Accident
Insurance
Pays you benefits for
treatment and services regardless
of other medical coverage.
Accident Insurance:
It couldn’t be easier
or more reasonable to
be better protected.
Get Accident Insurance Today!
Simply complete and sign this form and the payroll
deduction authorization. Then mail this postage-paid
brochure back to the Club. Or, call the City Employees
Club of Los Angeles at (800) 464-0452, and a friendly Club
Counselor will take your information over the phone.
Who is eligible to apply?
This insurance program is open to
members of the City Employees Club
of Los Angeles. If you’re a member,
great! If not, as a new policy holder
you will automatically be enrolled as a member of the
City Employees Club of Los Angeles. Members enjoy
valuable benefits like big discounts on movie tickets,
theme parks, attractions and events, the monthly Alive!
newspaper, group-rated insurance, scholarships, and
free notary service.
Go to www.CityEmployeesClub.com
for all the details.
Questions?
Club Counselors are ready to
answer your questions about
Accident Insurance. Call today.
(800) 464-0452
City Employees
Club of Los Angeles
®
CITY EMPLOYEES CLUB OF LOS ANGELES
www.CityEmployeesClub.com
120 West 2nd Street
Los Angeles, CA 90012
(800) 464-0452
www.cityemployeesclub.com
®
?
Why get Accident Insurance?
Accidents are by nature unpredictable,
and the costs arising from accident-related
injuries can be startling. While some
expenses may be covered by most medical
plans, others—such as travel to distant
treatment facilities—may not be.
Guaranteed Approval -
How does
Accident Insurance work?
Accident Insurance pays benefits when you or a family
member (depending on your coverage) become injured
as the result of a covered accident. If an accident results
in an injury requiring medical attention:
1.Get the treatment you need.
2.File a claim on your Accident
Insurance policy.
3.You’ll receive a benefit for each
covered treatment received.
Traditional Medical Insurance
compared to Accident Insurance
vs
Accident
Insurance
PAYS
PAYS
04/2014 JJLA: ACCIDENT
Traditional
Medical
Insurance
...typically pays
directly to the
hospital in the
event of an
accident.
...pays directly
to you to help
you pay for:
Out-of-network
costs
Travel to nonlocal facilities
Co-pays and
deductibles
Other expenses
What can
Accident Insurance
from the Club offer me?
When accidents happen, you need to focus your energy on
getting well without the added stress of costs like family
lodging, hospitalization, medical bills, treatment, x-rays,
and ambulance service.
As a member of the City
Coverage is
Employees Club of Los
available for
Angeles, you are entitled to
both spouse and
the added security of this
dependents.
Accident Insurance plan:
Added Security
• Provides benefits for surgery-related services.
• Allows you to cover your spouse and children on
the same policy.
• Coverage on and off the job.
Financial Advantages
• Pays benefits for treatments and services, regardless
of other medical coverage.
• Benefits paid directly to you, to use as you see fit.
• Budget-friendly rates.
Convenience and Flexibility
• All eligible members are guaranteed acceptance.
• Premiums paid through payroll deduction—
no checks to write.
Broad Coverage
• The plan covers a wide range of injuries, including
most children’s sports injuries, as well as expenses
not usually addressed by traditional health plans,
such as transportation and lodging costs for
treatment at a non-local facility.
MAILING THIS FORM: Fold this entire postage-paid brochure with the
Business Reply panel showing, tape closed (don’t staple) and drop in the mail.
Accident Insurance
Worksheet
m Current Club Member
Personal information (all information required)
Social Secruity No.
First Name
Middle Initial
Last Name
Home Address
City
Home Phone (
Work Phone ) _____ – ________ (
E-mail address*
Driver's License #
Cell Phone
) _____ – ________ (
m Yes, please send me e-mail updates.
) _____ – ________
Height (inches)
Weight (lbs.)
m New Club Member
-or-
State
Zip
Date of Birth (MM/DD/YY) State/Country of Birth
Gender:
m Male
m Female
Mother’s Maiden Name
State Issued
Are you a U.S. Citizen? m Yes m No
If No....
a) Date of entry _________________
b) VISA type_____________________
c) Expiration date________________
*The email address you provide will help us communicate with you regarding updates and benefits that may become available to you. Your e-mail address will be used solely by American General Life Insurance Company and the City Employees Club and will not be distributed to others.
Employment
m City employee #
City department #
m DWP employee #
(all information required)
OccupationDate Hired (MM/DD/YY)
Date of Birth (MM/DD/YY)
(provide if applies to you)
Spouse Last Name
Dependents
State/Country of Birth
Height (inches)
Spouse First Name
Weight (lbs.)
Gender:
m Male m Female
(provide if applies to you)
Dependent Child
Date of Birth (MM/DD/YY)
Gender:
m Male m Female
Dependent Child
Date of Birth (MM/DD/YY)
Gender:
m Male m Female
Dependent Child
Date of Birth (MM/DD/YY)
Gender:
m Male m Female
Dependent Child
Date of Birth (MM/DD/YY)
Gender:
m Male m Female
Beneficiary
(required)
First Beneficiary
Questions
Relationship to you
Second Beneficiary
Relationship to you
(required)
Do you have any pending insurance in force?
m Yes m No
Are you actively at work for 30 hours per week?
