Group Administration Manual
Welcome To
Greater Georgia Life Insurance Company
THANK YOU
... for selecting Greater Georgia Life Insurance Company to provide benefits for your employees.
We at Greater Georgia Life Insurance Company want to make the administration of your plan a successful experience. This
manual has been designed to supplement the personal attention you will receive from your Personal Service
Representative.
This manual is not a part of the policy and should not be viewed as such. The coverage provided under this plan is
governed at all times by the terms of your policy, and you should refer to your Group Insurance Policy and Certificate for
rate amounts and plan provisions.
You have selected Greater Georgia Life Insurance Company to provide benefits for your most important asset ... your
employees. We are dedicated to that commitment.
TABLE OF CONTENTS
SECTION
DESCRIPTION
PAGE
Section A.
CONTACT INFORMATION
3
Section
B.
BILLING
-
General
Information
4
Section C.
SAMPLE GROUP BILLING STATEMENT
5
Section
D.
ELIGIBILITY
16
D1. New Enrollments D2. Late Enrollees
D3. Changes
D4. Employee Terminations D5. Conversions
Section E.
TERMINATING THE GROUP POLICY
22
Section
F.
LIFE
CLAIMS
23
F1. Life and Dependent Claims F2. Beneficiary Designations
F3. Accidental Death and Dismemberment Claims F4. Accelerated Death Benefit Claims
F5. Waiver of Premium Claims
Section G.
SHORT TERM AND LONG TERM DISABILITY CLAIMS
27
G1. Short Term Disability Claims G2. Long Term Disability Claims
Section H.
FORMS
30
H1. Member Enrollment Forms H2. Member Change Forms H3. Claim Forms
Section A. CONTACT INFORMATION
LIFE and AD&D CLAIMS
Topic: Phone: Fax:
Claims - Customer Service, Life and AD&D Claims,Absolute Assignment, Waiver of Premium (800) 552 - 2137 ((770) 438 - 9712 Mailing Address: Greater Georgia Life Insurance Company - Life Claims Service Center
P.O. Box 724767, Atlanta, GA 31139 -1767
SHORT TERM and LONG TERM DISABILITY CLAIMS
Topic: Phone: Fax:
Claims - Customer Service (800) 232 - 0113 (770) 801- 9393(800) 850-0017 Mailing Address: Greater Georgia Life Insurance Company – Disability Service Center
P.O. Box 723058, Atlanta, GA 31139 - 0058
MEMBERSHIP, BILLING and GENERAL LIFE & DISABILITY QUESTIONS
Topic: Phone: Fax:
Membership/Billing (678) 443 - 5200OR (800) 851 - 8544
(678) 443 - 5299
Mailing Address: Greater Georgia Life Insurance Company P.O. Box 4445 Atlanta, GA 30302 – 4445
Payment Address: Greater Georgia Life Insurance Company P.O. Box 281487 Atlanta, GA 30384 - 1487
Section B. BILLING - General Information
B1.
What is included on the group bill?
The group billing statement provides the total amount due for all Greater Georgia Life Insurance Company (GGL) coverages included in your policy.
B2.
When will I receive the bill?
Approximately ten days before each billing due date, you will receive a group billing statement that identifies the total amount due.
B3.
When is payment due?
Payment is due on the first day of the billing period, which for customers billed monthly would be the first of each month. For example, the premium for March 1 to April 1 billing period is due on March 1. If premium is not received prior to the expiration of your grace period (31 days), your policy will lapse.
B4.
What do I return with the payment?
Along with your remittance check made payable to Greater Georgia Life, you should include a copy of the group billing statement. All enrollment application and change request forms should be mailed to the billing address in Section A – Membership.
B5.
How are new enrollments and changes reflected on the bill?
A signed enrollment application form or an enrollment change form is necessary to ensure proper coverage for your members. These forms may be submitted at any time during the month and should be mailed to the address shown in Section A - Membership. GGL’s membership and billing department will review and determine the eligibility of new enrollments and change requests. Approved membership changes processed between billing periods will be recapped in the Eligibility Adjustments section of your bill. Check your statement carefully to ensure all eligible employees are included on the statement and that benefits are correct.
B6.
What is the “Total Amount Due”?
Your monthly premium payment should always equal the “Total Amount Due” as shown on your group billing statement. There is no need to adjust or recalculate your monthly bill. Any adjustments due to eligibility changes to the “Total Amount Due” will be made on a future billing statement.
B7.
Whom do I call for help?
Your billing statement will include the name of the Personal Service Representative assigned to your group. Your assigned representative can be contacted at 1-800-851-8544 and is available to answer any questions you may have regarding your membership records or your group billing statement.
For specific claim related questions, please contact either the Life Claims Service Center or the Disability Service Center by using the numbers provided in Section A - Contact Information.
Section
C. SAMPLE GROUP BILLING STATEMENT
C1. Overview
The group billing statement includes the following three (3) sections:
• Cover Page
• Product Summary
• Billing Detail
- Eligibility Adjustments - Manual Adjustment Detail - Membership Detail
C2. Cover
Page
The Cover Page is a summary of all of the billing and payment activity that has occurred since your last month’s billing statement. It gives pertinent information regarding the following:
- your prior billed and paid amounts
- a premium subtotal of any eligibility adjustments submitted and processed since your last bill
- a premium subtotal of any manual adjustments made since your last bill
- a premium subtotal of all membership for the current billing period
- a total amount due for the bill
The Cover Page is designed to be folded in half and placed in the remittance window envelope and returned along with your premium payment. To help us identify the payment when returned, your group name, bill entity number, billing period, and due date are displayed on this page.
C3.
Product Summary Page
The Product Summary page displays the contract count totals for all product types, the current month’s charges, current volume, any retroactive adjustments and the rate for each product. This provides you with a detailed breakdown of the total amount due for each product.
C4. Billing
Detail
(a) Eligibility AdjustmentsThis section recaps the eligibility changes that were received and processed since the last billing statement was prepared, and details retroactive premium charges and credits. We recommend that you check this section carefully each month to ensure that all eligibility changes you requested were processed accurately. However, remember that new enrollments and eligibility changes received after the 5th of the month will most likely be reflected on your next billing statement.
(b) Manual Adjustment Detail
This section identifies any manual adjustment that was made to your Total Amount Due. A reason and a brief description of the adjustment are provided, along with the amount of the adjustment
.
(c) Membership Detail
The Membership Detail section lists all of the subscribers enrolled on your group coverage for the current billing period. This listing is usually in alphabetical order by the subscriber’s last name.
User's Guide to the Group Billing Statement
The following pages provide a field-by-field explanation of the group billing statement. It will help you read and understand your monthly statement.
USER'S GUIDE TO THE GROUP BILLING STATEMENT
Section C2: COVER PAGE
TOP HALF - This section provides a recap of the prior and current month’s billing amounts/totals.
Ref Field Name Description
1 Prior Bill Amount The total amount due for the previous billing.
2 Amount Paid The total premium payment applied toward the prior month’s billing.
3 Prior Balance Due Premium discrepancy amount (debit or credit) after last month’s billing was reconciled.
4 Eligibility Adjustment Subtotal
This amount represents the “net total” (debit or credit) for all retroactive membership changes processed after the last month’s billing was prepared.
