated
length of the program, but not for more than eight quarters. The last quarterly payment for a program
may be changed if the estimated and actual cost of the program differ.
ANNUAL MAXIMUM CARRYOVER
1. Visit a dentist between January 1 and December 31 of each year.
2. Submit a claim for a covered procedure prior to March 1 of the following year.
3. Total dental benets paid for the calendar year must be less than $500.00.
*Percentage based on Maximum Allowable Charge

23

If you meet all 3 requirements then you will be eligible for the Annual Maximum Carryover
benet. This benet will provide you with an additional $250 towards your annual dental
maximum for the following year. In future years, if you continue to meet these requirements
you will continue to see an increase in your annual maximum by $250 until you have reached
an annual maximum carryover limit of $1,000. This benet allows you to accumulate up to
a $2,250 annual dental maximum.
LATE ENTRANT PROVISION
There is a 12 month waiting period on all procedures (except cleanings, exams, and uoride
treatments) for employees and/or dependents who do not enroll within 31 days of becoming
eligible for coverage. This provision is waived for employees who enrolled during the initial
enrollment period. The initial enrollment period includes when the plan was rst offered through
Mark III, employees date of hire, and qualifying events. The initial enrollment period DOES NOT
INCLUDE each annual enrollment period.
DENTAL EXCLUSIONS (DEFERMENT PERIOD)
During the rst 36 months following your or your dependents Dental Coverage Effective Date, the
initial placement of dentures, partial dentures, or bridges, if it includes the replacement of teeth all
of which are missing prior to the effective date. (For currently covered insureds, Ameritas will use
the employees Date of Hire to determine the 36 month period.) This exclusion will not apply if the
prosthesis replaces a sound natural tooth which is extracted while the patient is insured under this
Dental Coverage and which is replaced within 12 months of the extraction. During the rst 36 months
of coverage, the replacement of bridges, partial dentures, dentures, inlays or crowns is excluded.
Exceptions to this exclusion will be made if the replacement is made necessary by: a) accidental
bodily injury to sound natural teeth (chewing injuries are not considered accidental bodily injuries), or
b) the extraction of a sound natural tooth provided the replacement is completed within 12 months
of the date of the injury or extraction.
ELIGIBLE EMPLOYEES
You are eligible for insurance if you are a full-time employee working at least 30 hours per week
or as a permanent part-time employee working at least 20 hours per week.
NOTE: Please inquire with your Benets Department if you are unclear if you qualify for
dental coverage.
ELIGIBLE DEPENDENTS
Provides Coverage On:
Your Spouse
Children up to age 26 regardless of student status
PREDETERMINATION OF BENEFITS
A treatment plan MAY be led if a proposed course of treatment will exceed $200.00. With this information,
Ameritas can determine the benets payable under this policy prior to the work actually being done. It
will give the insured the amount payable, along with an idea of the out of pocket expense.
COORDINATION OF BENEFITS
If you or any of your dependents incur charges which are covered by any other group plan, the
benets of this plan will be coordinated with the benets of the other plan so that the total benets
received are not greater than the charges incurred.

24

CERTIFICATE OF INSURANCE
This is a summary of coverage and is not a binding contract. A certicate of coverage will be made
available to you shortly which describes the benets in greater detail. Should there be differences
between this summary and the contract, the contract will govern.
This is only a partial description of the dental benets available under this policy. Consult your
certicate booklet for details.
SECTION 125
This policy is provided as part of the Policyholders Section 125 Plan. Each member has the option
under the Section 125 Plan of participating or not participating in this policy. A member may change
their election only during an annual election period, except for a change in family status. Examples
of such events would be marriage, divorce, birth of a child, death of a spouse or child or termination
of employment. Please see your plan administrator for details.
LIMITATIONS/EXCLUSIONS (This is not a complete list)
For any treatment which is for cosmetic purposes. Facings on crowns or pontics behind the 2nd
bicuspid are considered cosmetic.
Charges incurred prior to the date the individual became insured under this plan, or following the
date of termination of coverage.
Services which are not recommended by a dentist or which are not required for necessary care
and treatment.
Expenses incurred to replace lost or stolen appliances.
Expenses incurred by an insured because of a sickness for which he /she is eligible for benets
under Workers Compensation Act or similar laws.
ORTHODONTIA LIMITATIONS (This is not a complete list)
No benet is payable for expenses incurred:
In connection with a Treatment Program which was begun before the individual became insured
for orthodontic benets.
During any quarter of a treatment program if the individual was not continuously insured for
orthodontic benets for the entire quarter.
After the individuals insurance for orthodontic benets terminates.
AMERITAS MANAGED CARE PRODUCTS
Employers achieve a balance between cost efciency and employee choice.
Plan members are free to receive care from any dentist they choose. Their out-of-pocket expenses
are generally lower when using PPO dentist who have agreed to provide dental care at contracted fees.
Over 70,000 PPO provider access points are available nationwide.
PPO network dentists must meet our credentialing and quality assurance
evaluation requirements.

25

Ameritas Dental Plan PPO Monthly Rates

Employee Only

$29.94

Employee + Spouse

$59.23

Employee + Children

$64.20

Employee + Family

$96.80

NOTE: You are required to pay for the dental plan with pre-tax dollars. No changes are allowed
during the 12 month plan year unless there is a change in family status (qualifying event).

If you have any questions about PPO or the plan, please call:
Ameritas Group Claims Department at 800-487-5553
Or, visit the Ameritas website at:
www.AmeritasGroup.com

This plan is underwritten by Ameritas Life Insurance Corporation

26

Ameritas Dental PPO Plan Questions

COMMONLY ASKED PPO QUESTIONS
Pitt County Schools is proud to provide our employees with a dental program administered by Ameritas
Group. The plan provides excellent coverage for you and your eligible dependents. Please refer to the
plan highlight for more details. As an added bonus, our plan includes access to Ameritas Participating
Provider Organization (PPO).
DO I HAVE TO USE AN AMERITAS PPO PROVIDER?
No, employees and their covered dependents may utilize any licensed dental provider that they choose.
Please note, there is no difference in the coinsurance, deductible, and maximums on either plan whether
a PPO provider is utilized or not.
WHY WOULD I USE AN AMERITAS PPO PROVIDER?
By using a PPO provider:
A Participating Provider is a dentist who has entered into an agreement to provide services to insured
members of Ameritas plans for at a specic fee. Any insured member who chooses to go to a PPO
provider will receive this discounted fee for procedures performed by that provider.
As part of their contractual agreement with Ameritas, the PPO provider cannot back-bill the patient
for the difference between the dentists normal charges and the discounted fees that the dentist
agreed to charge as an Ameritas PPO provider.
PPO providers are required to le the claim for the patient.
PPO providers are required to wait for reimbursement from Ameritas before billing the patient for any
balances owed for deductibles, coinsurance, any amounts exceeding the annual maximum benets,
etc.
PPO panels are available in many areas. Please visit Ameritas website at www.ameritasgroup.com
to search for a provider in your area.
WHAT HAPPENS IF I DONT USE AN AMERITAS PPO PROVIDER?
For members that do not want to utilize an Ameritas PPO provider, or if a PPO provider is not available
in your area:
Pitt County Schools wants employees to have options regarding their choice of providers. You have
a choice of enrolling in the PPO plan or the Non-PPO plan.
For members enrolling in the PPO plan, you should utilize a participating provider for all procedures and
services in order to benet from the plan and the Maximum Allowable Charge (MAC) reimbursement
tied to the PPO option.
For members enrolling in the Non-PPO option, you can choose to visit any provider. Non-panel
providers can charge their standard fees for any service. Ameritas allows reimbursement based on
the 90th percentile of U&C which is considered to be one of the highest reimbursement levels in
the industry. This means that 9 out of 10 dentists charges will fall within the amount that Ameritas
allows for each procedure.

27

Non-panel providers have no specic requirements regarding ling of claims. However, we have
found that many dentists will assist the patient with the paperwork needed to le the claim. If a dentist
is not willing to le the claim on the patients behalf, the patient can simply attach the dentists bill to
a claim form that includes the patients name and identication number, and fax or mail the claim to
Ameritas for processing. Ameritas will process the claim, typically within 7-10 working days. Claim
payment can be made to the patient or directly to the dentist if noted on the claim form. The patient
can use Ameritas claim forms which are available in the Benets Department or on Ameritas web
site (this will be available via our Intranet in the near future), OR the patient can use any generic claim
forms that the dental ofce may have available. Filing claims is fast and easy with Ameritas!

If you have any questions about PPO or the plan, please call:
Ameritas Group Claims Department at 800-487-5553
Website at: www.AmeritasGroup.com

This plan is underwritten by Ameritas Life Insurance Corporation

28

Ameritas PPO Dental Plan

PLAN HIGHLIGHTS
The PPO Plan will mirror the current plan with a few differences:
LOWER PREMIUMS
Compared to the current plan, the PPO Plan can save you $53 - $171 per year depending on your
level of coverage.
MONTHLY
Current Plan

PPO Plan

ANNUAL
SAVINGS

Employee

$34.36

$29.94

$53.04

Employee & Spouse

$67.98

$59.23

$105.00

Employee & Child(ren)

$73.70

$64.20

$114.00

Employee & Family

$111.12

$96.80

$171.84

LOWER PROCEDURE COSTS

To access the full value of the PPO Plan, you are strongly encouraged to utilize In-Network providers.
(If you are not planning to utilize an In-Network Provider, do not sign up for the PPO Plan or your Outof-Network benets will be signicantly reduced.)
Many In-Network Providers have a lower negotiated rate for procedures. This not only saves you
money out-of-pocket, but also allows you to get more out of your Annual Maximum Allowance.
Please see below for examples of cost savings:
Procedure (Code)
Exam (D120)
Cleaning (D1110)
Filling (D2330)
Simple Extraction
(D7140)
Crown (D6750)
Pontic (Bridge)
(D6240)

% covered
under plan1
100%

Out-of-Network Cost2
$45

Your
Cost
$0

In-Network
Cost3
$29

Your
Cost
$0

100%
80%

$82
$153

$0
$30.60

$61
$96

$0
$19.20

$0
$11.40

80%

$162

$32.40

$91

$18.20

$14.20

50%

$1,017

$508.50

$713

$356.50

$152

50%

$1,052

$526

$764

$382

$144

Savings4
$0

1 - $25 deductible per covered individual per calendar year applies for Type 2 (Basic) and Type 3
(Major) Procedures.
2 - Cost represents Usual & Customary Charges in the Greenville area
3 - Cost represents the Maximum Allowable Benet for In-Network Providers
4 - Savings is your total out-of-pocket savings. You are also saving on dollars applied toward your
Annual Maximum Allowance.
29

Ameritas/VSP Vision Plan

Deductibles
Exam (every 12 months)

VSP Network

Out of Network

$15 co-pay

$15 co-pay
(The out of network allowance is $45)

Eye Glass Lenses

Materials

See materials
$15 (co pay)

