Manage your Liberty Mutual
group benefits online.
MyLibertyConnection.com offers convenient access to online tools to
help you manage your group benefits.
To get started, visit www.MyLibertyConnection.com and register by
clicking the "New User" link next to the Login tab. Use the Company
Code: MUSCP and answer the prompted questions.
Once registered, you may then submit an evidence of insurability
application and access additional tools to help you manage your
benefits.
MyLibertyConnection.com
Saves Time: There are no paper forms to fax or mail
Convenient: Information is available day or night, whenever you need it
Secure: You must sign in with the University Medical Associates
Service ID: MUSCP. Your information is sent directly to Liberty Mutual.
www.MyLibertyConnection.com
Group products offered by Liberty Life Assurance Company of Boston, a member of the Liberty Mutual Group. Home Office: Boston, MA. Coverage is provided subject to the terms and conditions of the policy.
Group Short-Term Disability
and Life Insurance
Enrollment Guide
Who’s Eligible?
All active, full-time employees working a minimum of 30 hours per week are eligible to participate in the University Medical
Associates Group Short-Term Disability (STD) and Life Insurance plan underwritten by Liberty Life Assurance Company of
Boston.
What are my Coverage Options for Short Term Disability?
The University Medical STD Insurance plan is sponsored by your employer. If you purchase this coverage, become disabled
(as defined in the plan), and remain disabled through the elimination period, you will receive your elected weekly benefit
amount, less other deductible sources of income (e.g. state mandated benefits, sick pay, etc. See your plan booklet for
details).
You may choose a weekly benefit amount of either: $200, $300, $400, $500, $600, $700 or $800. This amount may not
exceed 66.7% of your basic weekly earnings. You also have the option to choose whether your insurance provides benefits
after 7 days or 14 days of initial disability. This initial benefit wait period is referred to as an Elimination Period.
What is the Cost for Short-Term Disability Insurance?
The cost of this program is paid for by you and the rate is based on your age as of January 1, 2015. To calculate your cost,
find the rate that matches your age and desired elimination period. Multiply this rate by 2 for a $200 benefit, 3 for a $300 benefit,
etc.
Age
7 Day Elimination Period
14 Day Elimination Period
Bi-Weekly Cost per $100 of Benefit
Bi-Weekly Cost per $100 of Benefit
<30
$1.99
$1.68
30-39
$2.06
$1.68
40-44
$1.98
$1.70
45-49
$2.10
$1.54
50-54
$2.17
$1.61
55-59
$2.74
$1.67
60-64
$3.51
$2.10
65+
$3.51
$2.69
Example: A 42 year old requesting $400 of benefits to begin after 14 days (14-Day Elimination Period) would have a bi-weekly
deduction amount of $6.80.
The information above and below provides highlights of the insurance program. It does not and is not intended to cover the program in
detail. Please refer to the policy for a complete description of the coverage, limitations and exclusions.
Group products and services are offered by Liberty Life Assurance Company of Boston, a Liberty Mutual company. Home Office: Boston, MA.
What are my Coverage Options for Life Insurance?
Term Life Coverage Options
Employee
Basic Term Life and AD&D: Coverage is equal to 1 times your base annual salary. This amount may
not exceed $50,000. Coverage is employer-paid.
Optional Term Life: You may purchase increments of $25,000 to a maximum of $300,000. The biweekly
rate is based on amount selected and your age as of January 1, 2015.
Optional Spouse Life: You may purchase increments of $5,000 to a maximum of the lesser of $150,000
or 100% of the Optional Employee Term Life amount. The biweekly rate is based on amount selected
Dependents and your spouse’s age as of January 1, 2015.
Optional Child Life: You may purchase an amount equal to $10,000.
What is the Cost for Optional and Dependent Term Life Insurance?
The cost of this program is paid for by you. The cost for Child coverage in the amount of $10,000 is $0.23 per bi-weekly pay
period. Use the rate tables below to calculate the employee and spouse cost.
Age
Employee Rate
Bi-weekly cost per $1,000
Age
Spouse Rate
Bi-weekly cost per $1,000
<30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
$0.026
$0.027
$0.038
$0.049
$0.082
$0.126
$0.205
$0.264
$0.449
$0.798
$3.027
<30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
$0.022
$0.023
$0.030
$0.042
$0.063
$0.096
$0.161
$0.243
$0.412
$0.732
$2.777
The following example calculates the biweekly cost for a 36-year old employee who would like to purchase $100,000 in Optional
Life insurance coverage.