5 Manual Adjustment
Subtotal An amount will only appear here if a manual adjustment is processed (e.g., reinstatement fees)
6 Membership Detail
Subtotal This amount represents the “net premium total” for the "current billing period only".
7 Total Amount Due The sum of the prior balance due, eligibility adjustment, manual adjustment and the membership detail.
LOWER HALF - This section includes pertinent address and billing information.
When mailing your payment, it is important to write the amount of your check in the field “Enter Amount Paid”. (Field 14)
Ref Field Name Description
8 Group Information The group’s name and billing address.
9 Bill Entity No. The primary group number that consolidates all suffixes under one group number for billing purposes.
10 Invoice Number A unique invoice number will appear on your group billing statement each time a bill is issued for your group.
11 Billing Period The period of time for which you are being billed.
12 Date Billed The calendar date that your billing was generated.
13 Total Due The total premium due.
14 Enter Amount Paid The amount that you are remitting to GGL.
15 GGL Address Greater Georgia Life’s remittance address.
16 Sys For internal use only.
17 Desk For internal use only.
18 Bill Entity The primary group number that consolidates all suffixes under one group number for billing purposes.
19 MBS Number For internal use only.
20 Due Date The date by which your premium payment should be received by Greater Georgia Life.
USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued)
COVER PAGE
Invoice Number 000001628A Billing Entity No. GAA042C001
1 Prior Bill Amount $ 442.42
2 Amount Paid 442.42
3 Prior Balance Due $ 0.00
4 Eligibility Adjustment Subtotal 0.00
5 Manual Adjustment Subtotal 0.00
6 Membership Detail Subtotal 298.20
7 Total Amount Due $ 298.20
Please Return this Page With Your Check
---
Please Fold Here for Mailing
GREATER GEORGIA LIFE P.O. BOX 281487
ATLANTA, GA 30384-1487
8 FAMILY TREE ENTERPRISES 9 Bill Entity No.: GAA042C001 21555 OXNARD ST.
WOODLAND, GA 30612 10 Invoice Number: 000001628A
11 Billing Period: 04-01-03 To 05-01-03
12 Date Billed: 03-16-03
13 Total Due: $298.20
14 Enter Amount Paid __ , __ __ __ , __ __ __ . __ __
15
Make Check Payable To:………GREATER GEORGIA LIFE
P.O. BOX 281487
ATLANTA, GA 30384-1487
16 17 18 19 20
BILL MBS
SYS DESK ENTITY NUMBER Due Date 2 9007 GAA042C001 LSG00000 04-01-03 5812
USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued)
Section C3: PRODUCT SUMMARY
The Product Summary section provides a detailed breakdown of the total amount due for each group/product. It displays the contract counts for all contract types, the current month’s charges, current volume, any retroactive adjustments and the rate for each product. This gives you the opportunity to quickly determine the monthly charge for each of your products.
Ref Field Name Description
1 Billing Entity Name The group’s name.
2 Billing Entity No. The primary group number that consolidates all suffixes under one group number for billing purposes.
3 Invoice No. A unique invoice number will appear on your group billing statement each time a bill is issued for your group.
4 Page No. The page number of the bill.
5 Group Contact The first and last name of the person that Greater Georgia Life contacts when billing or reconcilement issues need to be resolved.
6 Personal Service
Representative The name of the personal service representative assigned to administer your account.
7 Desk No. The desk number of the personal service representative (this is not an extension number).
8 Telephone The phone number of the personal service representative.
9 Billing Period The period of time for which you are being billed.
10 Date Billed The calendar date that your billing was generated.
11 Payment Due Date The date your premium payment is to be received by Greater Georgia Life.
12 Group/Product
Contract Type Your group numbers/product names with the appropriate contract type codes within each product.
13 Current Count The subscriber counts within each contract type.
14 Current Volume Current total volume for all products billed.
15 Billing Charges The premium charges being billed, by contract type, for the “current month” only.
16 Retro The premium charges being billed, by contract type, for “retroactive changes”only.
17 Total The total of all current month’s premium plus retroactive amounts being billed.
18 Rate The rate for your group will be displayed by group suffix for each contract type.
19 Total The total for each group suffix, by the number of subscribers, current month charges, retroactive charges and the total premium due.
20 Subtotal/All Products The subtotal for all products.
21 Legend Description of all contract types.
Note:The subtotal shown for current billing charges will also appear by the membership detail subtotal on the cover page. The subtotal shown for retroactive charges also appears by the eligibility adjustment subtotal on the cover page.
USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued)
PRODUCT SUMMARY
1 Billing Entity Name: FAMILY TREE ENTERPRISES 3 Invoice No.: 00001628A
2 Billing Entity No.: GAA042C001 4 Page No.: 1
5 Group Contact: FRANCES JONES
6 Personal Service Representative: SALLY SMITH 7 Desk No.: 9007 8 Telephone: (800) 851-8544
9 Billing Period: FROM 04-01-03 TO 05-01-03
10 Date Billed: 03-16-03
11 Payment Due Date: 04-01-03
12 13 14 15 16 17 18
Group/Product Current Current Billing
Contract Type Count Volume Charges Retro Total Rate
GAA042B001 AD&D - ACTIVE
OFFERED BY GREATER GEORGIA LIFE
LSUB 5 150,000 7.50 0.00 7.50 0.050***
19 Total 5 150,000 7.50 0.00 7.50
GAA0042C001 BASIC LIFE TERM - ACTIVE
OFFERED BY GREATER GEORGIA LIFE
LSUB 1 30,000 7.80 0.00 7.80 0.260***
19 Total 1 30,000 7.80 0.00 7.80
GAA042F001 LIFE WITH DEP - ACTIVE
OFFERED BY GREATER GEORGIA LIFE
LSUB 4 120,000 31.20 0.00 31.20 0.260***
LDEP 6.80 0.00 6.80 1.700****
19 Total 4 120,000 38.00 0.00 38.00
GAA042L001 LONG TERM DISABILITY - ACTIVE
OFFERED BY GREATER GEORGIA LIFE
00 – 24 0.00 0.00 0.00 0.550** 25 – 29 1 900 7.02 0.00 7.02 0.780** 30 – 34 0.00 0.00 0.00 1.070** 35 – 39 0.00 0.00 0.00 1.500** 40 – 44 3 7,300 153.30 0.00 153.30 2.100** 45 – 49 1 1,100 32.78 0.00 32.78 2.980** 50 – 54 0.00 0.00 0.00 4.030** 55 – 59 0.00 0.00 0.00 4.780** 60 – 64 0.00 0.00 0.00 4.780** 65 – 69 0.00 0.00 0.00 4.780** 70 – 99 0.00 0.00 0.00 4.780**
GAA042W001 SHORT TERM DISABILITY - ACTIVE
OFFERED BY GREATER GEORGIA LIFE
LSUB 5 1,480 51.80 0.00 51.80 0.35*
19 Total 5 1,480 51.80 0.00 51.80
20 Subtotal/ALL Products 310,780 298.20 0.00 298.20 * Rate per $10
USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued)
Section C3: PRODUCT SUMMARY
21 LEGEND
S = SUBSCRIBER ONLY 2P = TWO PARTY CONTRACT FAM = FAMILY CONTRACT DEP = ONE DEPENDENT
DEPS =TWO OR MORE DEPENDENTS
S+DEP = SUBSCRIBER + 1 DEPENDENT (NO SPOUSE)
S+DEPS = SUBSCRIBER + 2 OR MORE DEPENDENTS (NO SPOUSE) LSUB = LIFE SUBSCRIBER
LSPS = LIFE SPOUSE LCHD = LIFE CHILD
USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued)
CALCULATING PREMIUM
To calculate the premium due for a particular coverage, please follow the formulas provided below. Please refer to your insurance contract to determine the coverage amounts for your employees.