Lenses (per pair)- every 12 months

Single Vision
Bifocal
Trifocal
Lenticular

Covered in full
Covered in full
Covered in full
Covered in full

$35
$50
$70
$90

Contact Lens allowance

(in lieu of glasses)
Fit & Follow Up Exams
Elective
Medically Necessary

Covered- every 12 months

Up to $105
Covered in full

Covered- every 12 months

Up to $105
Up to $210

Frames (every 24 months)

Up to $120

Up to $50

12/12/24

12/12/24

Discounts at Network
Providers

Not Covered

Frequencies (months)
Exam/Lens/Frame
**Receipt of Contact Lenses
resets Frame frequency
Refractive Eye Surgery

See materials
$15 (co pay)

ADDITIONAL FOCUS FEATURES

CONTACT LENSES ELECTIVE
Cost of the tting and evaluation is deducted from the allowance and any amount left is deducted from
the material allowance. Allowance can be applied to disposables, but the dollar amount must be used
all at once (provider will order 3 or 6 month supply). Applies when contacts chosen in lieu of the lens
benet.
ADDITIONAL GLASSES
20% discount off the retail price on additional pairs of prescription glasses (complete pair).
LOW VISION
Insureds can receive professional services for treatment of severe visual problems that are not
correctable with regular lenses. The treating provider determines if an Insureds condition meets the
criteria for coverage of this benet. Insureds may contact VSPs Customer Care Division for details at
(800-877-7195) for additional information.
30

LASER VISIONCARE
VSP offers an average discount of 15% on LASIK and PRK. The maximum out-of-pocket per eye for
members is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for
PRK. In order to receive the benet, a VSP provider must coordinate the procedure.
DEPENDENT ELIGIBILITY
Your children are covered to age 26.
EYE CARE PLAN MEMBER SERVICE
Focus eye care from Ameritas Group features the money-saving eye care network of VSP. Customer
service is available to plan members through VSPs well-trained and helpful service representatives.
Call or go online to locate the nearest VSP network provider, view plan benet information and more.
If you would like a complete copy of your vision insurance certicate, please visit our website at
www.ameritasgroup.com.

Monthly Premium Rates

Employee Only

$9.70

Family

$23.76
VSP Call Center
1.800.877.7195

Service representative hours:

9 am to 10 pm EST Monday through Friday
Interactive Voice Response available 24/7
Locate a VSP provider at:
www.ameritasgroup.com/provider
View plan benet information at:
www.vsp.com
This information is a highlight of plan benets provided by Ameritas Life Insurance Corp. as
selected by your employer. It is not a certicate of insurance and does not include exclusions
and limitations. For exclusions and limitations, or a complete list of covered procedures, contact
your benets administrator.

31

Aac Accident Insurance

The Aac coverage described in this booklet is subject to plan limitations, exclusions, denitions, and provisions.
For detailed information, please see the plan brochure, as this booklet is intended to provide a general summary
of the coverage. This overview is subject to the terms, conditions, and limitations of policy series CAI7700.

What is Aac accident insurance? Why shoud I consider it?

Aac accident insurance provides benets for the treatment of injuries suffered as the result of a covered
accident. These benets are payable regardless of any other insurance you may have.
Many families dont budget for out-of-pocket costs associated with accidents. While we all hope to
steer clear of accidents, at some point most of us will probably take a trip to the local emergency room.
When you (or a covered family member) are injured in an accident, the last things on your mind are the
charges that may be accumulating for services like the following:
Ambulance ride
Surgery and Anesthesia
Casts

Crutches

Emergency room use

Stitches

Wheelchairs
Bandages
These costs add up- fast. While major medical insurance can help with the cost of treatment, what
about the out-of-pocket expenses that pile up while you or a loved one is out of work as a result of
a covered accident? Aac accident insurance benets are paid directly to you (unless otherwise
assigned) to use as you see t. You can use the benets to help with mortgage or rent payments,
groceries, car payments- however you like.
What are some of the highlights of the Aac accident plan?
No limit on the number of claims you can le.
An annual Wellness Benet is included.
Benets available for spouse and/or dependent children.
Provides 24-hour protection (on and off-the-job)
Benets for both inpatient and outpatient treatment of covered accidents.
Guaranteed Issue (which means you may qualify for coverage without having to answer health
questions).
Payroll Deduction - Premiums are paid by convenient payroll deduction.
Coverage will be effective the date you sign the enrollment form.
Your plan is portable (with certain stipulations). That means you may be able to take your coverage
with you if you leave your job.

Underwritten by Continental American Insurance Company

A proud member of the Aac family of insurers
1/14

32

What is guarnteed-issue coverage?

Guarntee-issue refers to certain types of coverage that may be issued without your having to answer
health questions. Guarnteed-issue coverage is offered during yout employers initial enrollment period
(and for new hires after the enrollment period).
Am I eligible for Aac accident coverage? What about my family?
You are eligible to apply for Aac accident coverage if you:
Are between the ages of 18 and 69;
Are a full-time, benet-eligible employee;
Are working at least 20 hours per week;
Are not a seasonal or temporary employee.
Your spouse must be between the ages of 18 and 64 to be eligible for coverage, and dependent children
must be younger than age 26.
What core benets does Aac accident plan feature?
Accident Benets
You may receive benets if you incur one of the following covered events:
o
o
o
o
o

Fractures
Dislocations
Paralysis
Lacerations
Injuries requiring surgery
Eye injuries
Removal of foreign body
Ruptured disc
Torn knee cartilage
Tendons/ligaments

o
o
o
o
o
o

Burns (second- and third-degree)

Concussion
Coma
Internal injuries
Exploratory surgery
Emergency dental work

Medical Fees Benet

You may receive this benet for up to six treatments per covered accident for physician charges,
emergency room services and supplies, and X-rays.

Accident Follow-Up Treatment Benet

You may receive this benet for up to six treatments per covered accident for follow-up treatment.

Physical Therapy Benet

You may receive this benet for up to six treatments per covered accident for physical therapy.

Ambulance Benet
You may receive this benet if you require transportation to a hospital by a professional ambulance
service within 90 days after a covered accident.

Transportation Benet
You may receive this benet if your doctor recommends hospital treatment or diagnostic study as a
result of a covered accident (and the treatment/study isnt available in your hometown).

Blood/Plasma Benet
You may receive this benet if you receive blood and plasma within 90 days of a covered accident.
33

Prosthesis Benet
You may receive this benet if a covered accident requires the use of a prosthetic device (hearing
aids, wigs, or dental aids-including (but not limited to) false teeth-are not covered).

Appliance Benet
You may receive this benet for use of medical appliance due to injuries received in a covered accident (payable for crutches, wheelchairs, leg braces, back braces, and walkers).

Family Lodging Benet

If you are required to travel more than 100 miles for inpatient treatment of injuries suffered in
a covered accident, you may receive this benet for an immediate family members lodging
(payable up to 30 days per accident while the insured is conned to the hospital).

Wellness Benet
You may receive this benet for one routine examination or other preventive testing once each
12-month period (payable for one covered person annually). Benets are payable for the following:
o Annual physical exams
o Mammograms
o Pap smears
o Eye examinations
o Immunizations
o Flexible sigmoidoscopies
o PSAs
o Ultrasounds
o Blood screenings

Hospital Admission Benet

You may receive this benet if you are admitted to a hospital and conned as a resident bed patient
because of injuries received in a covered accident within six months of the accident.

Hospital Connement Benet (per day)

You may receive this benet on the rst day of hospital conmement for up to 365 days. The
connement must begin within 90 days after the date of the accident (payable once per connement).

Hospital Intensive Care (per day)

You may receive this benet up to 30 days per covered accident (payable in addition to the Hospital
Connement Benet).

Accidental-Death and -Dismemberment Benet

o Accidental Death
o Accidental Common Carrier Death (common carrier refers to an airline carrier, railroad train, or
ship that is licensed for passenger service)
o Dismemberment
o Loss of One or More Fingers and Toes
o Partial Amputation of Fingers or Toes
34

What else do I need to know about the Aac accident plan?

You should know that the plan includes:

A pre-existing condition limitation. A pre-existing condition is a sickness or physical condition

that, within the 12 month period before your plans effective date, resulted in the insureds receiving
medical advice or treatment. No benets are payable for any condition or illness starting within 12
months of an insureds effective date that is caused by, contributed to, or resulting from a pre-existing
condition.

Certain Exclusions. No benets are payable for loss resulting from:

Participating in war or any act of war, declared or not, or participating in the armed forces of or
contracting with any country or international authority. This exclusion does not include acts of
terrorism. We will return the prorated premium for any period not covered when you are in such
service.
Operating, learning to operate, serving as a crew member on, or jumping or falling from any aircraft,
including those which are not motor-driven.
Participating or attempting to participate in an illegal activity or working at an illegal job.
Committing or attempting to commit suicide, while sane or insane.
Injuring or attempting to injure yourself intentionally.
Having any disease or bodily/mental illness or degenerative process. We also will not pay benets
for any related medical/surgical treatment or diagnostic procedures for such illness.
Traveling more than 40 miles outside the territorial limits of the United States, Canada, Mexico,
Puerto Rico, The Bahamas, Virgin Islands, Bermuda and Jamaica except under the Accidental
Common Carrier Death Benet.
Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.
Participating in any organized sport, professional or semi-professional.
Being legally intoxicated or under the inuence of any narcotic unless taken under the direction of
a physician.
Driving any taxi or intrastate or interstate long-distance vehicle for wage, compensation or prot.
Mountaineering using ropes and/or other equipment, parachuting or hang-gliding.
Having cosmetic surgery or other elective procedures that are not medically necessary or having
dental treatment except as a result of covered accident.