Calculate Your Cost
Step 1
Using the table above, enter the rate that
corresponds with your age.
Step 2
Enter the desired coverage amount in dollars
Step 3
Divide Step 2 $1,000.
Step 4
Calculate the biweekly cost. Multiply Step 1 by
Step 3.
Example
You
$0.038
$
$100,000
$
100
$
$3.80
$
Cost of insurance may change in the future due to age and/or coverage amount elected. Rates are subject to change.
Group products and services are offered by Liberty Life Assurance Company of Boston, a Liberty Mutual company. Home Office: Boston, MA.
University Medical Associates
Enrollment Form
Group Life and Disability Insurance
Please return completed form to your benefits department
Employer Name
Group Policy Number
University Medical Associates
01-261423
Employer Address (City, State, Zip Code)
Coverage Effective Date
1180 Sam Rittenberg Blvd. Charleston, SC 29407
Employee Name (Last, First, Middle)
Address (City, State, Zip Code)
Social Security Number
Hire Date (MM/DD/YY)
Date of Birth (MM/DD/YY)
Gender
Annual Salary
Male
Female
Type of Enrollment
Marital Status
Single
Married
New Employee
Qualified Life Event
$
Divorced
Widowed
Annual/Open Enrollment
Rehire
Rehire Date:
Coverage Elections
Please indicate your coverage elections below. The Employee must enroll in Optional Life coverage to elect Optional Dependent Life
coverage. The Optional Spouse Benefit cannot be greater than 100% of the Employee Optional Benefit. All dependent children will be
covered. Evidence of Insurability may be required. Please see your plan booklet for additional information.
Type of Coverage
Selection
Decline
Optional Short-Term Disability
Coverage Amount Elected
$
7-Day Elimination Period
14-Day Elimination Period
*Enter an amount equal to $200, $300, $400, $500,
$600, $700 or $800. This amount may not exceed
66.7% of your basic weekly earnings.
$
Employee Optional Life
Yes
No
*Must be increment of $25,000 up to $300,000.
Statement of Health required for amounts above
$150,000 (see instructions below)
Spouse Optional Life
Yes
No
$
Child(ren) Optional Life
Yes
No
$10,000
*Must be increment of $5,000. Cannot exceed
150,000 or 100% of Employee Optional Amount.
Statement of Health required for amounts above $50,000
(see instructions below)
Statement of Health Instructions
If you are requesting an amount of Employee Optional Life Insurance above $150,000 or an amount of Spouse Optional Life
Insurance above $50,000, you must complete the Statement of Health by going to www.mylibertyconnection.com. You will need to
register to the site using the company code “MUSCP” and then complete the application that is initiated by clicking the “Complete
Statement of Health” button.
Group products and services are offered by Liberty Life Assurance Company of Boston, a Liberty Mutual company. Home Office: Boston, MA.
If electing for Dependent Coverage (Spouse and Child), please complete the following:
Spouse Name:
Date of Birth:
Child Name:
Date of Birth:
Child Name:
Date of Birth:
Child Name:
Date of Birth:
Child Name:
Date of Birth:
Dependent Child(ren) coverage is available to eligible dependent child(ren) under 19 years of age, or 25 if a full-time student.
Employee Signature and Authorization
ACCEPT: I declare that all information given in this enrollment form is true and complete to the best of my knowledge and belief. I request coverage under my employer’s plan of benefits as indicated above. I authorize my employer to deduct from my earnings my contributions for the
coverage(s) selected. I understand that with respect to coverages I have declined, Liberty Mutual Insurance has the right to require Evidence
of Insurability in order to consider any later request to change this decision and that my request may be denied. I am an employee in active
employment working at the employer’s regular place of business.
DECLINE: I hereby decline all optional coverage as offered by my Employer. I certify that I have been given the opportunity by my Employer
to enroll for coverage. I understand that Liberty has the right to require Evidence of Insurability in order to consider any later request to change this
decision and that my request may be denied. I am an employee in active employment working at the Employer’s regular place of business.
Employee Signature:
Date:
Completion of this enrollment form does not guarantee coverage. Evidence of Insurability may be required. Please see your plan
booklet for additional information.
Submit completed form to your employer and retain a copy for your records.
Group disability income and life insurance policies are issued by Liberty Life Assurance Company of Boston, a member of the Liberty
Mutual