SHORT TERM DISABILITY (*)
The cost of weekly income (or short term disability) insurance is calculated based on the actual benefit provided to the employee if that employee becomes disabled. Rates are per $10 of benefit.
Use the formula below to calculate the cost of WI/STD coverage. BENEFIT AMOUNT X RATE = PREMIUM
$10
EXAMPLE: (STD coverage for John Smith)
According to the contract under which he is covered, John's benefit amount will be 60% of his weekly earnings.
The maximum benefit allowed under this group plan is $250. 60% of John's weekly earnings : $285.09
Maximum Benefit Amount: $250
Cost of John's coverage:
250.00 = 25.00 x .44 = $11.00 10
LONG TERM DISABILITY INSURANCE (**)
Traditional LTD rates are based on a per $100 of monthly covered payroll. However, the payroll rate must be converted to a monthly covered benefit rate and premium is calculated based on monthly benefit.
Payroll rate .38 = .633 (benefit rate) Benefit percentage .60
Use this formula to calculate the cost of LTD coverage: MONTHLY BENEFIT X RATE = PREMIUM
$100
EXAMPLE: (LTD insurance for Julie Johnson)
According to the group contract, this plan will cover a 60% maximum per member's monthly benefit of $5,000 and has a rate of $.38 of monthly covered payroll.
Julie's monthly earnings: $3,012 x .60 = 1,807.20 (Julie's benefits)
Cost of Julie's coverage:
1,807.20 = 18.07 x .633 = $11.44 100
** This applies to LTD coverage that was effective prior to June 1,2003. If you have any questions on your LTD premium calculation, please contact your personal service representative.
BASIC LIFE/AD&D INSURANCE (***)
Life and AD&D rates are per $1,000 of coverage, so premium should be calculated based on the actual benefit amounts provided to each employee. Use the formula listed below to calculate the cost:
BENEFIT AMOUNT X RATE = PREMIUM $1,000
EXAMPLE: (Life insurance for John Smith) 25,000 = 25.00 x .55 = $13.75 1,000
EXAMPLE: (AD&D insurance for John Smith) 25,000 = 25.00 x .05 = $1.25 1,000
DEPENDENT LIFE INSURANCE (****)
Dependent life insurance rates are per family unit.
The same rate is charged per family regardless of the actual number of dependents covered.
Use the formula below to calculate the cost of dependent life insurance:
FAMILY UNIT X RATE = PREMIUM
EXAMPLE: (Dependent life insurance for John and Sarah Smith and children)
USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued)
Section C4: BILLING DETAIL
a) ELIGIBILITY ADJUSTMENTS
This section of the billing recaps all eligibility changes that were received and processed after the last billing statement was prepared. This section also details all “retroactive premium charges.”
Ref Field Name Description
1 Cert. No. Subscriber’s certificate number (generally the employee’s social security number).
2 Subscriber Name The name of the subscriber.
3 Dept. No. Employee department number if group requests.
4 Group No. Each of the group numbers that were impacted by the subscriber’s eligibility changes.
5 Prod Type Each of the product types that were impacted by the subscriber’s eligibility changes.
6 Cont. Type The new contract code resulting from the membership change.
7 No Cvd. Number of members covered.
8 From Date The “ from” date of the change*.
9 To Date The “ to” date of the change*.
10 Mo/Da Indicates the number of months/days affected by the adjustment change. Zeros will be displayed for all changes made during the current billing period.
11 Calc. Rate The rate amount used to calculate retroactive premium (calculation rate) x (number of months/days).
12 Prem. Adj. Premium adjustments resulting from the membership change. The premium adjustment for changes processed as of the current billing period will display with zeros due. Premium amounts for the current billing period are shown in the “ membership detail” section. Premium adjustment amounts shown here represents “ retroactive premiums” only.
13 Code Short description of the membership change processed (See General Terms).
14 Eligibility Adjustment
Subtotal The net subtotal of the eligibility adjustments.
We recommend that you audit this section of the billing each month to ensure that all eligibility changes requested were processed accurately.
* If the change is effective as of the current billing period, the " from" and "to" dates will be the same. If the change is effective retroactive to the current billing period, the effective date will be displayed in the "from date" column.
b) MANUAL ADJUSTMENT DETAIL
This section identifies any manual adjustment that had to be made to your “Total Amount Due.” A reason and a brief description of the adjustment are provided, along with the amount of the adjustment.
Ref Field Name Description
15 Grp/Suf The group number to which the adjustment has been made.
16 Reason The reason for the adjustment.
17 Description A brief explanation of the adjustment.
18 From Date The “from” date of the change.
19 To Date The “to” date of the change.
20 Amount The dollar amount of the adjustment.
USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued)
BILLING DETAIL
Billing Entity Name: FAMILY TREE ENTERPRISES Invoice No.: 00001628A Billing Entity No.: GAA042C001 Page No.: 2
Group Contact: FRANCES JONES
Premium Specialist: SALLY SMITH Desk No.: 9007 Telephone: (800) 851-8544 Billing Period: FROM 04-01-03 TO 05-01-03
Date Billed: 03-16-03 Payment Due Date: 04-01-03
ELIGIBILITY ADJUSTMENTS *
*Eligibility changes received after the 5th of the month may be reflected on your next bill.
1
2
3 4 5 6 7 8 9 10 11 12 13
Dept Group Prod Cont No. From To Mo/ Calc Prem
Cert No. Subscriber Name No. No. Type Type Cvd Date Date Da Rate Adj Code
14
Eligibility Adjustment SubtotalMANUAL ADJUSTMENT DETAIL
15
16
17
18
19
20
GRP/SUF Reason Description From Date To Date Amount
USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued)
c) MEMBERSHIP DETAIL
This section of the group billing statement lists all of your subscribers who are enrolled for the billing period in your group plan.
Ref Field Name Description
1 Cert. No. Subscriber’s certificate number (generally the employee’s social security number).
2 Dept. No. This area will remain blank unless your organization utilizes department numbers for billing purposes.
3 Emp. No. This area will remain blank unless your organization utilizes employee numbers for billing purposes.
4 Subscriber
Name The name of the subscriber.