35

Monthly Premium Rates

Employee

$16.21

Employee and Spouse

$23.18

Employee and Dependent Children

$30.90

Employee, Spouse, and

Dependent Child(ren)

$37.87

Continental American Insurance Company (CAIC), a proud member of the Aac family of insurers,
is a wholly-owned subsidiary of Aac Incorporated and underwrites group coverage. CAIC
is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands.
Continental American Insurance Company 2801 Devine Street Columbia, South Carolina
29205 1-800-433-3036 toll-free 1-866-849-2970 fax www.aacgroupinsurance.com

36

Allstate Benets
Group Cancer Plan
In the United States, about 1,596,670 new cancer cases were expected to be diagnosed in 2011. 1
Group Voluntary Cancer
If you suddenly become diagnosed with cancer, it can be difcult on your familys nancial and emotional
stability. Having the right coverage to help when you are sick and undergoing treatment or when you
cannot work is important. Our cancer insurance can help provide security when you need it most.
Meeting Your Needs:
Our cancer coverage can help offer you and your family member nancial support during a period of
unexpected illness.
Benets will be paid directly to you unless otherwise assigned
Coverage can be purchased for you and your entire family
Waiver of premium after 90 days of disability due to cancer for as long as your disability lasts*
Includes coverage for 29 other specied diseases**
Portable coverage
Benet Coverage Highlights
Group Voluntary Cancer Insurance offers you coverage should you be diagnosed with cancer or 29
specied diseases. It can help you and your family 24 hours a day, seven days a week. Each prepackaged plan doesnt just cover you; if you choose, it also covers your dependents (which can include
spouse and dependent children.) Our valuable coverage can help supplement your traditional medical
insurance which may only cover a small portion of the non-medical expenses that can be incurred with
such a diagnosis as cancer.
You and each covered family member can be sure they will receive:
Benets that help pay for treatment, hospital stays, transportation, and much more!
Easy enrollment without required evidence of insurability
A cancer diagnosis can mean unforeseen expenses that may be difcult to pay, especially if you arent
working. Hospital stays, medical or surgical treatments, and transportation by air or ground ambulance
can add up quickly and be very costly. Our Group Voluntary Cancer Supplemental Insurance can help
offset some of the expenses your health insurance may not cover, so you can focus on getting well.
In the U.S., men have slightly less than a 1 in 2 lifetime risk of developing cancer, for women,
the risk is a little more than 1 in 3.2
Your Benet Coverage
Benets are paid for cancer and specied diseases and can help cover the costs of specic treatments
and expenses as they happen. Terms and conditions for each benet will vary.
Specied Diseases
Amyotrophic Lateral Sclerosis (Lou Gehrigs Disease), Muscular Dystrophy, Poliomyelitis, Multiple
Sclerosis, Encephalitis, Rabies, Tetanus, Tuberculosis, Osteomyelitis, Diphtheria, Scarlet Fever,
Cerebrospinal Meningitis (bacterial), Brucellosis, Sickle Cell Anemia, Thalassemia, Rocky Mountain
Spotted Fever, Legionnaires Disease (conrmation by culture or sputum), Addisons Disease, Hansens
*Primary insured only
**List of covered diseases on page 37-38
1 Cancer Facts & Figures, American Cancer Society, 2011
2 Cancer Facts & Figures, American Cancer Society, 2011.

37

Disease, Tularemia, Hepatitis (Chronic B or Chronic C with liver failure or Hepatoma), Typhoid Fever,
Myasthenia Gravis, Reyes Syndrome, Primary Sclerosing Cholangitis (Walter Paytons Liver Disease),
Lyme Disease, Systemic Lupus Erythematosus, Cystic Fibrosis, and Primary Biliary Cirrhosis.
Continuous Hospital Connement
A $100 benet will be paid for each day of continuous hospital connement for the treatment of cancer
or specied diseases.
Government or Charity Hospital
A $100 benet will be paid for each day a covered person is conned to:
1. a hospital operated by or for the U.S. Government (including the Veterans Administration); or
2. a hospital that does not charge for the services it provides (charity).
This benet is paid in lieu of all other benets in the policy (except Waiver of Premium Benet).
Surgery
Up to a $3,000 benet will be paid when a covered surgery (**amount per surgery depends on type
of surgery) is performed on a covered person. This benet pays the actual charges, up to the amount
listed in the Schedule of Surgical Procedures for the specic procedure. Two or more procedures
performed at the same time through one incision or entry point are considered one operation; Allstate
Benets pays the amount for the procedure with the greatest benet. Allstate Benets pays for a covered
surgery performed on an outpatient basis at 150% of the scheduled benet. This benet does not pay
for surgeries covered by other benets in the Schedule of Benets.
Second Opinion
A $400 benet will be paid for a second opinion, if physician recommends surgery or treatment for
covered condition. This second opinion must be rendered prior to surgery or treatment being performed,
and obtained from a physician not in practice with the physician rendering the original recommendation.
Physical or Speech Therapy
A $50 benet will be paid per day, for physical or speech therapy for restoration of normal body
function.
Anesthesia
25% of the surgery benet will be paid for anesthesia.
Ambulatory Surgical Center
A $500 benet will be paid for a surgical procedure covered under the Surgery benet that is performed
at an ambulatory surgical center.
Radiation/Chemotherapy for Cancer
Up to a $10,000 (Low) or $20,000 (High) benet will be paid per 12 month period for radiation therapy
and chemotherapy received by a covered person. This benet pays the actual cost and is limited to
the amount shown per 12 month period beginning with the rst day of benet under this provision.
Administration of radiation therapy or chemotherapy other than by medical personnel in a physicians
ofce or hospital, including medications dispensed by a pump, will be limited to the costs of the drugs
only, subject to the maximum amount payable per 12 month period.
Anti-Nausea Benet
Up to a $200 benet will be paid per calendar year for the actual cost of anti-nausea medication
prescribed for a covered person by a physician. This benet does not pay for medication administered
while the covered person is an inpatient.

38

Inpatient Drugs and Medicine

A $25 benet will be paid per day for drugs and medicine while continuously hospital conned. This
benet does not pay for drugs and/or medicine covered under the Radiation/Chemotherapy Benet or
the Anti-Nausea Benet.
Hematological Drugs
Up to a $200 (Low) or $400 (High) benet will be paid per year for the actual cost of drugs intended
to boost cell lines such as white blood cell counts, red blood cell counts and platelets. This benet is paid
only when the Radiation/Chemotherapy for Cancer benet is paid.
Medical Imaging
Actual cost up to a $500 (Low) or $1,000 (High) benet will be paid per calendar year if a covered
person receives an initial diagnosis or follow-up evaluation based upon one of the following medical
imaging exams: CT scan; Magnetic Resonance Imaging (MRI) scan; bone scan; thyroid scan; Multiple
Gated Acquisition (MUGA) scan; Positron Emission Tomography (PET) scan; transrectal ultrasound; or
abdominal ultrasound. This benet is limited to 1 payment per calendar year per covered person.
Private Duty Nursing Services
A $100 benet will be paid per day while hospital conned, if a covered person requires the full-time
services of a private nurse. Full-time means at least 8 hours of attendance during a 24 hour period.
These services must be required and authorized by a physician and must be provided by a nurse.
New or Experimental Treatment
Actual charges up to a $5,000 benet will be paid per 12 month period, for new or experimental
treatment. New or Experimental Treatment is covered for cancer and specied disease when: the
treatment is judged necessary by the attending physician; and no other generally accepted treatment
produces superior results in the opinion of the attending physician. This benet is limited to the maximum
shown per 12 month period beginning with the rst day of treatment under this provision. This benet
does not pay if benets are payable for treatment covered under any other benet in the Schedule of
Benets.
Blood, Plasma, and Platelets
Up to a $10,000 (Low) or $20,000 (High) benet will be paid per 12-month period for the actual cost
of blood, plasma and platelets (including transfusions and administration charges), processing and
procurement costs and cross-matching. Does not pay for blood replaced by donors or immunoglobulins.
Physicians Attendance
A $50 benet will be paid for a visit by a physician during hospital connement. Benet is limited to
one visit by one physician per day of hospital connement. Admission to the hospital as an inpatient is
required.
At Home Nursing
A $100 benet will be paid per day for private nursing care and attendance by a nurse at home. At
home nursing services must be required and authorized by the attending physician. Benet is limited to
the number of days of the previous continuous hospital connement.
Prosthesis
Up to a $2,000 benet will be paid per amputation, per covered person for the actual charges
for prosthetic devices which are prescribed as a direct result of surgery and which require surgical
implantation.
Hair Prosthesis
A $25 benet will be paid every 2 years, for a wig or hairpiece if the covered person experiences hair
loss.
39

Nonsurgical External Breast Prosthesis

Up to a $50 benet will be paid for the actual cost of the initial, nonsurgical breast prosthesis following
a covered mastectomy or partial mastectomy that is paid for under the policy.
Ambulance
A $100 benet will be paid per continuous hospital connement for transportation by a licensed
ambulance service or a hospital owned ambulance to or from a hospital in which the covered person is
conned.
Hospice Care
A $100 benet will be paid for one of the following when a covered person has been diagnosed by a
physician as terminally ill as a result of cancer or specied disease, is expected to live 6 months or less
and the attending physician has approved services:
1. Freestanding Hospice Care Center A benet will be paid per day for connement in a licensed
freestanding hospice care center. Benets payable for hospice centers that are designated areas of
hospitals will be paid the same as inpatient hospital connement; or
2. Hospice Care Team A benet will be paid per visit, limited to 1 visit per day, for home care services
by a hospice care team. Home care services are hospice services provided in the patients home.
Benet is payable only if: (a) the covered person has been diagnosed as terminally ill; and (b) the
attending physician has approved such services. Does not pay for: food services or meals other than
dietary counseling; or services related to well-baby care; or services provided by volunteers; or support
for the family after the death of the covered person.
Extended Care Facility
A $100 benet will be paid for each day a covered person is conned in an extended care facility for
the treatment of cancer or specied disease. Connement must be at the direction of the attending
physician and must begin within 14 days after a covered hospital connement. Benet is limited to the
number of days of the previous continuous hospital connement.
Outpatient Lodging
A $50 benet will be paid for lodging per day when a covered person receives radiation or chemotherapy
treatment on an outpatient basis, provided the specic treatment is authorized by the attending physician
and cannot be obtained locally. Benet is the actual cost of a single room in a motel, hotel, or other
accommodations acceptable to us during treatment, up to the maximum $2,000 per 12 months
beginning with the rst day of benet under this provision. Outpatient treatment must be received at a
treatment facility more than 100 miles from the covered persons home.
Non-Local Transportation
$0.40 per mile or actual cost of round trip coach fare on a common carrier benet will be paid for
treatment at a hospital (inpatient or outpatient); or radiation therapy center; or chemotherapy or oncology
clinic; or any other specialized freestanding treatment center nearest to the covered persons home,
provided the same or similar treatment cannot be obtained locally. Benet pays up to 700 miles for
round trip in personal vehicle. Non-Local means a round trip of more than 70 miles from the covered
persons home to the nearest treatment facility. Mileage is measured from the covered persons home
to the nearest treatment facility as described above. Does not cover transportation for someone to
accompany or visit the person receiving treatment; visits to a physicians ofce or clinic; or for services
other than actual treatment.
Family Member Lodging and Transportation
Up to a $50 benet per day will be paid for lodging and $0.40 per mile or the actual cost of round
trip coach fare on a common carrier will be paid for one adult member of the covered persons family
to be near the covered person, when a covered person is conned in a non-local hospital for specialized
treatment.
40