In the last 5 years, has any Proposed Insured had a reckless driving charge, had a driving while intoxicated charge, had a driver’s license revoked
or suspended, or within the last 3 years had multiple moving violations in any vehicle(s) operated by any Proposed Insured.
m Yes m No
m Yes m No
Review the Plan Benefits and decide which plan is right for you:
Accident Insurance Plan Rates
(Rates listed are per month.)
Instructions:
Indicate your desired coverage level by checking
one circle. Rates are listed as monthly deductions.
Premiums DO NOT INCREASE with age!
COVERAGE TIER
Member
Member & Spouse
Member & Child(ren)
Family
SILVER
GOLD
m $23.13
m $33.55
m $35.33
m $47.66
m $34.95
m $52.06
m $54.90
m $74.30
Membership in the Club!
®
As a new policyholder, you will automatically be enrolled as a member of the City Employees club of Los Angeles, a membership
program of the Los Angeles City Employees Association, where you will get all Club benefits for a payroll deduction of only $4.50
per month. Annual membership fees of $54.00 include $24.00 for a one-year, non-deductible subscription to the Alive! Newspaper.
04/2014 JJLA: ACCIDENT
Spouse
Annual Income
Accident Insurance Application
INSTRUCTIONS:
Complete the Accident Insurance Worksheet (previous page).
Then complete and sign this Payroll Deduction Authorization.
Mail both pages to:
City Employees Club of Los Angeles
350 South Spring Street, Suite 1300
Los Angeles, CA 90013
Complete and sign this Payroll Dedcution Authorization as part of your Accident Insurance application.
In addition to payroll deductions for group benefits, if any, you will receive all Club benefits for a payroll deduction of only $4.50
per month. You authorize these monthly deductions by signing the Payroll Deduction Authorization form. Annual membership
fees of $54.00 for active employees include $24.00 for a one-year, non-deductible subscription to the Alive! newspaper.
Name: ______________________________________________________________________________________
City Department #:
__________________
(5 or 6 digits)
m City Employee #: ______________________m DWP Employee #: ____________________
To: Controller–City of Los Angeles, or
City Employees Club of Los Angeles
Fire and Police Pension, or
City Employees Retirement System, or
Paymaster–Department of Water and Power
I hereby authorize the deduction from my salary or pension of
amounts sufficient to cover premiums/membership fees on any
of my group benefits provided by City Employees Club of Los
Angeles. In the event any premiums should change due to age,
increase in salary or benefits, or a general rate increase for the
entire Association, I authorize you to make such change upon
notification from the City Employees Club of Los Angeles and
such deduction to remain in force until canceled by me in writing.
Sign
Here
Sign Here
See Plan Benefits and
Terms and Conditions
on the next page.
FOR OFFICE USE ONLY
Code
X
City/DWP Employee
®
311 South Spring Street, Suite 1300 • Los Angeles, CA 90013
1-800-464-0452
[email protected] • www.cityemployeesclub.com
Date
Deduction
04/2014 JJLA: ACCIDENT
Payroll Deduction Authorization
Accident Insurance
Plan Benefits Hospital Cash Benefit
(Maximum of 30 consecutive days paid per
admission; 365 days lifetime maximum)
Maximum per admission
Daily benefit, when confined to hospital
Daily benefit, when confined to intensive care unit
(15 days per accident)
Daily benefit, when confined to rehabilitation facility
(30 days per confinement, 60 per year)
COVERAGE TIER
$1,400
300
SILVERGOLD
$350
75
75300
$225
1,500
$2,000
4,000
10,000
$300
2,000
2080
$1,500
3,000
7,500
$5,100$6,800
1,350
1,800
1,3501,800
1,350
1,800
600800
600800
1,350
1,800
$1,350$1,800
450
600
450600
450
600
600800
600800
750
1,000
$6,000
$8,000
3,0004,000
1,500
2,000
1,500
2,000
1,500
2,000
1,500
2,000
3,000
4,000
1,500
2,000
600800
– continued opposite side
Ambulance Benefit Schedule
Ground Ambulance
Flight Ambulance
Burns Benefit Schedule
Third degree burns over 10% of body
Third degree burns over 20% of body
Third degree burns over 30% of body
Dislocation Benefit Schedule
(Open Reduction)
Hip
Knee (not kneecap)
Shoulder
Foot or Ankle
Wrist
Elbow
Lower Jaw (mandible)
Dislocation Benefit Schedule
(Closed Reduction)
Hip
Knee (not kneecap)
Shoulder
Foot or Ankle
Wrist
Elbow
Lower Jaw (mandible)
Fracture Benefit Schedule
(Compound)
Hip or Thigh
Leg
Hand, Wrist or Forearm
Foot, Ankle or Kneecap
Shoulder Blade or Collarbone
Lower Jaw (mandible)
Vertebrae or Pelvis
Upper Jaw, Upper Arm or Face
Rib
Tear form on perforation to retain the Plan Benefits table.