5 COBRA End
Date Does not apply to Life benefits.
6 Group No.
/Suffix The group number(s) in which the subscriber is enrolled.
7 Grp Type Group type associated with the group the subscriber is enrolled in (e.g. A=Active)
8 Prod Type A brief description of the benefit associated with each group suffix. Refer to the General Terms section for a complete list.
9 Cont Type Current contract type for each subscriber (i.e., S=Subscriber Only, FAM=Family)
10 No. Cvd Total number of members currently covered on the subscriber’s contract.
11 Volume Product volume per subscriber.
12 Prem. Amt. Premium amount due for the current billing period for each subscriber.
13 Total
Subscribers The total number of subscribers.
14 Volume Total The total volume for subscriber products for your group for the current billing period.
15 Membership
Detail Subtotal The premium sub total amount due for the current billing period.
16 Total Amount
USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued)
BILLING DETAIL
Billing Entity Name: FAMILY TREE ENTERPRISES Invoice No.: 00001628A Billing Entity No.: GAA042C001 Page No.: 2
Group Contact: FRANCES JONES
Premium Specialist: SALLY SMITH Desk No.: 9007 Telephone: (800) 851-8544 Billing Period: FROM 04-01-03 TO 05-01-03
Date Billed: 03-16-03 Payment Due Date: 04-01-03
MEMBERSHIP DETAIL
1
2
3
4
5
6
7
8
9
10
11
12
Dept Emp. COBRA Group No. Grp Prod Cont No. Prem.
Cert No. No. No. Subscriber Name End Date / Suffix Type Type Type Cvd Volume Amt.
123456780 ATON, VIVIAN GAA042B001 A ADD LSUB 30,000 1.50
GAA042F001 A LDEP LSUB 30,000 7.80
GAA042F001 A LDEP LDEP 1.70
GAA042L001 A LTD 40 - 44 5,000 105.00 GAA042W001 A STD LSUB 500 17.50
123456781 ANNT, XAVIER GAA042B001 A ADD LSUB 30,000 1.50
GAA042F001 A LDEP LSUB 30,000 7.80
GAA042F001 A LDEP LDEP 1.70
GAA042L001 A LTD 40 - 44 1,100 23.10
GAA042W001 A STD LSUB 250 8.75
123456782 HOOVER, YVONNE GAA042B001 A ADD LSUB 30,000 1.50
GAA042C001 A LBAS LSUB 30,000 7.80
GAA042L001 A LTD 25 - 29 900 7.02 GAA042W001 A STD LSUB 200 7.00
123456783 MMEL, ZEEK GAA042B001 A ADD LSUB 30,000 1.50
GAA042F001 A LDEP LSUB 30,000 7.80
GAA042F001 A LDEP LDEP 1.70
GAA042L001 A LTD 40 - 44 1,200 25.20 GAA042W001 A STD LSUB 280 9.80
123456784 SMITH, JOE GAA042B001 A ADD LSUB 30,000 1.50
GAA042F001 A LDEP LSUB 30,000 7.80
GAA042F001 A LDEP LDEP 1.70
GAA042L001 A LTD 45 - 49 1,100 32.78 GAA042W001 A STD LSUB 250 8.75 14 Volume Total 310,780 13 Total Subscribers: 5 15 Membership Detail Subtotal 298.20
16 Total Amount Due 298.20
Section
D. ELIGIBILITY
D1. New Enrollments
(a) Who is eligible to enrollTo obtain coverage under your group policy, an employee must meet the eligibility requirements as defined in your policy, reach an eligibility effective date as designated by the group policy probation period, and enroll by completing a Group Insurance Application or Member Enrollment Application Form.
General eligibility requirements for coverage under your group policy include (actual eligibility provisions may vary - please refer to your group policy for details):
Employees
a. Must be full-time active employees working 30 hours or more per week. b. Must have completed the required probationary period.
Dependents (Applicable to Life Only)
a. Employee must complete the required probationary period.
b. Must be a dependent of a member employee who has elected dependent coverage. Dependents include:
- Legal spouse (only one spouse may be enrolled at one time) under the age AND not legally separated from the employee.
- Unmarried children who are financially dependent upon the employee for support. Children are considered financially dependent if they qualify as dependents for Federal Income Tax purposes
- Unmarried children who meet all the other unmarried children criteria AND who are enrolled as full-time students at an accredited secondary school, college or university. Please refer to your group policy for specifics pertaining to your group.
- Age restrictions apply. Please see your policy for details. Notes:
1) An unmarried child may include the employee’s natural child, stepchild, legally adopted child, and a child under custody pursuant to a court order or legal guardianship. (Note: Copies of the court documents are required.)
2) The term “dependent” does NOT include any person who: - is eligible as an employee
- is a member of the armed forces of any country
- is residing outside the United States and Canada
(b) Employees who do not wish to enroll
If an employee declines coverage, an application marked "refused" or the "Life/Disability Coverage Waiver Authorization Form" needs to be completed. This is necessary to document that the employee was given an opportunity to enroll through the group plan, but elected not to do so at that time. An employee who declines coverage when first eligible or who does not elect coverage for his eligible family members during the initial eligibility period may apply at a later date, but will be subject to medical underwriting. Refer to Section D2 -Late Enrollees for more information.
Section D: ELIGIBILITY (continued)
(c) When may employees enrollEligible employees may apply for coverage as a new hire within 31 days of employment or within 31 days of any group's specific employee probationary period. If an employee does not enroll for coverage by completing the enrollment application form within 31 days from his or her eligibility date, the employee and dependents become late enrollees and are subject to medical underwriting. Refer to Section D2 - Late Enrollees for more information.
(d) How to enroll new employees
Eligible employees may enroll by completing the Group Insurance Application or Member Enrollment Application Form. These forms are created to clearly convey information between you and GGL and it's parent and affiliates.
Please take a moment to review and verify that all items have been completed accurately. Errors or missing information could cause a delay in processing and the application being returned.
Important points to help your employees enroll:
• New employees should complete enrollment forms when hired.
Applications must be submitted within 31 days from an employee’s eligibility date, or the employee will be required to apply for coverage as a late enrollee. Having the form completed when the employee is hired will help in meeting the 31-day timeliness requirement in the event that you or the applicant are away from the office when eligibility occurs.
• Be sure that each employee indicates the exact coverage(s) desired.
This is especially important when dependent term life insurance is desired. If the employee pays any portion of the premium for dependent term life insurance, the box for dependent term life insurance must be checked. If the box is not checked, the dependent life coverage will not be effective.
• Each member must name a primary beneficiary.
(1) A primary beneficiary is the person(s) who will receive the death benefit upon the death of the member. If more than one primary beneficiary is named, be sure to indicate the percentage each person is to receive. If percentages are not indicated, the proceeds will be divided equally.
(2) If no beneficiary is named or surviving at the member’s death, benefits will be paid to the member’s estate.
(3) When designating children as beneficiaries, note that we cannot make payment to children under the age of 18. If the beneficiary is under 18, we will pay benefits to a court appointed guardian of property (conservator).