1. Lodging-This benet is for a single room in a motel, hotel, or other accommodations acceptable to
Allstate Benets. Benet is limited to 60 days for each period of continuous hospital connement.
2. Transportation-Benet is limited to 700 miles per continuous hospital connement if traveling in
personal vehicle. Mileage is measured from the visiting family members home to the hospital where
the covered person is conned. Does not pay the Family Member Transportation Benet if the personal
vehicle transportation benet is paid under the Non-Local Transportation Benet, when the family
member lives in the same city or town as the covered person.
Waiver of Premium (primary insured only)
If while coverage is in force the insured employee becomes disabled due to cancer rst diagnosed after
the effective date of coverage and remains disabled for 90 days, Allstate Benets pays premiums due
after such 90 days for as long as the insured employee remains disabled.
Bone Marrow or Stem Cell Transplant*
A 1. $1,000*, 2. $2,500*, 3. $5,000* benet will be paid for the following types of bone marrow or stem
cell transplants performed on a covered person.
1. A transplant which is other than non-autologous.
2. A transplant which is non-autologous for the treatment of cancer or specied disease, other than
Leukemia.
3. A transplant which is non-autologous for the treatment of Leukemia.
*This benet is payable only once per covered person per calendar year.
ADDITIONAL BENEFITS
Wellness
A $100 benet will be paid per calendar year per covered person for one of the following wellness
tests: Biopsy for skin cancer; Blood test for triglycerides; Bone Marrow Testing; CA15-3 (cancer antigen
15-3 - blood test for breast cancer); CA125 (cancer antigen 125 blood test for ovarian cancer);
CEA (carcinoembryonic antigen blood test for colon cancer); Chest X-ray; Colonoscopy; Doppler
screening for carotids; Doppler screening for peripheral vascular disease; Echocardiogram; EKG
(Electrocardiogram); Flexible sigmoidoscopy; Hemoccult stool analysis; HPV (Human Papillomavirus)
Vaccination; Lipid panel (total cholesterol count); Mammography, including Breast Ultrasound; Cervical
Cancer Screening; PSA (prostate specic antigen blood test for prostate cancer); Serum Protein
Electrophoresis (test for myeloma); Stress test on bike or treadmill; Thermography; and Ultrasound
screening of the abdominal aorta for abdominal aortic aneurysms. This benet is paid regardless of the
result of the test.
OPTIONAL BENEFITS
Cancer Initial Diagnosis (First Occurrence)
A one time benet of $3,000 will be paid when a covered person is diagnosed for the rst time in their
life as having cancer other than skin cancer. The rst diagnosis must occur after the effective date of
coverage for that covered person. Benet is payable only once per covered person.
Intensive Care**
A benet will be paid for each day for the following types of intensive care connement:
A. Hospital Intensive Care Unit Connement $600* - This benet is for hospital intensive care unit
connement for any illness or accident.
B. Step-Down Hospital Intensive Care Unit Connement $300*- This benet is for step-down hospital
intensive care unit connement for any illness or accident.
*This benet is limited to 45 days for each period of such connement. A day is a 24 hour period.
If connement is for only a portion of a day, then a pro-rata share of the daily benet is paid.
**This benet is not disease specic and pays a benet for covered connement in a hospital
intensive-care unit for any covered illness or accident from the rst day of coverage.
41

C. Ambulance - Allstate Benets pays the actual charges for transportation of a covered person
by licensed air or surface ambulance service to a hospital for admission to an intensive care unit for
a covered connement. This benet is not paid if an ambulance benet is paid under the Ambulance
benet in the policy.
Issue Ages: 18 and older while Actively at Work.
Certicates - Certicates under this plan are issued on a guaranteed basis only at the time of the initial
enrollment. A completed Evidence of Insurability form is required for late entrants into the group plan.
Eligibility - Family members eligible for coverage include: you, your spouse or domestic partner; and
children under age 26.
Portability Privilege -Allstate Benets will provide portability coverage, subject to these provisions.
Such coverage will not be available for you, unless: coverage under the policy terminates under the
General Provision entitled Termination of Coverage, we receive a written request and payment of the
rst premiums for the portability coverage not later than 63 days after such termination and the request
is made for that purpose. No portability coverage will be provided to you if your insurance under the
policy terminated due to your failure to make required premium payments.
Termination of Coverage - As long as you are insured, your coverage under the policy ends on the
earliest of: the date the policy is canceled, the last day of the period for which you made any required
premium payments, the last day you are in active employment except as provided under the Temporary
Layoff, Leave of Absence or Family and Medical Leave of Absence provision, the date you are no
longer in an eligible class, or the date your class is no longer eligible.
Allstate Benets will provide coverage for a payable claim incurred while you are covered under the
policy. If your spouse is a covered person, the spouses coverage ends upon valid decree of divorce or
your death. If your domestic partner is a covered person, the domestic partners coverage ends upon
termination of the domestic partnership or your death. If your child is a covered person, the childs
coverage ends when the child reaches age 26, unless he or she continues to meet the requirements of
an eligible dependent.
Coverage does not terminate on an incapacitated dependent child who:
(1) is incapable of self-sustaining employment by reason of mental or physical incapacity; and
(2) became so incapacitated prior to the attainment of the limiting age of eligibility under the coverage;
(3) and is chiey dependent upon you for support and maintenance. Dependent coverage continues
as long as the coverage remains in force and the dependent remains in such condition. Proof of the
incapacity and dependency of the child must be furnished within 60 days of the childs attainment of
the limiting age of eligibility. Thereafter, such proof must be furnished as frequently as may be required,
but no more frequently than annually after the childs attainment of the limiting age for eligibility. If
Allstate Benets accepts a premium for coverage extending beyond the date, age or event specied for
termination as to a covered person, such premium will be refunded, coverage will be refunded, coverage
will terminate and claims will not be paid.
Limits, Exclusions, and Exceptions - We do not pay for any benet due to, or caused by, a preexisting condition, as dened, during the 12-month period beginning on the date that person became a
covered person. This exclusion will not apply to your newborn, adopted or foster child under the age of
18 if Allstate Benets is notied within 31 days of the childs birth or date of placement. A Pre-Existing
Condition is a disease or physical condition for which medical advice or treatment was recommended
or received from a medical professional within the 12-month period prior to the effective date. Allstate
Benets does not pay for any loss except for losses due directly from cancer or specied disease. We
42

do not pay for any other conditions or diseases caused or aggravated by cancer or a specied disease.
Diagnosis must be submitted to support each claim. For the Surgery, New or Experimental Treatment
and Prosthesis Benets, if specic charges are not obtainable as proof of loss, Allstate Benets will
pay 50% of the applicable maximum for the benets payable. Treatment must be received in the United
States or its territories.
Intensive Care Exclusions and Limitations - The Hospital Intensive Care Unit Connement benet
does not pay for intensive care if a covered person is admitted because of an attempted suicide, intentional
self-inicted injury, intoxication or being under the inuence of drugs not prescribed or recommended
by a physician, or alcoholism or drug addiction. Allstate Benets does not pay for connements in
any care unit that does not qualify as a hospital intensive care unit. Progressive care units, sub-acute
intensive care units, intermediate care units, and private rooms with monitoring, step-down units and
any other lesser care treatment units do not qualify as hospital intensive care units. We do not pay for
step-down hospital intensive care unit connement if a covered person is admitted and conned in the
following type of units: telemetry or surgical recovery rooms, post-anesthesia care units, progressive
care units, intermediate care units, private monitored rooms, observation units located in emergency
rooms or outpatient surgery units, beds, wards, or private or semi-private rooms with or without telemetry
monitoring equipment, an emergency room, labor or delivery rooms, or other facilities that do not meet the
standards for a step-down hospital intensive care unit. We do not pay this benet for continuous hospital
intensive care unit connements or continuous step-down hospital intensive care unit connements that
occur during a hospitalization that begins before the effective date. We do not pay for ambulance if paid
under the cancer and specied disease ambulance benet.
Coverage Subject to the Policy - The coverage described in the certicate of insurance is subject in
every way to the terms of the policy that is issued to the policyholder (your employer). It alone makes
up the agreement by which the insurance is provided. The group policy may at any time be amended or
discontinued by agreement between Allstate Benets and the policyholder. Your consent is not required
for this. Allstate Benets is not required to give you prior notice.
The policy is Limited Benet Cancer and Specied Disease Insurance. This is not a Medicare
Supplement Policy. If eligible for Medicare, review Medicare Supplement Buyers Guide available from
American Heritage Life Insurance Company. Subject to COBRA continuation of coverage.
The coverage does not constitute comprehensive health insurance coverage (often referred
to as major medical coverage) and does not satisfy the requirement of minimum essential
coverage under the Affordable Care Act. This material is valid as long as information remains current,
but in no event later than January 15, 2017. Group Cancer and Specied Disease benets are provided
by policy GVCP3, or state variations thereof. This brochure highlights some features of the policy but
is not the insurance contract. Only the actual policy provisions control. The policy sets forth in detail,
the rights and obligations of both the policyholder (employer) and the insurance company. For complete
details, call 1-800-521-3535. This is a brief overview of the benets available under the Group Voluntary
Policy underwritten by American Heritage Life Insurance Company. Details of the insurance, including
exclusions, restrictions and other provisions are included in the certicate issued.
Allstate Benets, The Workplace Marketer
1776 American Heritage Life Drive, Jacksonville, Florida 32224
Customer Care Center: 1.800.521.3535
www.allstate.com or allstatebenets.com

43

For newly eligible employees, or those hired in the last twelve months, the High and Low Options
are offered with Guaranteed Issue. For all other employees, Evidence of Insurability will be required,
meaning that a few health questions must be answered.

Low Option without Optional Benets

Insureds

Monthly Premium

Employee

$20.07

Employee + Child(ren)

$27.71

Employee + Spouse

$30.96

Family

$38.57

Low Option with Optional Benets

Insureds

Monthly Premium

Employee

$26.06

Employee + Child(ren)

$36.81

Employee + Spouse

$41.50

Family

$52.23

High Option without Optional Benets

Insureds

Monthly Premium

Employee

$31.09

Employee + Child(ren)

$43.65

Employee + Spouse

$47.51

Family

$60.04

High Option with Optional Benets

Insureds

Monthly Premium

Employee

$37.08

Employee + Child(ren)

$52.75

Employee + Spouse

$58.05

Family

$73.70

Allstate Benets is the marketing name used by American Heritage Life Insurance Company
(Home Ofce, Jacksonville, FL), a subsidiary of The Allstate Corporation.

