Act Now!
You must apply within 60 days of termination
GIVE YOUR FAMILY PEAK PROTECTION
Group Long Term
Disability Insurance
Conversion Plan
Enrollment Kit
Customer Service Center
888-262-6873
Monday through Friday
8:00 a.m. to 8:00 p.m. (ET)
0212395-00001-00
WHAT’S INSIDE
How to determine if you are eligible . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Why you need to convert your LTD coverage . . . . . . . . . . . . . . . . . . . . . . 5
How much coverage you can buy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
What this conversion plan offers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
How much it will cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
How to apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
What to do if you become disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Enrollment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2
The Prudential Insurance Company of America is pleased to offer
you this Group Long Term Disability (LTD) Conversion Plan. There is a
growing need for this type of coverage and your former employer
has made it possible for you to take advantage of this group plan at a
reasonable cost, which may be more cost effective than coverage you
would be able to purchase on your own.
Prudential’s Group LTD Conversion Plan was designed to help
ensure that there is no gap in your income protection insurance
while you transition from this employer to the next.
Yet, this is a time-sensitive opportunity. You must complete the
attached enrollment form and return it within 60 days of
termination of employment, or you will forfeit your opportunity
to do so. Please review this kit carefully and apply promptly.
The kit explains:
n
Why you need Prudential’s Group LTD Conversion Plan
n
The advantages of converting your current LTD coverage
n
How much you can purchase
n
Complete and return the
attached Enrollment Form
within 60 days of termination
of employment. Keep a copy
of the Enrollment Form for your
records. Please be advised that
this kit is only a summary of
the benefits, limitations, and
exclusions offered to you
under Prudential’s Group LTD
Conversion Plan. The BookletCertificate provided upon
approval of this coverage
will provide the necessary
plan details.
How much it will cost
Helping you bridge the gap of your coverage is important to Prudential.
An insurance leader for over 135 years, we have the resources, financial
strength, and stability to honor long-term commitments. With your
financial security at stake, you owe it to yourself to consider the
opportunity described in this kit.
Applying is easy! Simply review the information, then complete and
return the attached Enrollment Form within 60 days of termination
of employment. Don’t miss out on this valuable coverage!
3
ACT NOW for Group LTD
conversion coverage.
You must submit your application
within 60 days of termination
of employment to be eligible for
conversion coverage.
If you do not apply within 60 days,
you will forfeit your opportunity
to apply for this important income
protection insurance.
“Am I eligible?”
You are eligible to apply for Prudential’s Group LTD Conversion Plan
if you meet all the following requirements:
n
Your
n
You
employment ends for a reason other than retirement
are under the age of 70 when your employment ends
n
At
the time your employment ends, you were covered for at least
12 consecutive months under a group long-term disability plan with
your former employer
n
You
are not disabled, as defined by the terms of your former employer’s
Group LTD plan, at the time your employment terminates
n
You
do not become eligible for group long-term disability coverage
under any other long-term disability plan within the 60 days following
the end of your employment
n
You
are a member of an eligible class of employees when your
employment ends
coverage under your former employer’s LTD plan has not ended due
Your
n
to cancellation of the Group Contract, or your failure to pay premiums.
APPLY TODAY
with the enclosed
Enrollment Form!
4
“Why is LTD conversion important?”
As a participant in your former employer’s Group LTD plan, you may
already understand the importance of having long-term disability
insurance. But did you know that:
n
ust over one in four of today’s 20-year-olds will become disabled
J
before reaching age 67.1
n
Almost 70% of wage earners said a disability would keep a person out
of work for more than one year, but 38% said they could only pay bills
for three months or less if they lost their income.2
n
PEACE OF MIND
from Prudential
Prudential’s resources, financial
strength, and stability allow us to
honor long-term commitments,
which means that we’ll be here
when you and your family need us.
We’ve been a top insurance provider for over 135 years and have
received positive insurance claims
paying ratings.
Social Security disability payments are limited to disabilities expected to
last at least 12 months or end in death. To qualify, you must be unable
to engage in any type of work as defined by Social Security.
If you’re sick or injured and can’t work, Prudential’s Group LTD Conversion
Plan can help:
n
Provide
a source of income based on a percentage of your earnings
prior to termination
n
Get
n
you back to work with rehabilitation programs
for your LTD premium while you are disabled
Pay
“Why should I continue my coverage now?”
By converting your current Group LTD insurance, you can continue disability
coverage at a reasonable group rate, under the conversion privilege in the
plan offered by your former employer. If you wait to enroll for long-term
disability coverage with your next employer, you may experience a lengthy
waiting period before your coverage begins. Any gap in your long-term
disability coverage can put you and your family at risk of not having income
protection when you need it most.
Applying now can help give you peace of mind in knowing that you have
the long-term disability coverage you need from a company you know
and trust.
1 Social Security Administration, Fact Sheet, March 2011
2 ouncil for Disability Awareness (CDA) 2010 Consumer Disability Awareness Survey,
C
The Disability Divide
5
“How much LTD coverage can I buy?”
Having the right amount of disability insurance is important. It helps replace a portion of your
income for a period of time to help maintain your standard of living if you become disabled.