(4) Use the full first and last name of the beneficiary; do not use initials only for the first name. (5) A member cannot name his/her employer as their beneficiary.
(6) A member cannot name himself as beneficiary. However, a member can name his estate or a trust. When naming a trust as beneficiary, we will need both the name and date of the trust.
Section D. ELIGIBILITY (continued)
(e) Effective date of coverageIf an employee applies for coverage when first eligible, the effective date of coverage will be as stipulated in accordance with the “Eligibility” section of the Group Term Life Insurance Master Application.
Example 1:
Assume that your Group Term Life Insurance Master Application provides that employees and their dependents become eligible for coverage on the first day of the month following 30 days of employment. Here is how coverage would begin for a new employee hired on August 15:
1. Date of hire 08/15
2. Date probationary period is completed (Hire date plus 09/14 term of probationary period as shown in the Group
Policy)
3. Date coverage begins (as specified in your Group 10/01 Policy)
4. First billing period for which premiums must be paid 10/01-10/31
Example 2:
Now let us see how coverage and the first premium payment would differ if the employee is hired on August 1 (rather than August 15):
1. Date of hire 08/01
2. Date probationary period is completed 08/31 3. Date coverage begins 09/01
Section D. ELIGIBILITY (continued)
D2. Late Enrollees
(a) Who is a late enrollee?Contributory Products (Employee and Employer Paid)
Late enrollment rules apply to employees who elected not to apply when first eligible or who did not enroll prior to the expiration of the enrollment probationary period.
Additionally, if an employee has existing coverage with GGL and initially declined dependent life coverage for dependents, but later elects to provide coverage for those dependents, a Member Enrollment Change Form and a Medical Questionnaire are required for the dependents.
Non-Contributory Products (Employer Paid)
Late enrollment rules do not apply. All employees should be enrolled during their initial eligibility period. Coverage will be effective as of the date first eligible.
(b) How to enroll late enrollees
Late enrollees may apply for coverage by completing the Group Insurance Application or the Member Enrollment Application and a Medical Questionnaire.
The Medical Questionnaire is a self-explanatory form with clear instructions. A copy has been enclosed in this manual. Information on the form should be verified by the employee and the group administrator for completeness and accuracy to prevent a delay in processing.
Our Underwriting department will review the application and medical questionnaire. For legal and audit purposes, please be sure the original forms are filled out in ink and are signed by the employee and spouse (if applying). The forms should be mailed immediately to the address in Section A – Membership. Please note that applications with signatures more than 60 days old will not be accepted. In some instances, additional medical information may be required. The originals of all questionnaires are to be submitted to GGL; duplicates or facsimiles cannot be accepted. If such health evidence is required, GGL will not be liable for any of the costs related to acquiring the additional documents.
It will take approximately 30 days to process the application and medical questionnaire. If approved, the effective date of coverage will be the first of the month following approval by our underwriting department.
D3. Changes
The Member Enrollment Change Form or Request for Change Form provides documentation that a member has made a change in beneficiary, dependent status (adding or deleting dependent life coverage) or a change in name. All of the appropriate sections of the form must be completed, signed and dated by the employee and must include the employee’s certificate number and group number(s).
Events that might occur after an employee is originally enrolled include the following: - Primary beneficiary dies
Submit change form to specify a new primary beneficiary; otherwise, benefits will be paid to the contingent beneficiary, if one was named; if no contingent beneficiary was designated, benefits will be paid to the member’s estate.
Section D. ELIGIBILITY (continued)
- Spouse or dependent loses eligibility (divorce, spouse or dependent’s death, dependent’s attainment of policy’s maximum age, dependent’s marriage, etc.)
Employee submits Member Enrollment Change Form within 31 days of the event for consideration. The effective date of the change will be the date of the event unless otherwise specified in your policy. Note that the loss of eligibility may also qualify the individual for a conversion policy. Refer to Section D6 - Conversions for more information.
- Employee wishes to add a new spouse (marriage or change in employment status of spouse.)
A Member Enrollment Change Form must be received within 31 days of the event; the coverage effective date will be the first of the month following the event. If not received within 31 days of the event, a Medical Questionnaire will also be required; the effective date of coverage will be the first of the month following medical underwriting approval.
- Employee wishes to assign benefits
An employee may request an assignment of benefits by submitting an Absolute Assignment of Group Life Insurance Form to GGL (form available from the Life Claims Service Center ). The request must be approved by GGL to be a valid assignment under the policy. To be valid, an assignment must also be absolute and irrevocable. GGL assumes no liability for its sufficiency.
D4. Retroactivity
Retroactivity is generally defined as any change affecting additions or terminations of a member or members with an effective date prior to the date received by GGL. The processing of all retroactive changes is solely at the discretion of GGL, and the following guidelines are in place:
Non-Contributory Products: Retroactive terminations and changes will be processed for effective dates up to six months prior to GGL receipt. Retroactive additions will be added back to the date first eligible.
Contributory Products: Retroactive terminations and changes that reduce benefits will be processed for effective dates up to 90 days prior to GGL receipt for billing purposes.
Additions and changes that increase benefits must be applied for within 31 days of becoming eligible. Premium will be billed from the date first eligible.
Additions and changes that increase benefits that are not applied for within 31 days of becoming eligible will require the submission of a medical questionnaire and will not be effective until the first of the month following underwriting approval.
Requests for effective dates other than what would be provided using the above guidelines must be approved by the Underwriting Department.
Section D. ELIGIBILITY (continued)
D5. Employee
Terminations
Written notification should be received by GGL when loss of eligibility occurs. Written notification may be provided on your group billing statement, a change form, or letter. This information should be provided as soon as the termination occurs and include the term effective date.
If termination is due to death of an employee, please write “deceased” next to the employee’s name along with the date of death.
D6. Conversions
Eligible employees or spouses may apply, without evidence of insurability, for an individual policy of life insurance when they have lost their eligibility to be covered under the group policy for the following reasons:
a. termination of the employee’s employment b. death of the employee
c. loss of eligibility in a class under this policy
Consult your group policy for additional reasons that may allow an eligible employee or spouse to apply for an individual policy. Note: Dependent children are not eligible for conversion.
The steps to follow if an eligible employee or eligible dependent wishes to exercise his of her conversion option: a. The employer must complete Section I of the Request for Group Life Conversion Information Form.
b. The employer forwards the request to the employee to complete Section II of the form and mail to the address at the bottom of the form.
c. The employee will then be sent an application for life conversion, along with the rates for a conversion policy. The employee completes the application and returns it, along with appropriate premium, to the address designated on the form.
NOTE: IN ORDER TO MEET THE CONVERSION PROVISIONS SET FORTH IN THE POLICY, THE COMPLETED CONVERSION APPLICATION AND APPROPRIATE PREMIUM MUST BE RECEIVED WITHIN 31 DAYS OF TERMINATION OF YOUR LIFE INSURANCE BENEFITS UNDER YOUR GROUP INSURANCE POLICY.