44

Aac Critical Illness Insurance Plan

Benet Amounts Available:
Employee: $5,000, $10,000, $15,000, $20,000, $25,000, $30,000, $35,000, $40,000, $45,000,
$50,000
Spouse: $5,000, $7,500, $10,000, $12,500, $15,000, $17,500, $20,000, $22,500, $25,000
Guaranteed Issue Amounts:
Employee: $20,000
Spouse: $10,000
Health Screening Benet: $100.00
The Aac coverage described in this booklet is subject to plan limitations, exclusions, denitions, and
provisions. For detailed information, please see the plan brochure, as this booklet is intended to provide
a general summary of the coverage. This overview is subject to the terms, conditions, and limitations
of policy series CAI2800.
What is Aac critical illness insurance? Why should I consider it?
Aac critical illness insurance provides lump sum benets upon the diagnosis of each covered critical
illness or event, including the following:

Major Organ Transplant

End-Stage Renal Failure
Stroke
Coma
Paralysis
Burns
Cancer (optional)

Loss of Sight
Loss of Hearing
Loss of Speech
Heart Attack
Coronary Artery Bypass Surgery
Specic Heart Procedures

Any of these diagnoses or events would be life-changing. While major medical insurance can help with
the costs of treatment, what about the out-of-pocket expenses that pile up while you or a loved one
is out of work as a result of a covered critical illness? Aac critical illness insurance benets are paid
directly to you (unless otherwise assigned) to use as you see t. You can use the benets to help
with mortgage or rent payments, groceries, car paymentshowever you like.
What are some of the highlights of the Aac critical illness plan?
An annual Health Screening Benet is included.
Spouse coverage is available.
Benet amounts range from $5,000 to $50,000 for employees. The benet amount for spouses is
$5,000 to $25,000.
Each dependent child is covered at 50% of the primary insureds amount at no additional charge.
Coverage may be guaranteed-issue (which means you may qualify for coverage without having to
answer health questions).
Your premiums are paid through the convenience of payroll deduction.
Your plan is portable (with certain stipulations). That means you may be able to take your coverage
with you if you leave your job.
Am I eligible for Aac critical illness coverage? What about my family?
You are eligible to apply for Aac critical illness coverage if you:
45

 Are between the ages of 18 and 69;

Are a full-time, benet-eligible employee;
Are working at least 20 hours per week;
and
Are not a seasonal or temporary employee.
Your spouse must be between the ages of 18 and 69 to be eligible for coverage, and dependent children
must be younger than age 26.
What core benets does the Aac critical illness plan feature?
First Occurrence Benet
After the waiting period, you may receive up to 100% of the benet selected upon the rst diagnosis of
each covered critical illness.
Additional Occurrence Benet
After the waiting period, you may receive benets for each different covered critical illness. Dates of
diagnosis must be separated by at least six months.
Reoccurrence Benet
You may receive benets for the recurrence of any covered critical illness. Dates of diagnosis must be
separated by at least 12 months.
Heart Benet
After the waiting period, you may receive benets for the following covered heart surgeries and
procedures:
Coronary Artery Bypass Surgery (reduces the benet for heart attack)
Mitral valve replacement or repair
Aortic valve replacement or repair
Surgical treatment of abdominal aortic aneurysm
AnjioJet clot busting*
Balloon angioplasty (or balloon valvuloplasty)*
Laser angioplasty*
Atherectomy*
Stent implantation*
Cardiac catherization*
Automatic implantable (or internal) cardioverter debrillator (AICD)*
Pacemaker insertion*
*Benets for these procedures are payable at a percentage of your maximum benet and will reduce the
benet amounts payable for other covered heart procedures.
Health Screening Benet
After the waiting period, you may receive a maximum of $100 for any one covered screening test per
calendar year (regardless of the test results). This benet is payable for you (the employee) and your
covered spouse, not for dependent children. Covered screening tests include the following:
Stress test on a bicycle or treadmill
Fasting blood glucose test, blood test for triglycerides or serum cholesterol test to determine level of
HDL and LDL
Bone marrow testing
Breast ultrasound
CA 15-3 (blood test for breast cancer)
CA 125 (blood test for ovarian cancer)
46

CEA (blood test for colon cancer)

Chest X-ray
Colonoscopy
Flexible sigmoidoscopy
Hemocult stool analysis
Mammography
Pap smear
PSA (blood test for prostate cancer)
Serum protein electrophoresis (blood test for myeloma)
Thermograph

What else do I need to know about the Aac critical illness plan?
You should know that the plan includes:
A 30-day waiting period. This means that no benets are payable for any insured before coverage
has been in force 30 days from your effective date of coverage.
A pre-existing condition limitation. A pre-existing condition is a sickness or physical condition
which, within the 12-month period prior to your plans effective date, either: (1) resulted in you
receiving medical advice or treatment; or (2) caused symptoms for which an ordinarily prudent
person would seek medical advice or treatment. No benets are payable for any condition or
illness starting within 12 months of the effective date which is caused by, contributed to, or resulting
from a Pre-existing Condition.
Certain exclusions. No benets are payable for loss resulting from:
Intentionally self-inicted injury or action;
Suicide or attempted suicide while sane or insane;
Illegal activities or participation in an illegal occupation;
War, whether declared or undeclared or military conicts, participation in an insurrection or riot,
civil commotion or state of belligerence;
Substance abuse; or
Diagnosis and/or treatment received outside the United States.

Note: If this coverage will replace any existing individual policy, please be aware that it may be in your best interest to maintain your
individual guaranteed-renewable policy.
Continental American Insurance Company (CAIC), a proud member of the Aac family of insurers, is a wholly-owned subsidiary of
Aac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the
Virgin Islands.
Continental American Insurance Company 2801 Devine Street Columbia, South Carolina 29205
Continental American Insurance Company is not aware of whether you receive benets from Medicare, Medicaid, or a state variation.
If you or a dependent are subject to Medicare, Medicaid, or a state variation, any and all benets under this plan could be assigned.
This means that you may not receive any of the benets in the plan.
As a result, please check to the coverage in all health insurance policies you already have or may have before you buy this insurance to
verify the absence of any assignments or liens.
800.433.3036 | aacgroupinsurance.com
Underwritten by Continental American Insurance Company
A proud member of the Aac family of insurers
47

48

49

Aac Hospital Indemnity Plan

Effective Date: April 1, 2015
Plan Features

Benets are available for spouse and/or dependent children.

Premiums are paid by convenient payroll deduction.
The plan covers injuries and sickness.
Admission and per-day hospital connement benets are included.
Wellness benet is included.
Surgery and anesthesia benets are included.
High or Low Plan Options

Issue Ages

Employee: 1864
Spouse: 1864
Children: under age 26
Full-time, benet-eligible employees working at least 20 hours per week are eligible to apply.
Employees must be actively at work on the date of application and the effective date of coverage.
Seasonal and temporary employees are not eligible.
The employee may purchase supplemental hospital indemnity coverage for his spouse and/or
dependent children. The spouse and dependent children cannot participate if the employee is not
eligible for coverage or elects not to participate.
A spouse is the person married to the employee on the effective date of this coverage. A spouse
means the legal spouse who is between the ages of 18 and 64. A spouse must not be hospitalized
or unable to perform his or her normal duties or activities on the date of application and the effective
date of coverage.
Dependent child means natural children, stepchildren, foster children, legally adopted children, or
children placed for adoption who are under age 26.
Guaranteed-Issue
During the initial enrollment and for newly eligible employees, coverage is guaranteed-issue,
provided the applicants are eligible for coverage. Enrollments take place once each 12- month
period. Late enrollees cannot enroll outside of an annual enrollment period and will be underwritten.
Portability
When coverage is effective and would otherwise terminate because the employee ends employment
with the employer, coverage may be continued. An employee may continue the coverage that is in
force on the date employment ends; this includes dependent coverage that is in effect.
The employee will be allowed to continue the coverage until the date the employee fails to pay the
required premium or the date the group master policy is terminatedwhichever is earlier. Coverage
may not be continued if the employee fails to pay any required premium, the employee attains
age 70, or the group master policy terminates. Premium for ported coverage is paid directly by the
insured.
50

Benets
Hospital Connement (per day)

High Option

Low Option

$150

$100

We will pay the amount shown when an insured is conned to a hospital as a resident bed patient as
the result of injuries received in a covered injury or because of a covered sickness. To receive this
benet for injuries received in an injury, the insured must be conned to a hospital within six months
of the date of the covered accident.
The maximum period for which a covered person can collect benets for hospital connements
resulting from covered sickness or from injuries received in the same covered accident is 180 days.
This benet is payable for only one hospital connement at a timeeven if the connement is a result
of more than one covered accident, more than one covered sickness, or a covered accident and a
covered sickness.

Hospital Admission (per connement)

High Option

Low Option

$1,500

$500

We will pay the amount shown when an insured is admitted to a hospital and conned as a resident
bed patient because of an injury or because of a covered sickness. To receive this benet for injuries
received in a covered accident, an insured must be admitted to a hospital within six months of the
date of the covered accident.
We will not pay benets for connement to an observation unit, for emergency room treatment, or for
outpatient treatment.
We will pay this benet only once for each covered accident or covered sickness. If an insured is
conned to the hospital because of the same or related injury or sickness, we will not pay this benet
again.
This benet option will be based on the insureds current major medical plans deductible to assist the
insured in meeting the out-of-pocket liability.

Surgical Benet (per procedure)

High Option

Low Option

Up to $1,500

Up to $750

If an insured has surgery performed by a physician due to an injury or because of a covered sickness,
we will pay the appropriate surgical benet amount shown in the Schedule of Operations. The
surgical benet paid will never exceed the maximum surgical benet designated in the plan. The
surgery can be performed in a hospital (on an inpatient or outpatient basis), in an ambulatory surgical
center, or in a physicians ofce.
If an operation is not listed in the Schedule of Operations, we will pay an amount comparable to that
which would be payable for the operation listed in the Schedule of Operations (the operation that is
nearest in severity and complexity).
If two or more surgical procedures are performed at the same time through the same or different
incisions, only one benetthe largestwill be provided.
51

Anesthesia Benets

High Option

Low Option

Up to $375

Up to $187.50

When an insured receives benets for a surgical procedure covered under the Surgical Benet,
we will pay the appropriate benet amount shown in the Schedule of Operations for anesthesia
administered by a physician in connection with such procedure. However, the Anesthesia Benet paid
will not exceed 25 percent of the amount paid under Surgical Benet.

Wellness Benet

High Option

Low Option

$50

$50

We will pay the amount shown when an insured visits a doctor and he is neither injured nor sick. This
benet is payable once per calendar year per insured.

Pre-Existing Condition Limitation

A pre-existing condition means, within the 12-month period prior to the insureds effective date,
conditions for which medical advice or treatment was received or recommended.
We will not pay benets for any loss or injury that is caused by, contributed to by, or resulting from a
pre-existing condition for 12 months after the insureds effective date or for 12 months from the date
medical care, treatment, or supplies were received for the pre-existing conditionwhichever is less.
A claim for benets for loss starting after 12 months from the effective date of the insureds certicate
will not be reduced or denied on the grounds that it is caused by a pre-existing condition.
Pregnancy is considered a pre-existing condition if conception was before the coverage effective
date.
If the certicate is issued as a replacement for a certicate previously issued under this plan, then the
pre-existing condition limitation provision of the new certicate applies only to any increase in benets
over the prior certicate. Any remaining pre-existing condition limitation period of the prior certicate
continues to apply to the prior level of benets.