Plan Benefits, continued
Fracture Benefit Schedule, cont.
(Compound)
Nose or Heel
Coccyx
Vertebral Processes
Skull (depressed)
Fracture Benefit Schedule
(Closed)
Hip or Thigh
Leg
Hand, Wrist or Forearm
Foot, Ankle or Kneecap
Shoulder Blade or Collarbone
Lower Jaw (mandible)
Vertebrae or Pelvis (excluding coccyx)
Upper Jaw, Upper Arm or Face (excluding nose)
Rib
Nose or Heel
Coccyx
Vertebral Processes
Skull (simple)
Paralysis Benefit Schedule
GOLD
COVERAGE TIER
SILVER
1,050
1,400
600800
3,000
4,000
3,750
5,000
$3,000
$4,000
1,5002,000
750
1,000
750
1,000
750
1,000
750
1,000
1,500
2,000
750
1,000
300400
300
400
300400
450
600
1,200
1,600
$600
600
600
300
300
1,200
1,200
300
$200
60
200
200
300
40
1,000
600
$800
800
800
400
400
1,600
1,600
400
$3,000$4,000
4,5006,000
7,50010,000
(payable for primary insured and spouse only)
Paraplegia
Hemiplegia
Quadriplegia
Surgical Benefit Schedule
Tendons or Ligaments
Torn Rotator Cuffs
Ruptured Disc
Torn Knee Cartilage
Arthroscopy (without surgical repair)
Open Abdominal (excluding exploratory Laparotomy)
Cranial, Hernia or Thoracic
Miscellaneous Surgery (requires general anesthesia)
Other Benefits
$150
45
150
150
225
30
750
450
AGLC104806-BS R04/11
City Employees Club of Los Angeles
(800) 464-0452 • www.cityemployeesclub.com
Emergency Treatment Benefit
Accident Follow-up Benefit
Family Lodging Benefit (maximum of 30 nights)
Laceration Benefit (minimum of 2 stitches)
Diagnostic Exams
Physical Therapy Benefit (per treatment)
Prosthesis (non-surgical and non-implant)
Transportation Benefit (per treatment)
®
Tear form on perforation to retain this Plan Benefits table.
Accident Insurance
TERMS AND CONDITIONS
Pre-existing Conditions and Exclusions:
No benefits are payable if covered services are not related to a covered accident.
No benefits are payable for a pre-existing condition until the policy has been
in force for two years from its effective date or most recent reinstatement
date. All benefits payable are subject to the terms and conditions of the policy,
including benefits, limitations and exclusions. We will not pay any benefit for
any accident or sickness of the insured caused in whole or in part by, or resulting
in whole or in part from: (a) the insured’s suicide, attempt at suicide, intentional
self-inflicted injury or sickness, or attempt at intentional self-inflicted injury or
sickness, while sane or insane; or (b) the insured’s being under the influence of
an excitant, depressant, hallucinogen, narcotic; other drug; or intoxicant including
those taken as prescribed by a physician; or (c) the insured’s commission of or
attempt to commit a felony or assault; or (d) the insured’s engagement in an
illegal activity or occupation; or (e) the insured’s voluntary participation in any
riot or civil insurrection; or (f) declared or undeclared war, or any act of declared
or undeclared war; or (g) the insured’s operating, learning to operate, serving as
a crew member of, or jumping, parachuting, or falling from an aircraft or hot air
balloon, including those not motor driven; or (h) the insured’s engaging in hang
gliding, bungee jumping, parachuting, sail gliding, parasailing or parakiting,
or any similar activity; or (i) the insured’s riding in or driving any motor-driven
vehicle in a race, stunt show or speed test; or (j) the insured’s practicing for or
participating in any semiprofessional or professional competitive athletic contest
for which the insured receives any type of compensation or remuneration; or (k)
the insured’s operating any type of land, water or air vehicle while having a blood
alcohol content at or above the level made illegal for operation of such vehicle by
the jurisdiction where the accident occurred; or (l) any illness, loss or condition
specifically excluded from the definition of accident under the policy.
Effective Date:
You will be insured on the date stated in writing by American General Life
Insurance Company, provided the required premium is paid. You must be actively
at work on the date your insurance is to take effect.
City Employees Club of Los Angeles
311 South Spring Street, Suite 1300
Los Angeles, CA 90013
(800) 464-0452
www.cityemployeesclub.com
End Date:
As long as you continue to pay your premiums on time, your coverage will not end.
®
Policies issued by:
American General Life Insurance Company
Houston, Texas
Policy Form Number: 04120
AGLC104806-BS
-FOR USE IN CALIFORNIA ONLY-
R04/11
The underwriting risks, financial and contractual obligations and support functions
associated with products issued by American General Life Insurance Company
(AGL) are its responsibility. AGL does not solicit business in the state of New
York. Policies and riders not available in all states. Guarantees are subject to the
claims-paying ability of the issuing insurance company.
This is a summary only of products and services offered. All products are subject
to the terms, conditions, limitations and exclusions of the policy. Please see policy
and certificate for details.
© 2011. All rights reserved.
LACEA-AI