Section E. TERMINATING THE GROUP POLICY
Termination of a group from GGL coverage can be initiated by a request from the group or by GGL. If the group requests cancellation of its policy, a letter signed by an authorized representative of the company is required. The letter must include the requested cancellation date and be received at least 30 days prior to the next premium due date. Your group policy will clearly outline all of the above in detail.
Example:
Next premium due date 06-01-2003 Letter must be received by GGL or
the group must receive GGL's notice of termination no later than 05-01-2003 Cancellation of the group occurs on 06-01-2003
If no written notice is given, the policy renews under the same terms and conditions.
If premium due for a group is not paid before the end of the grace period, GGL will cancel that policy as of the paid to date of the policy.
Section F.
LIFE
CLAIMS
Life claims are processed by a claims unit that specializes in the administration and payment of life related claims. Please submit all Life, AD&D, Waiver of Premium, and Accelerated Death claims to the Life Claims Service Center. Our goal is to process all life claims with complete information within 5 - 7 days of receipt.
For specific details regarding the benefits provided by your policy, please refer to the benefit provisions of your policy.
Life Claims Contact Information
Topic:
Phone:
Fax:
Claims - Customer Service (800) 552 - 2137 (770) 438 - 9712 Mailing Address: Life Claims Service Center P.O. Box 724767 Atlanta, GA 31139-1767
Claims Submissions
F1. Life and Dependent Claims
Life Claims require the following: • Beneficiary Claim Form• Certified copy of death certificate
• Enrollment Form
• Any change of beneficiary designation, if applicable
F2. Beneficiary Designations
In the event of a claim, the Group Administrator is responsible for providing copies of the enrollment form (with beneficiary information) plus any other beneficiary designation forms that the member completed.
Valid beneficiary designations should include a name, social security number, relationship to member and birth date. In addition, the form must be signed and dated by the member. Multiple beneficiaries may be named on the same form. If percentages are not filled in, equal shares will be assumed. Primary and secondary beneficiaries may also be named on the form. If the primary beneficiary is not living at the time of the member's death, the secondary beneficiary will receive the benefit.
If no beneficiary is living at time of death, or none is named, the benefit will be paid as shown in the certificate booklet. Standard wording would be..."Benefits are payable to the executor or administrator of the estate. If there is no executor or administrator, we may at our option:
- (a) pay benefit to the spouse if living; or
- (b) if there is no living spouse, pay equal shares of the benefit to your children if living; or - (c) if there are no living children, pay the benefit in equal shares to the direct parents if living." It is important to review the wording in the certificate booklet that applies to your benefits.
ABSOLUTE ASSIGNMENT BENEFICIARY DESIGNATIONS are a special type of beneficiary designation that can ONLY be changed if the new owner agrees to the change. They change the ownership of the group life benefit. They are often done for estate planning, taxation issues, and for viatical arrangements. Forms are available from the Life Claims Service Center.
Refer to Section A - Contact Information for more information.
F3. Accidental Death & Dismemberment (AD&D) Claims
(a) Accidental Death Claims require the following:• Beneficiary Claim Form
• Certified copy of death certificate
• Enrollment form
• Any change of beneficiary designation if applicable
• Newspaper clipping and/or police report
• Employer provides payroll records for last period worked AD&D includes the following benefits in addition to life insurance:
Accidental Death - Benefit paid if death is by accidental means. Usually, the benefit equals the life benefit.
Dismemberment - Benefit paid due to loss of limbs or vision in the event of an accident.
Seatbelt - Additional benefit of 10% of face amount or $25,000 (whichever is less), if accidental death was caused while using an unaltered seat belt.
Repatriation - Pays up to an additional $5,000 to return remains of member to a mortuary, if accidental death occurred more than 100 miles from primary residence.
Education Benefit - Pays an additional benefit in four equal installments of $3,000 to a maximum of $12,000 for the education of the child of the deceased.
F4. Accelerated Death Benefit (ADB) Claims
ADB may be included with the Basic Life. It is not available for AD&D or Dependent Life coverages. This benefit is also referred to as Living Life Benefit (LLB).
This provision offers up to 50% of the life benefit when an active member becomes terminally ill* and life expectancy is 12 months or less. Employees can request for less than the maximum, but only one payment will be made during the member's lifetime.
*Refer to contract wording for specific definition.
(a) Typical steps for an ADB claim:
1. Claim forms completed by group, member and physician: a) "Claim for Personal Accelerated Death Benefit"
b) "Accelerated Death Benefit Attending Physician's Statement" 2. Employer provides payroll records for last period worked
3. Submit claim forms to Life Claims Service Center 4. Life Claims Service Center reviews
5. If approved, Life Claims Service Center pays ADB benefit to member
6. Employer should reduce the life benefit by the ADB amount paid (reducing monthly cost to employer) 7. Member may file for waiver of premium benefit on remaining benefit, if not already completed. Refer to Section F5 - Waiver of Premium Claims for more information.
8. Upon death of member, group files death claim
a) Employer provides payroll records for last period worked b) Life Claims Service Center pays remaining amount to beneficiary c) Employer terminates member from billing statement
F5. Waiver of Premium Claims
Waiver of Premium (also referred to as "W of P", "Total and Permanent Disability" or "TPD") (WAIVER) is a standard provision of group basic and supplemental life policies throughout the industry. It is not available for AD&D or for dependent life.
A member may qualify for WAIVER if he/she becomes totally disabled* before age 60 (65 in certain contracts), and is continuously totally disabled for 6 months. If WAIVER is approved, life coverage remains in force, without premium payments, assuming continuous total disability. Approvals are usually for one year with re-certification required annually.
*If a member was totally disabled and under age 60 when coverage terminated, and dies within the first 12 months of continuous total disability, a death benefit may be payable even if premium payments ended. Proof of total disability would be required with the death claim.
(a) Waiver of Premium Claims require the following: • "Disability Claim" form
• "Application for Group Life Insurance Disability Benefits" form
• "Attending Physician's Statement" form
• Employer provides payroll records for last period worked Refer to Section H - Claim Forms for a list of forms.
(b) How to apply for waiver:
To apply for WAIVER, the group and member must complete the "Disability Claim" form. The doctor must complete the "Application for Group Life Insurance Disability Benefits" and the "Attending Physician's Statement" form. These forms should be completed no earlier than three months before the end of the WAIVER waiting period. Assuming a nine-month waiting period, proof can be submitted when the member has been continuously totally disabled six months but must be submitted prior to 12 months from the date disability commenced.
(c) When waiver is approved:
The member and group are notified of approval by letter. The "Re-certification for Waiver of Premium" form is sent with the member's letter that indicates the time frame in which to submit the re-certification assuming continuous total disability. We may request a copy of the Notice of Award for Social Security Disability benefits. Under certain conditions, we may also require an examination by our physician, at our expense, at reasonable intervals.
A member cannot be covered under WAIVER and a conversion policy simultaneously. If a member converted when group coverage terminated, the conversion policy must be returned when WAIVER is approved. Conversion premiums are then refunded.
(d) When waiver ends:
Waiver ceases when any of the following occur:
• The member is no longer totally disabled.