Exclusions
We will not pay benets for loss contributed to by, caused by, or resulting from:
1. War Participating in war or any act of war, declared or not, or participating in the armed forces
of or contracting with any country or international authority. We will return the prorated premium
for any period not covered by this certicate when the insured is in such service.
2. Suicide Committing or attempting to commit suicide, while sane or insane.
3. SelfInicted Injuries Injuring or attempting to injure yourself intentionally.
4. Traveling Traveling more than 40 miles outside the territorial limits of the United States, Canada,
Mexico, Puerto Rico, the Bahamas, Virgin Islands, Bermuda, and Jamaica.
5. Racing Riding in or driving any motordriven vehicle in a race, stunt show or speed test.
6. Aviation Operating, learning to operate, serving as a crew member on, or jumping or falling from
any aircraft, including those, which are not motordriven.
7. Intoxication Being legally intoxicated, or being under the inuence of any narcotic, unless such is
taken under the direction of a physician.
52

8. Illegal Acts Participating or attempting to participate in an illegal activity, or working at an illegal

job.
9. Sports Participating in any organized sport: professional or semiprofessional.
10. Routine physical exams and rest cures.
11. Custodial care. This is care meant simply to help people who cannot take care of themselves.
12. Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related
procedures, including complications.
13. Services performed by a relative.
14. Services related to sex change, sterilization, in vitro fertilization, reversal of a vasectomy or tubal
ligation.
15. A service or a supply furnished by or on behalf of any government agency unless payment of the
charge is required in the absence of insurance.
16. Elective abortion.
17. Treatment, services, or supplies received outside the United States and its possessions or
Canada.
18. Injury or sickness for which benets are paid or payable by Workers Compensation.
19. Dental services or treatment.
20. Cosmetic surgery, except when due to medically necessary reconstructive plastic surgery.
21. Mental or emotional disorders without demonstrable organic disease.
22. Alcoholism, drug addiction, or chemical dependency.

Terminations
An employees insurance will terminate on the earliest of:
The date the plan is terminated;
The 31st day after the premium due date, if the required premium has not been paid;
The date an employee ceases to meet the denition of an employee, unless the employee takes
advantage of the portability privilege;
The premium due date which falls on or rst follows the Employees 70th birthday; or
The date an employee no longer belongs to an eligible class.
Insurance for an insured spouse or dependent child will terminate the earliest of: The date the plan
is terminated;
The date the spouse or dependent child ceases to be a dependent; or
The premium due date following the date we receive written request to terminate coverage for an
insureds spouse and/or all dependent children.
If the group master policy and/or certicate terminates, we will provide coverage for claims arising
from covered accidents or sickness that occurred while the plan was in force.
Continental American Insurance Company is not aware of whether you receive benets from Medicare, Medicaid, or a
state variation.
If you or a dependent are subject to Medicare, Medicaid, or a state variation, any and all benets under this plan could be
assigned.
This means that you may not receive any of the benets in the plan.
As a result, please check to the coverage in all health insurance policies you already have or may have before you buy
this insurance to verify the absence of any assignments or liens.

53

Monthly Premium Rates

High Option

Low Option

Employee

$30.96

$15.69

Employee and Spouse

$61.17

$31.03

Employee and Dependent Child(ren)

$42.91

$21.50

Employee and Family

$73.12

$36.84

Note: If this coverage will replace any existing individual policy, please be aware that it may be in your
employees best interest to maintain their individual guaranteed-renewable policy.

Continental American Insurance Company (CAIC) is a wholly-owned subsidiary of Aac Inc. CAIC
underwrites group coverage but is not licensed to solicit business in Guam, Puerto Rico, or the
Virgin Islands. In California, group coverage is underwritten by Continental American Life
Insurance Company, and in New York group coverage in underwritten by American Family Life
Assurance Company of New York.

Continental American Insurance Company

2801 Devine Street
Columbia, South Carolina 29205
1-800-433-3036 toll-free
1-866-849-2970 fax
Aacgroupinsurance.com

54

AUL Short-Term Disability Plan

Why should you consider purchasing disability insurance protection at your workplace?
Many of us lead busy lives and seldom take time to think about lifes risks. Consider the following reasons many people purchase disability insurance:
Lost wages
Daily living expenses, such as mortgage/rent, utilities, car payment, food, childcare, eldercare, hobbies, pet care
Advantages of shopping at work include:
Affordable group rates
Convenient payroll deduction
Guaranteed issue for timely applicants
Easy access

Less than 5% of disabling accidents and illnesses are work related. The other
95% are not, meaning Workers Compensation doesnt cover them.
(Source: Council for Disability Awareness, Long-Term Disability Claims Review, 2011. http://www.disabilitycanhappen.org/research/CDA_LTD_Claims_Survey _2011.asp)
90% of disability are caused by illness.
(Source: Council for Disability Awareness, http://www.disabilitycanhappen.org/chances_disability _stats.asp., August 2012.)
64% of wage earners believe they have a 2% or less chance of being disabled
for 3 months or more during their working career. The actual odds for a worker
entering the workforce today are about 30%.
(Source: Social Security Administration website, ssa.gov, Fact Sheet,
March 18, 2011.)
Less than half (35.6%) of the 2.9 million workers who applied for Social Security
Disability Insurance (SSDI) benets in 2011 were approved.
(Source: Social Security Administration website, ssa.gov, Monthly Statistical
Snapshot, December 2012.)

You have life insurance, home insurance, and automobile insurance.

But is your income insured?

55

Class Description
All Full-Time Eligible Employees working a minimum of 20 hours per week, electing to participate in the
Voluntary Short Term Disability Insurance
Disability
You are considered disabled if, because of injury or sickness, you cannot perform the material and
substantial duties of your regular occupation. You are not working in any occupation and are under the
regular attendance of a physician for that injury or sickness
Monthly Benet
You can choose to insure up to 70% of an Employees covered basic monthly earnings to a
maximum monthly benet of $2,000. The minimum benet is $500.
Elimination Period
This means a period of time a disabled Employee must be out of work and totally disabled before
weekly benets begin; seven (7) consecutive days and Zero (0) for an injury.
Benet Duration
This is the period of time that benets will be payable for disability. You can choose a maximum STD
benet duration, if continually disabled, of thirteen (13) weeks.
Basis of Coverage
24 hour coverage, on or off the job.
Maternity Coverage
Benets will be paid the same as any other qualifying disability, subject to any applicable pre-existing
condition exclusion.
STD Pre-Existing Condition Exclusion
3/12, If a person receives medical treatment, or service or incurs expenses as a result of an Injury or
Sickness within 3 months prior to the Individual Effective Date, then the Group Policy will not cover any
Disability which is caused by, contributed to by, or resulting from that Injury or Sickness; and begins
during the rst 12 months after the Persons Individual Effective Date. This Pre-Existing Condition
limitation will be waived for all Persons who were included as part of the nal premium billing
statement received by AUL/ OneAmerica from the prior carrier and will be Actively at work on
the effective date.
Recurrent Disability
If you resume Active Work for 30 consecutive workdays following a period of Disability for which the
Weekly Benet was paid, any recurrent Disability will be considered a new period of Disability. A new
Elimination Period must be completed before the Weekly Benet is payable.
Portability
Once an employee is on the AUL disability plan for 3 consecutive months, you may be eligible to port
your coverage for one year at the same rate without evidence of insurability. You have 31 days from
your date of termination to submit an application to AUL in order to port your coverage. The application
to port coverage is located on the Mark III website.
The Portability Privilege is not available to any person that retires (when the person receives payment
from any employers retirment plan as recognition of past services or has concluded his/her working
career).
56

Annual Enrollment
Employees that did not elect coverage during their initial enrollment period are eligible to sign up for
$500 to $1000 monthly benet without medical questions,subject to pre-existing exclusion. Employees
may increase their coverage up to $500 monthly benet without medical questions. The maximum
benet cannot exceed 70% of basic monthly earnings and must be in $100 increments. The preexisting exclusion will apply to the increased benet.
Employees that elect to increase their benet duration may do so only during the annual enrollment
period. The pre-existing exclusion will apply to the increased benet duration.
Exclusions and Limitations
This plan will not cover and disability resulting from war, declared or undeclared or any act of war; active
participation in a riot; intentionally self inicted injuries; commission of an assault of felony; or a preexisting condition for a specied time period.
This information is provided as a summary of the product. It is not a part of the insurance
contract and does not change or extend AULs liability under the group policy. If there are any
discrepancies between this information and the group policy, the group policy will prevail.
Please refer to the Mark III website for a copy of your certicate, claim forms or an application
to port form.
Customer Service
1.800.553.5318
Disability Claims
1.866.258.8744
Fax: 1.207.591.3048
Disability Claims Email: claims@disabilityrms.com
www.employeebenets.aul.com

57

AUL Short-Term Disability

Monthly Rates
Benet Duration:
13 Weeks
Monthly

Monthly

Benet

Premium

$500

$10.36

$600

$12.43

$700

$14.50

$800

$16.57

$900
$1,000

$18.64
$20.71

$1,100

$22.78

$1,200

$24.85

$1,300

$26.92

$1,400

$28.99

$1,500

$31.07

$1,600
$1,700

$33.14
$35.21

$1,800

$37.28

$1,900

$39.35

$2,000

$41.42

58

AUL Long-Term Disability Plan

LTD Class Description
All Full-Time Eligible Employees working a minimum of 20 hours per week, electing to participate in the
Voluntary Long Term Disability Insurance.
LTD Monthly Benet
You can choose to insure up to 60% of an Employees covered basic monthly earnings to a maximum
monthly benet of $2,000 in $500 increments. The minimum benet is $500.
LTD Elimination Period
This means a period of time a disabled Employee must be out of work and totally disabled before
weekly benets begin; 90 consecutive days for a sickness or injury.
LTD Benet Duration
This is the period of time that benets will be payable for long term disability. Up to 5 years if disabled
prior to age 61, or if disabled after age 61, as outlined below:
Age When Total Disability Begins

Maximum Period Benets are Payable

Prior to Age 61

5 Years

61

Lesser of SSFRA or 5 Years

62

3.5 Years

63

3 Years

64

2.5 Years

65

2 Years

66

21 Months

67

18 Months

68

15 Months

Age 69 and over

12 Months

LTD Total Disability Denition

An Insured is considered Totally Disabled, if, because of an injury or sickness, he cannot perform
the material and substantial duties of his Regular Occupation, is not working in any occupation and
is under the regular care of physician. After benets have been paid for 24 months, the denition
of disability changes to mean the Insured cannot perform the material and substantial duties of any
Gainful Occupation for which he is reasonably tted for by training, education or experience.
LTD Mental & Nervous / Drug & Alcohol
Benet payments will be limited to benet duration or 24 months, whichever is less, cumulative for each
of these limitations for treatment received on an outpatient basis. Benet payments may be extended
if the treatment for the disability is received while hospitalized or institutionalized in a facility licensed to
provide care and treatment for the disability.
Special Conditions
Benets for Disability due to Special Conditions, whether or not benets were sought because of
the condition, will not be payable beyond 24 months. Benet payments for Special Conditions are
cumulative for the lifetime of the contract.
59

Other Income Offsets

AUL will not reduce your LTD disability benet with other disability income benets that you might be
receiving from AUL or external sources such as Social Security or other disability or income benets
you may receive, or be eligible to receive.
Waiver of Premium
AUL will waive the premium payments for your coverage while you are disabled and will continue to be
waived during the elimination period and the benet eligibility period.
Pre-Existing Condition Exclusion
3/12, If a person receives medical treatment, or service or incurs expenses as a result of an Injury or
Sickness within 3 months prior to the Individual Effective Date, then the Group Policy will not cover any
Disability which is caused by, contributed to by, or resulting from that Injury or Sickness; and begins
during the rst 12 months after the Persons Individual Effective Date.
This Pre-Existing Condition limitation will be waived for all Persons who were included as part of the
nal premium billing statement received by AUL/OneAmerica from the prior carrier and will be Actively
at work on the effective date
Portability
Once an employee is on the AUL disability plan for 3 consecutive months, you may be eligible to port
your coverage for one year at the same rate without evidence of insurability. You have 31 days from
your date of termination to submit an application to AUL in order to port your coverage. The application
to port coverage is located on the Mark III website.
The Portability Privilege is not available to any person that retires (when the person receives payment
from any employers retirment plan as recognition of past services or has concluded his/her working
career).
Annual Enrollment
Enrollees that did not elect coverage during their initial enrollment are eligible to sign up for $500 or
$1000 monthly LTD benet without medical questions. The maximum benet cannot exceed 60% of
basic monthly earnings.
Exclusions and Limitations
This plan will not cover any disability resulting from war, declared or undeclared or any act of war;
active participation in a riot; intentionally self-inicted injuries; commission of an assault or felony; or a
pre-existing condition for a specied time period.

