Short Term Disability Enrollment Form
Offered by Reliance Standard Life Insurance for
Campbell University
Eligibility Elimination
Period
Each active, full·time employee, except any person employed on a temporary or seasonal basis 3 options
available:
Class 1: 0 Day Elimination / 26 Week Benefit Duration
Class 2: 14 Day Elimination / 24 Week Benefit Duration
Class 3: 30 Day Elimination / 22 Week benefit Duration
You may choose increments of $25 up to $1,500 a week maximum. Not to exceed 60% of your salary.
Benefit Amount
Definition of Disability
Benefit Duration
During disability, you will be considered Totally Disabled if, as a result of sickness or injury, you are unable to perform the
material duties of your regular job.
Benefits for any of the 3 plans chosen will be a maximum of 26 weeks
Coverage is 100% employee paid through convenient payroll deduction
Contributions
Additional Provisions
Yes
No, rates will not vary or change based on age
This is a one time open enrollment and new employees enrolling in the plan and increased amounts are
subject to the pre ex (if you decide at a later time that you would like to purchase the Short Term Disability
coverage Evidence of Insurability or proof of good health would be required).
Mental and nervous coverage: Included
Pre-existing condition limitation: 3/12
Yes
Maternity Coverage:
Partial Disability:
Age rated:
Guarantee Issue:
Election Information
Name
Salary
Employee ID
I ELECT THE FOLLOWING ELIMINATION PERIOD (CIRCLE ONE):
#1-1ST DAY ACCIDENT/8TH DAY ILLNESS
#2-15TH DAY ACCIDENT AND ILLNESS
#3·31ST DAY ACCIDENT AND ILLNESS
AMOUNT OF COVERAGE ELECTED (IN INCREMENTS OF $25, NOT TO EXCEED 60% OF YOU SALARY TO A MAXIMUM BENEFIT OF $1,500) MONTHLY PREMIUM
DATE OF HIRE
EFFECTIVE DATE
Employee Signature: _________________________________________________________________ Date Signed:
_
_
Certification & Authorization: I certify that all infonnation on this form is true and complete to the best of my knowledge and belief. I understand that this insurance is subject to all of the
terms of the Plan of Insurance contained in the group policy and summarized in the announcement material provided me and the certificate issued me.
I understand that, in the event I fail to sign this form within 31 days of the effective date of eligibility or that for any reason Reliance Standard does not receive notice of the Enrollment/Change
Request within a reasonable time following the date I was eligible to enroll or change my coverage, my and my dependents' eligibility may be affected.
I request my employer to arrange for the issuance of Group Coverage for which I am or may become eligible and authorize deductions of the required contributions from my earnings.
RELIANCE STANDARD
Please note that this is only a brief summary of your plan. It is not a certificate of insurance or evidence of coverage.
In the event a discrepancy exists, the policy certificate will govern.
Monthly Payroll Costs
Annual Earnings
$8,760.00
$13,000.00
$17,340.00
$21,460.00
$26,000.00
$30,340.00
$34,670.00
$39,000.00
$43,340.00
$47,670.00
$52,000.00
$56,340.00
$60,670.00
$65,000.00
$69,340.00
$73,670.00
$78,000.00
$82,340.00
$86,670.00
$91,000.00
$95,340.00
$99,670.00
$104,000.00
$108,340.00
$112,670.00
$117,000.00
$121,340.00
$125,670.00
$130,000.00
Weekly Benefit
$50.00
$100.00
$150.00
$200.00
$300.00
$350.00
$400.00
$450.00
$500.00
$550.00
$600.00
$650.00
$700.00
$750.00
$800.00
$850.00
$900.00
$950.00
$1,000.00
$1,050.00
$1,100.00
$1,150.00
$1,200.00
$1,250.00
$1,300.00
$1,350.00
$1,400.00
$1,450.00
$1,500.00
1st/8th/26 weeks ($.90/$10)
$4.50
$9.00
$13.50
$18.00
$27.00
$31.50
$36.00
$40.50
$45.00
$49.50
$54.00
$58.50
$63.00
$67.50
$72.00
$76.50
$81.00
$85.50
$90.00
$94.50
$99.00
$103.50
$108.00
$112.50
$117.00
$121.50
$126.00
$130.50
$135.00
15th/15th/24 weeks ($.50/$10)
$2.50
$5.00
$7.50
$10.00
$15.00
$17.50
$20.00
$22.50
$25.00
$27.50
$30.00
$32.50
$35.00
$37.50
$40.00
$42.50
$45.00
$47.50
$50.00
$52.50
$55.00
$57.50
$60.00
$62.50
$65.00
$67.50
$70.00
$72.50
$75.00
31st/31st/22 weeks ($.32/$10)
$1.60
$3.20
$4.80
$6.40
$9.60
$11.20
$12.80
$14.40
$16.00
$17.60
$19.20
$20.80
$22.40
$24.00
$25.60
$27.20
$28.80
$30.40
$32.00
$33.60
$35.20
$36.80
$38.40
$40.00
$41.60
$43.20
$44.80
$46.40
$48.00
RELIANCE STANDARD
Please note that this is only a brief summary of your plan. It is not a certificate of insurance or evidence of coverage.
In the event a discrepancy exists, the policy certificate will govern.