• Written proof of continuous disability is not provided when required.
• The member refuses an examination by our physician when required.
• The benefit schedule provides for a termination or reduction of benefits at a specific age or retirement. When WAIVER ceases, or coverage is reduced, the conversion privilege is applicable.
Section G.
STD & LTD CLAIMS
Short Term Disability claims are processed by a claims unit that specializes in disability benefits. For disability claim forms or questions related to disability claims, please contact the Disability Service Center by calling 1-800-232-0113, Monday through Friday, 8:00 a.m. to 5:00 p.m. EST.
G1. Short-Term Disability (STD) Claim
• Claims for weekly disability benefits should be filed using the "Short Term Disability Claim Form".
• You, as the employer, complete Section II. The employee should complete Section I and the attending doctor completes Section III. Mail or fax the completed claim form to the address below.
• All disability checks will be mailed directly to your member employee. Please contact the Disability Service Center to report the employee’s return to work date.
STD Claims Contact Information
Topic:
Phone:
Fax:
Claims - Customer Service (800) 232 - 0113 (770) 801-9393 (800) 850-0017 Mailing Address: Greater Georgia Life Insurance Company, Disability Service Center
P.O. Box 723058, Atlanta, GA 31139-0058
STD MEMBER CLAIM PROCESS OVERVIEW
The administration of Short Term Disability (STD) claims involves a comprehensive review of eligibility, medical information, job requirements and any corresponding functional limitations to determine whether or not a claimant is totally disabled under the provisions of the disability policy. The claim process begins with the completion of a three-part STD Claim Form, including data from the employee, the employer and the attending physician. Eligibility for benefits is confirmed by the policyholder's Benefit Representative who completes the employer's portion of the form. The claim should be submitted as soon as it becomes evident that the employee will be out of work in excess of the plan's initial elimination period. The claim form may be either faxed or mailed to GGL.
Upon receipt of all three parts of the completed claim form and any clinical information (if requested), the Disability Case Manager (DCM) is in a position to evaluate the claim. The DCM works closely with policyholder's Benefit Representatives to obtain physical job descriptions and evaluate any opportunities for modified or light duty work. A claim decision is made within three days of receipt of all required information. The Claim Form with clinical documentation and occupational requirements are taken into consideration when a claim is reviewed.
Section G: LONG TERM DISABILITY CLAIM (continued)
G2. Long Term Disability (LTD) Claim
Long Term Disability claims are processed by a claims unit that specializes in disability benefits. For disability claim forms or questions related to disability claims, please contact the Disability Service Center by calling 1-800-232-0113, Monday through Friday, 8:00 a.m. to 5:00 p.m. EST. Submit the following Long Term Disability forms approximately 30 days before the end of the benefit waiting period:
1. "Long Term Disability Employee's Disability Benefits Application"
The claimant must complete the Long Term Disability Employee's Disability Benefits application and have his/her physician(s) complete the "Long Term Disability Attending Physicians Statement Form". Send completed forms and items listed below to the Disability Service Center:
• Copy of awards from other sources of benefits: Social Security, Worker's Compensation, retirement, state disability, no-fault auto insurance and any other disability income.
• Proof of claimant's age. (Certified copy of the claimant's birth certificate)
• Give claimant additional "Attending Physician's Statement" forms for completion if claimant has more than one treating physician.
2. "Long Term Disability Employee Authorization For Release of Information"
The claimant must complete the Long Term Disability Employee Authorization Release of Information form.
3. "Long Term Disability Employer's Report of Claim"
The Employer should complete the Employer's Report of Claim in full and include the following:
• Job description (detailed duties, including physical requirements)
• Documentation of earnings in accordance with your plan description
• Workers Compensation information (copy of first report of accident and the decision, if any has been determined at this time).
4. "Long Term Disability Attending Physician's Statement"
The claimant must complete the Long Term Disability Employee's Disability Benefits application and have his/her physician(s) complete the "Long Term Disability Attending Physicians Statement Form". Send completed forms and items listed below to the Disability Service Center.
All forms must be completed to avoid undue delays in processing the claimant's request for benefits. Any questions about LTD claim filing procedures should be referred to:
LTD Claims Contact Information
Topic:
Phone:
Fax:
Claims - Customer Service (800) 232 - 0113 (770) 801-9393 (800) 850-0017 Mailing Address: Greater Georgia Life Insurance Company, Disability Service Center
Section G: LONG TERM DISABILITY CLAIM (continued)
LTD MEMBER CLAIM PROCESS OVERVIEW
The administration of Long Term Disability (LTD) claims involves a comprehensive review of eligibility, medical information, job requirements and any corresponding functional limitations to determine whether or not a claimant is Totally Disabled under the provisions of the disability Policy. The claim process begins with the completion of the employee’s, employer's and attending physician’s portion of the LTD claim forms. The claim forms should be completed as soon as it becomes evident that the employee’s illness or injury may exceed the Elimination Period under the LTD Policy.
Each LTD claim undergoes an extensive review process by several individuals. The Disability Case Manager (DCM) is the primary person responsible for the assessment of the claim and making the appropriate determination. All LTD claims go through an initial screening to determine if Vocational Rehabilitation may be a possibility or if Social Security Disability benefits should be immediately pursued. If this initial review does not indicate either option at that time, the claim is reviewed again periodically. Furthermore, certain diagnoses are required to be immediately referred for Social Security assistance and certain other diagnoses require a mandatory review by an R.N. Additionally, all behavioral health claims are reviewed by our staff Psychologist.
Once a claim is approved, LTD benefits are issued to the claimant on a monthly basis. The DCM continues to monitor each claim closely, requesting periodic updates as needed.
Section H. FORMS
H1.
MEMBER ENROLLMENT FORMS
(a) Group Insurance Application [82-M-A2] (b) Medical Questionnaire 0103 MQuest (1/03)] (c) Life/Disability Coverage Waiver Authorization Form
(d) Request for Group Life Conversion Information
H2.
MEMBER CHANGE FORMS
a) Request for Change Form [83-A-RC] b) Group Life & Disability Change of Beneficiary or Insured’s Name UN17G(GGL) 11/02
NOTE: IF YOUR GROUP HAS MEDICAL COVERAGE WITH BLUE CROSS BLUE SHIELD OF GEORGIA, COMBINED MEDICAL AND LIFE FORMS MAY BE USED FOR ENROLLMENT.
H3.
CLAIM FORMS
LIFE and AD&D
(a) Death Claim Forms [17568 Ed. 7/01]
1. Beneficiary Claim Form & Group Policyholder's Statement
(b) Accidental Dismemberment or Loss of Sight Forms [GA84 (7/03)] 1. Accidental Dismemberment or Loss of Sight Claim Form
2. Proof of Accidental Dismemberment Attending Physician's Statement
(c) Accelerated Death Benefit Forms
1. Claim for Personal Accelerated Death Benefit [GA6224 (7/03)] 2. Accelerated Death Benefit Attending Physician's Statement [GA6223 (297)]
(d) Continuation of Life Insurance Forms
1. Disability Claim Form [297-G (GGL)] 2. Application for Group Life Insurance Disability Benefits [UN766G (GGL) (7/03)] 3. Attending Physician's Statement
4. Attending Physician's Statement Group Waiver of Premium
Or Continuation of Benefits (Renewal purposes). [767G(GGL) Rev. 7/03]
SHORT TERM DISABILITY
Short Term Disability Claim Form
LONG TERM DISABILITY
Long Term Disability Employee Authorization For Release of Information Long Term Disability Employee's Disability Benefits Application
Long Term Disability Attending Physician's Statement Long Term Disability Employer's Report of Claim
Greater Georgia Life Insurance Company
Three Ravinia Dr, Ste. 1770 Atlanta,GA 30346 Please type or print all information.