60

Voluntary Long Term Disability

Monthly Benet

Monthly Rate

$500

$6.40

$1,000

$12.80

$1,500

$19.20

$2,000

$25.60

Customer Service
800-553-5318
Disability Claims
866-258-8744
Fax: 207-591-3048
Disability Claims Email: claims@disabilityrms.com
www.employeebenets.aul.com

This information is provided as a Benet Outline. It is not a part of the insurance policy and does not
change or extend American United Life Insurance Companys liability under the group Policy. Employers
may receive either a group Policy or a Certicate of Insurance containing a detailed description of the
insurance coverage under the group Policy. If there are any discrepancies between this information and
the group Policy, the Policy will prevail.
Please refer to the Mark III website for a copy of your certicate, claim forms or an application
to port form.

61

Reliance Standard Group Voluntary

Term Life Insurance Plan
Effective Date: pending underwriting approval
VOLUNTARY EMPLOYEE LIFE INSURANCE
To help meet this need, you have the opportunity to elect group life insurance under the additional
portion of your program to go along with any personal insurance coverage you may have.
VOLUNTARY DEPENDENT LIFE INSURANCE
Provides coverage on:
Your Spouse
Unmarried child(ren) between the ages of 15 days and 21 years (up to age 25 if wholly dependent
upon you for maintenance and support and if enrolled as a full time student in an accredited school
or college). Handicapped children can continue to be covered with no age limit. Children can only be
covered by one parent.
It is your responsibility to notify the Benets Department when a spouse or dependent child is no longer
eligible for coverage. (i.e. divorce, child no longer full-time college student, etc.)
FLEXIBILITY
Simply choose the amount of coverage that suits your needs from the selection provided, as outlined
on the back of this folder.
FEATURES
The plan features easy eligibility and simple enrollment procedures.
LOW COST
Your cost is lower than for comparable insurance on an individual basis due to the wholesale economies
inherent in group insurance. Additionally, your Employer absorbs the cost of administering the program
which is underwritten by Reliance Standard - a leader in the eld of group coverage.
ELIGIBILITY
You will be eligible for this plan if you are a full-time active employee working 30 hours or more per week
or if you are a permanent part time employee working 20 hours per week.
ENROLLMENT
Enrollment is simple - just ll out the application provided by your employer. Make sure you supply all
the required information and return the form where you work. Thats all. You will be notied as to when
coverage starts.
BENEFICIARY
You have the right to designate the beneciary of your choice under employee coverage. You are
automatically the beneciary under Dependent Life.
WHEN YOUR INSURANCE STARTS
If you enroll on or before the day you become eligible, your employer provided insurance becomes
effective on the date of your eligibility if you are then actively at work; otherwise, on the day you return to
62

active work. If you have elected Voluntary Employee or Dependent Life Insurance, you will be notied
as to when that coverage begins. Anyone electing not to enroll when rst eligible or within three months
thereafter can enroll later only if evidence of insurability satisfactory to the Insurance Company is
provided.
WAIVER OF PREMIUM
Your Basic and Voluntary Life coverages include a wavier of premium provision. If an employee is
unable to engage in any occupation as a result of injury or sickness for a minimum of 6 months, prior to
age 60, premium will be waived for the employees life insurance benet until the employee is no longer
disabled or reaches age 65, whichever occurs rst. Your Voluntary Dependent Life Insurance may be
continued provided you remit the applicable premium to your employer.
CONVERSION
If your employment terminates while you are covered under the plan, you may purchase without medical
evidence of insurability, any individual insurance policy, except a term policy, issued by Reliance
Standard Life Insurance Company, in any amount up to the amount of your life coverage in effect on
your date of termination. You must apply for this policy within 31 days after the date your coverage
terminates.
This privilege applies to Voluntary Life Insurance and Dependent Life Insurance.
PORTABILITY
Voluntary Life benets may be portable upon termination for the employee and/or his insured spouse. If
an insured employee or spouse elects portability, he may also elect to continue Dependent Child(ren)s
coverage. Ported coverage terminates at age 70. Please refer to the certicate of coverage for details
on the requirements to be eligible for portability.
ACCELERATED BENEFITS OPTION
Reliance Standard Life Insurance Company has included an Accelerated Benet Option (ABO) as part
of your group life benets. Under this option, if you are diagnosed as having a terminal illness, you may
be eligible to receive a portion of your group life benets at such a difcult time. Please refer to your
Group Certicate for details.
GROUP POLICY AND CERTIFICATE
The insurance briey described in this folder is subject to the terms and conditions of the Group Policy
issued by Reliance Standard Life Insurance Company. If you become insured, you will receive a
certicate outlining your benets under the policy.
CLAIMS PROCEDURE
Claim forms needed to le for benets under the group insurance plan can be obtained from your
employer who will also be ready to answer questions about the insurance benets and to assist in ling
claims. The instructions on the claim form should be followed carefully. This will expedite the processing
of the claim. Be sure all questions are answered fully. If there is any question about a claim payment,
an explanation can be requested from your employer, who is usually able to provide the necessary
information.
REDUCTION OF BENEFITS
The Term life coverage reduces as follows:
By 50% on the employee at age 70
Terminates at age 70 on the spouse
63

SCHEDULE OF BENEFITS
VOLUNTARY EMPLOYEE LIFE INSURANCE
You choose the following amounts on yourself:
$10,000, $20,000, $30,000, $40,000, $50,000, $60,000, $70,000, $80,000, $90,000, $100,000,
$150,000, $200,000, $250,000, $300,000
The Employee must have voluntary life coverage to sign up for the Spouse or Family voluntary
life coverage.
VOLUNTARY DEPENDENT LIFE INSURANCE SPOUSE
You choose the following amounts on your spouse:
$5,000, $10,000, $20,000, $30,000, $40,000, $50,000, $60,000, $70,000, $80,000, $90,000, $100,000,
$150,000
The spouse amount cannot exceed 50% of the employee amount. (This includes the total amount
between the Spouse Dependent life and the Family life).
CHILD(REN)
$ 10,000 on each of your eligible children (no matter how many)
Covered from Birth to 21 years of age, or to age 25 if a full time student
ELIGIBILITY REMINDERS
Employees under age 60 must furnish evidence of insurability for amounts over $100,000.
Employees age 60-69 must furnish evidence of insurability for amounts over $20,000.
Employees age 70 and over must furnish evidence of insurability for all amounts of coverages.
Spouses under age 70 must furnish evidence of insurability for amounts over $10,000.
If you are an existing employee and you are increasing your current coverage amount or if you are
applying for coverage the very rst time (did not apply when rst hired) you are required to complete a
health statement. This applies to your dependents as well. EXCEPTION: Qualifying event such as
marriage.
GI AMOUNTS (GUARANTEED ISSUE):
These GI amounts do not apply if you are an existing employee and have had the opportunity to
apply for term life coverage. These amounts apply to new hires only.
Employee- $10,000 to $100,000
Spouse-$10,000
If you have questions about a Life claim that you have submitted, please call
Reliance Standard directly at 1.800.351.7500 x.4149
This is only a brief summary of the life insurance benets available. Some restrictions may apply.
For more specic information about the coverage details, including limitations, exclusions and other
requirements, please refer to your certicate booklet or contact your Benets Department.

64

Reliance Standard Term Life Monthly Rates

Employee
Coverage Amount

Monthly
Premium

$10,000

$1.80

$20,000

$3.60

$30,000

$5.40

$40,000

$7.20

$50,000

$9.00

$60,000

$10.80

$70,000

$12.60

$80,000

$14.40

$90,000

$16.20

$100,000

$18.00

$150,000

$27.00

$200,000

$36.00

$250,000

$45.00

$300,000

$54.00

Spouse
Coverage Amount
The spouse amount cannot exceed 50% of the
employee amount. (This includes the total amount
between the Spouse Dependent life and the Family life).

Monthly
Premium

$.90
$1.80
$3.60
$5.40
$7.20
$9.00
$10.80
$12.60
$14.40
$16.20
$18.00
$27.00

$5,000
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$150,000
Family
Coverage

Monthly
Premium

$10,000 on
Spouse&
Child(ren)

$3.16

It is your responsibility to notify the Benets Department and Reliance Standard when a dependent
is ineligible for coverage. Examples of ineligible dependent status are divorce, death or a child
graduates from college.
If you are an existing employee and you are increasing your current coverage amount or if you
are applying for coverage the very rst time (did not apply when rst hired) you are required to
complete a health statement. This applies to your dependents as well.
Customer Service:1.800.351.7500
Website: www.reliancestandard.com

65

Boston Mutual Life Insurance Company

Employee Life Option (ELOP) Life Plus
BML Whole Life Coverage is effective on the date the application is signed.
Guaranteed Benets, Level Premiums and Policy Values
The Employee Life Option is more than just life insurance at an affordable price. It combines the
guaranteed premiums, coverage and values that have always been so attractive in whole life insurance
with the advantages of cash accumulation at current interest rates. This policy is an endowment at 95
with coverage to age 95.
Affordable, Flexible Protection
You choose the amount of insurance or the amount of premium that best suits your needs and budget.
All eligible employees and their spouses through insurance age 72 may purchase coverage under the
Basic Plan. Weekly deductions range from $2.00-$30.00 per week.
Insurance is also available for your spouse, unmarried dependent children and grandchildren even if you
choose not to buy coverage on yourself.
Policy Values*
As long as premiums are paid, your ELOP Basic Plan offers a guaranteed cash value that can grow
over the years. The cash value can be used to supplement retirement income, for emergency cash,
as an education fund or to provide a paid-up insurance benet. While this value can never be less
than the guaranteed amount, ELOP gives you the advantage of potential cash values in excess of the
guaranteed amount. The current interest rate in effect when your policy is issued is guaranteed for the
rst year. On each policy anniversary date, you will receive an annual statement outlining your policys
accumulated value and changes in the interest rate, if any.
* The actual cash value may be decreased by loans or withdrawals.
Constant Coverage
ELOP participants are protected worldwide, 24 hours a day. Your policy is owned by you and supplements
any other insurance you may have.
Benets You Can Keep
Once purchased, your ELOP plan remains in force as long as premiums continue to be paid; and your
permanent plan premiums cannot be increased. If you change jobs or retire, as long as you continue
to pay premiums, your insurance will remain in force without interruption. Boston Mutual will bill you at
home and you may choose from several payment options annual, semi-annual, quarterly, monthly
coupon book or monthly automatic check plan.
Accidental Death Benet (ADB)
This option could double or even triple your ELOP death benet. This benet pays an additional amount
equal to the basic coverage to the beneciary if the insured is killed accidentally. If accidental death
occurs while the insured is a passenger on a bus, plane, train or any other common carrier, this benet
pays the accidental death benet as above but will also pay an additional benet of the basic coverage
(up to $100,000). This extra protection is available at affordable rates. Any Basic Plan participant age 5
years through age 60 is eligible for this benet.