Life/Disability Coverage Waiver
Authorization Form
I understand that my employer offers a group life and/or disability insurance program which is underwritten by Greater Georgia Life Insurance Company and that, as an employee, I have a right to obtain such coverage for myself and my dependents. I also understand that some or all portions of this program may be available at no cost to me. However, after carefully considering the benefits and my rights, I have decided not to enroll in the following:
Check appropriate box(es): (a) Basic Life and AD&D Insurance ■■
(b) Dependent Life Insurance ■■
(c) Short-Term Disability Insurance ■■
I understand that if I wish to participate in this program at some future date, my coverage or my dependents’
cover-age will not be effective until after I submit evidence of insurability to Greater Georgia Life Insurance Company or its
designee and I/we are approved for coverage. I understand that if a physical examination or further medical information is required for evidence of insurability, I will be responsible for any expenses associated with obtaining the physical examination or the medical information.
Employee Name (please print): Social Security Number:
Employee Signature: Date Signed (mo/day/yr):
Group/Policy Number: Policyholder (Employer) Name:
To the Employer: When this form is completed and signed by the employee, please make two copies. 1) Mail the original to: Greater Georgia Life Insurance Company
P.O. Box 4445
Atlanta, Georgia 30302
2) Maintain one copy in the employee’s personnel file. 3) Give the second copy to the employee.
GROUP LIFE & DISABILITY
EMPLOYEE – Send this info to POLICYHOLDER – Complete section “1”before givingto employee.
SECTION I Required for Identification
Employer (or Policyholder) Name and Address Group Number
If more than one beneficiary is designated, settlement will be made in equal shares to such of the designated beneficiaries (or beneficiary) as survive me, unless otherwise provided herein. If no designated beneficiary survives me, settlement will be made as provided for in the policy(ies).
This change of beneficiary shall take effect as provided for in the policy(ies), and when received as so provided, the change shall be operative as of the date of this instrument whether or not I am alive at the time of such receipt, but without prejudice to the Company on account of any payment made by it before such receipt. The Company shall be bound by any trust deed, and shall not be liable for the application of monies by a trustee beneficiary.
SECTION II – CHANGE OF BENEFICIARY
I, , hereby revoke all previous
Name of Insured Person
nominations of beneficiaries under the Insurance on my life, including insurance for accidental death if any provided under
Group Policy(ies) # .
I nominate the following beneficiary(ies) with respect to all insurance now or hereafter provided under said policy(ies), in still reserving to myself the privilege of other and further changes, subject to the provisions of the policy or policies.
Full Name Address Relationship Age Social Security No.
SECTION III – CHANGE OR CORRECTION OF INSURED’S NAME OR BENEFICIARY’S NAME It is hereby requested that the name of the INSURED appearing on the Insurance records
It is hereby requested that the name of the appearing on the Insurance records It is hereby requested that the name of the BENEFICIARY appearing on the Insurance records
# as
be changed to because of
I HEREBY AUTHORIZE the changes in Section II and/or III. Date
Signature of Insured Person
It is most important for you, that all information contained herein be CLEARLY stated. A copy will be acknowledged and returned to you. This form when completed should be submitted to your Employer so that your insurance records may be changed.
SUGGESTED WORDING PERTAINING TO SECTION II – CHANGE OF BENEFICIARY
Type of Beneficiary Wording to be Used
1. Insured’s Estate 2. One beneficiary 3. Two beneficiaries
4. Two beneficiaries in unequal shares
5. Three or more beneficiaries in unequal shares
6. One Primary and one Secondary beneficiary 7. One Primary and two
Secondary beneficiaries
*8. One Primary and unnamed children as Secondary beneficiaries
9. Two Primary beneficiaries and one Secondary beneficiary
*10. One Primary and one or more named and unnamed children as Secondary beneficiaries *11. One Primary beneficiary with Common Disaster
Provision (specified period not to exceed 30 days) 12. Trustee
13. Trustee under the Last Will and Testament of Insured
14. Per stirpes provision for named children and their children
Insured’s Estate Dorothy Q. Smith, wife
Peter Smith, father, and Anna Smith, mother, equally, or the survivor. Peter Smith, father, as to three fourths (3/4) and Anna Smith, mother, as to one fourth (1/4), or the survivor.
Peter Smith, father, as to two fourths (2/4), Dorothy Q. Smith, wife, as to one fourth (1/4) and Anna Smith, mother, as to one fourth (1/4), the share of any deceased beneficiary to be payable to the survivors, in such proportions as their original shares are distributed, or the survivor.
Dorothy Q. Smith, wife, if living; otherwise Quincy Smith, son.
Dorothy Q. Smith, wife, if living; otherwise Quincy Smith, son, and Mary Smith, daughter, equally, or the survivor.
Dorothy Q. Smith, wife, if living; otherwise the children born of the marriage of the Insured and said wife, or the survivors, equally, or the survivor.
Peter Smith, father, and Anna Smith, mother, equally, or the survivor, if either survives; otherwise Dorothy Q. Smith, wife.
Dorothy Q. Smith, wife, if living; otherwise Quincy Smith, son, Mary Smith, daughter, and any other children born of the marriage of the Insured and said wife, or the survivors, equally, or the survivor. Dorothy Q. Smith, wife, if she survives the Insured for a period of ten (10) days; otherwise the children born of the marriage of the Insured and said wife, or the survivors, equally, or the survivor.
Dorothy Q. Smith, trustee under trust agreement dated
The Trustees under the last Will and Testament of the Insured, provided said last Will and Testament has been allowed within six months after the death of the Insured by the Court having jurisdiction thereof; other-wise the Estate of the Insured.
Dorothy Q. Smith, wife, if living; otherwise such of Richard Smith, William Smith and Mary Smith, children, who may be living and the surviving children of any of said children who may be deceased, per stirpes
*If it is the intent to include adopted children or stepchildren, add to the phrase children of the marriage of the Insured and said wife either (a) “and adopted children of either of both” or (b) “and the stepchildren of either” or (c) the names of the children intended. We will furnish you with the exact language necessary to your intent.
INSTRUCTIONS PERTAINING TO SECTION III – CHANGE OF NAME
This portion of the form is to be used in changing or correcting your name or beneficiary’s name. Names should always be shown using given names: Example: Dorothy Q. Smith, and not as Mrs. John Smith. The same procedure should be followed when designating a beneficiary in Section II.