66

Payor Waiver of Premium

This benet pays all the premiums on your policy, your spouses or dependents policy or policies in the
event the payor (employee) becomes totally disabled before age 60. The disability must last at least
six consecutive months and meet the denitions set forth in your policy. This benet is available for
issue on policies owned by employees up to and including issue age 55 at a cost of 10% of the basic
premium for each policy. This benet terminates on the policy anniversary on or following the Payors
60th birthday, as long as the Payor is not disabled at that time.
QUESTIONS AND ANSWERS
Can I buy this plan on my own?
No! This plan is available only to employees of companies that provide the convenience of payroll
deduction for the ELOP plan. Because your employer has chosen to offer ELOP, you receive the
advantages of more liberal underwriting and the convenience of payroll deduction. All of this results in
savings that reduce the cost of the policies.
Does this policy replace my present group insurance?
No! ELOP coverage is independent of and supplements your present group insurance program.
If I leave my employer what happens to my ELOP Plan?
You can take the ELOP plan with you when you leave with no change in cost or benets. We will bill you
at home.
What happens if I cant pay my premiums as a result of leave of absence or termination from
my employer?
Your policy includes the Automatic Premium Loan provision which will be used to pay your premium at
the end of your grace period, provided you have accumulated cash value.
What options does my ELOP policy provide at retirement?
Depending on how long your policy has been in force, you have the following options:
(1) continue your premium payments and value accumulation (2) opt for a paid-up policy (3) decide to
turn your policy in for its accumulated cash value.
Can I increase my coverage in the future?
You may apply for additional coverage in the future if you are actively at work with the employer-sponsored
company and will be subject to the ELOP underwriting guidelines.
Can I take a loan on my policy?
Yes. You may borrow all or part of your loan value at an 8% xed interest rate.
Does the ELOP coverage have a surrender charge?
If you discontinue your plan before the 21st policy year there will be a surrender charge. The amount
of this charge decreases every year. No charge is made if you decide to terminate your coverage after
it has been in force for at least 20 years.
Will ELOP benets be paid for suicide?
If suicide occurs during the rst 2 years your policy is in effect, benets will not be paid, but any premiums
paid will be refunded. After 2 years, benets will be paid if death is caused by suicide.

67

CONSIDER....
IF YOU HAVE A FAMILY
The ELOP plan enables you to build a cash reserve for yourself, your spouse and your children for less
than 1 hours pay per week. It is a sound way to protect your family without exceeding your present
budget.
IF YOURE SINGLE WITH NO DEPENDENTS
For a single working person insurance is the foundation for future nancial planning. The longer you wait
to buy insurance the more expensive it will be. The exibility of the ELOP plan enables you to expand
your coverage to meet future responsibilities.
IF YOU ARE OLDER AND NEARING RETIREMENT
A lot of obligations and responsibilities have probably come and gone in the past few years. Now you
can think about your future. Your ELOP plan can be continued after retirement.
No matter where you are in your life and career, you will benet from ELOP Life Insurance that Works
for Life.

Guaranteed Issue
Employee: up to $25 per week
Spouse: up to $3 / $5* per week
Must be able to answer NO to During the past six months, has your spouse been seen or treated,
including testing, in a hospital or any other medical facility, excluding physicians ofces for routine
medical care?
*Employee must purchase $5 in order for the spouse to be eligible for $5
Children: up to $3 per week
Child must be between ages 15 days and 25 years old to be eligible for coverage.
Grandchildren: up to $3 per week
Grandchildren must be between ages 15 days and 15 years old to be eligible for coverage
For questions concerning this policy please contact:
BOSTON MUTUAL LIFE INSURANCE COMPANY
120 Royall Street Canton, MA 02021
1.800.669.2668
781.828.7000
Website: www.bostonmutual.com
BOSTON MUTUAL
LIFE INSURANCE COMPANY SINCE 1891

Policy Series: ICC13 END-95 (ESO) 3/13 and END-95 (ESO) 3/13
68

Continuing Your Benets

Flexible Benet Administrators Reimbursement Accounts
If you have a positive balance (payroll deductions are greater than the amount you have received in
reimbursement) in your Health Care Reimbursement Account at the time of your termination, you may
continue participation in the Plan for the remainder of the Plan year. If you want to remain in the Plan,
you can do so by selecting one of the COBRA options. If you prefer to terminate your participation
and contribution to the Plan, any balance in your account on the date of termination will be forfeited if
expenses were not incurred prior to the date of termination. For more detailed information, please call
Flexible Benet Administrators at 1.800.437.3539.

Ameritas Dental and Vision Plans

Under the Ameritas Dental and Vision Plans, you and your covered dependents are eligible to continue
coverage through COBRA according to the qualifying events.
If you and your dependents are enrolled in the dental or vision plans, you will be eligible to continue
coverage through COBRA after you leave your employment for a specied period. In addition, while
covered under the plan, if you should die, become divorced or legally separated, or become eligible for
Medicare, your covered dependents may be eligible to continue dental and vision coverage through
COBRA. Also, while you are covered under the plan, your covered children who no longer qualify as an
eligible dependent may continue coverage through COBRA. Examples of an ineligible dependent would be
when your child graduates from college, or reaches the age of not being eligible for dependent coverage.
You will receive notication with premium and continuation options shortly following your termination
of employment. Should you have any questions you may contact Flexible Benet Administrators at
1.800.437.3539

AUL Short-Term and/or Long-Term Disability

Once an employee is on the AUL disability plan for 12 months, you can port the coverage for one year
at the same cost without evidence of insurability. You have 30 days from your date of termination to
contact AUL to Port your coverage by calling 1.800.553.5318.

Boston Mutual Whole Life

When you leave employment, you may continue your Boston Mutual Whole Life coverage by having
the premiums that are currently deducted from your paycheck drafted from your bank account. You may
contact Boston Mutual at 1.800.669.2668.

To Continue Other Policies

You may continue your Aac Group Accident, Aac Group Critical Illness, Aac Group Hospital
Indemnity, and Allstate Cancer policies by having the premiums currently deducted from your
paycheck drafted from you bank account or billed to your home.
For more information, contact:
Allstate at 1-800-521-3535
Aac Group at 1-800-433-3036
69

Reliance Standard Term Life

Conversion
If your employment terminates while you are covered under the plan, you may purchase without medical
evidence of insurability, any individual insurance policy, except a term policy in any amount up to the
amount of your life coverage in effect on your date of termination. You must apply for conversion within 31
days after the date your coverage terminates. This applies to Employee Voluntary Life & Dependent
Voluntary Life. To get information, rates, or applications, please contact Reliance Standard directly at
1.800.351.7500
Portability
Voluntary Life benets may be portable upon retirement or termination for the employee and insured
spouse. If an insured employee or spouse elects portability, he may also elect to continue Dependent
Child(ren)s coverage. Ported coverage terminates at age 70. To get information, rates, or applications,
please contact Reliance Standard directly at 1.800.351.7500.

For Retirees:
METLIFE DENTAL & SUPERIOR VISION INSURANCE PLANS FOR RETIREES OF
STATE OR LOCAL GOVERNMENT OFFERED THROUGH NORTH CAROLINA RETIRED
GOVERNMENTAL EMPLOYEES ASSOCIATION, INC.
With over 54,000 members, the North Carolina Retired Governmental Employees Association is the
largest single group representing retirees before the N.C. General Assembly, the Retirement Systems
Boards of Trustees, and the State Health Plan trustees. For retirees or future retirees of state or local
governments in North Carolina (including teachers, legislators, National Guard, and judicial), NCRGEA
is your voice for sustaining and increasing your benets after retirement.
Additionally, there are many benets included with membership at no additional cost ($10,000 AD&D
Insurance, bimonthly newsletter, weekly electronic legislative updates while the General Assembly is
in session, a toll-free number to call for information and assistance, hearing assistance and vision care
discount programs, and free district meetings).
The Association also offers optional MetLife Dental Insurance and Superior Vision Insurance plans for
our members. Those premiums are conveniently deducted from your retirement benet check monthly.
Please contact us at:
NCRGEA, PO Box 10561, Raleigh, NC 27605
1-800-356-1190
www.info@ncrgea.com or go to our website, www.ncrgea.com, for further information.

70

Contact Information for Questions and Claims

Flexible Benet Administrators
509 Viking Drive, Suite F
PO Box 8188
Virginia Beach, VA 23450
1-800-437-FLEX (1-800-437-3539)
Fax: (757) 431-1155
FlexDivision@ex-admin.com
www.ex-admin.com
Ameritas Dental
Customer Service
1-800-487-5553
www.ameritasgroup.com
Ameritas VSP Vision
VSP Call Center
1-800-877-7195
www.ameritasgroup.com
Aac Group
PO Box 427
Columbia, SC 29202
Customer Service
1-800-433-3036
www.aacgroupinsurance.com
Allstate Benets
1776 American Heritage Life Drive
Jacksonville, Florida 32224
For questions concerning your policy please call:
1-800-521-3535
For questions concerning your claim please call:
1-800-348-4489
or e-mail claimsresearch@allstate.com

71

American United Life (AUL)/OneAmerica

Claims Toll-Free Number
1-866-258-8744
Customer Service
1-800-553-5318
Boston Mutual Life Insurance Company
120 Royall Street Canton, MA 02021
1-800- 669-2668
1-781- 828-7000
www.bostonmutual.com
Reliance Standard Term Life
1-800-351-7500
Claims
1-800-351-7500 x.4149
Pitt County Schools Benets Department
1-252-830-4213
Mark III Brokerage
211 Greenwich Rd
Charlotte, NC 28211
1-800-532-1044
www.markiiibrokerage.com/pcsnc

72