If you are eligible, you may apply for a Monthly Benefit equal to the lesser of:
n
The
amount you were covered for under Prudential’s Group LTD plan with your
former employer
n
60%
of your monthly earnings at the time your coverage under your former plan
ended, but not more than $4,000 (or up to $8,000 if you have provided Prudential
satisfactory evidence of insurability)
Monthly earnings means your gross monthly income from your Prior Employer in effect on the date your long term disability
coverage under the Prior Plan ended. It does not include income received from commissions, bonuses, overtime pay, any
other extra compensation, or income received from sources other than your Prior Employer.
Your Monthly Benefit will be reduced by other sources of income you may receive, including,
but not limited to, the following:
n
Social
Security benefits (individual or family)
n
Disability
benefits paid under Workers’ Compensation or any other occupational disease law
n Unemployment
n
Any
benefits
employer plan which provides group disability benefits
n
Employer-funded
retirement benefits
Additional reductions that may apply are outlined in the Booklet-Certificate, which is
provided upon enrollment. Your minimum benefit will be $50.00 per month.
“Can I apply for a Monthly Benefit greater than the amount
provided under my former employer’s Group LTD plan?”
No, your Monthly Benefit under Prudential’s Group LTD Conversion Plan cannot exceed
the amount for which you were covered under your former employer’s Group LTD plan.
You can choose to reduce your coverage at any time, but once you reduce coverage, you
cannot increase it from that point forward.
“What if my Monthly Benefit is currently more than $4,000?”
You are not required to choose a Monthly Benefit greater than $4,000 under the
conversion plan. You can simply check off “Option 1” on the Enrollment Form to apply
for the $4,000 Monthly Benefit.
However, if you apply for a Monthly Benefit of $4,000 and change your mind, you cannot
increase it at any time.
If you wish to apply for a Monthly Benefit greater than $4,000, check “Option 2” on the
Enrollment Form. You will be sent an Evidence of Insurability Form to complete.
6
“What are the features of this plan?”
Benefit Begins:
180 days following accidental injury or sickness
Benefit Period*: to your normal retirement age under the Social Security Act.
Up
However, if you become disabled at or after age 65, benefits
are payable according to an age-based schedule
This provides only a summary of
benefits, limitations, and exclusions.
The Booklet-Certificate you will
receive after your insurance
becomes effective will provide
you with more details.
Limited Pay Period:
Disabilities due to mental illness, including substance abuse,
are limited to 24 months of benefits during your lifetime
*Prudential will stop sending payments while you are incarcerated as a result of a conviction.
“When does coverage begin?”
Your coverage becomes effective on the day after your coverage under your
former employer’s Group LTD plan ended, provided you make your first
premium payment within 31 days of the due date indicated on your first bill.
However, if you apply for a Monthly Benefit greater than $4,000, only the
first $4,000 will be effective immediately. The additional amount will not
become effective until it has been approved by Prudential. You will only
be billed for the first $4,000 of coverage until you are notified, in writing,
that the additional amount of coverage is approved. After you receive
approval, a bill for the amount of coverage over $4,000 will be issued.
“When does coverage end?”
Your coverage under the Group LTD Conversion Plan terminates when
the first of the following occurs:
n
You
elect to terminate your coverage
n
You
become eligible for coverage under another group long-term
disability plan
n
You
fail to pay your quarterly premium when due
n
You
reach age 70
n
The
Group Contract, which provides for this coverage, ends
“What are the benefit exclusions?”
You will not receive benefits for any period of disability caused by:
n
Any
intentionally self-inflicted injury
n
Any
war or act of war, including undeclared war
n
Active
participation in a riot
n
Commission
of a crime for which you have been convicted under
state or federal law
7
“How much will it cost?”
Your premium amount is based on your age, as of the premium due date, and your
Monthly Benefit. Premiums are payable on a quarterly basis. The quarterly premium rate*
for coverage is as follows:
Age
Quarterly Premium** Rate
Under age 30
$.0170
30–39
.0250
40–44
.0440
45–49
.0700
50–54
.1120
55–64
.1550
65–69
.1100
* Rates effective: January 1, 1993
Rates may change as the insured enters a higher age category, also rates may change if plan experience requires
a change for all insureds.
** remium payments are due on the first day of each calendar quarter (Jan.1, Apr. 1, July 1, and Oct. 1). You will receive
P
a quarterly premium statement approximately three weeks prior to your premium due date.
If you are enrolled during the middle of a quarter, your first bill will be prorated to cover
only the amount of time you were actually enrolled for that quarter.
Remit your payment promptly, to ensure timely receipt. If your payment is not received within
31 days of any due date, your coverage will be terminated and it will not be reinstated.
“Will the cost change?”
Your premium amount will be adjusted when your birthday places you in a new age
category as of the premium due date. Your premium amount will be automatically
adjusted and indicated on your quarterly premium statement.
Also, Prudential may revise the current premium rates at any time. You will be notified
at least 31 days in advance of any change in the premium rates.
“What number do I call for questions about my bill?”
For billing inquiries, you can call 888-262-6873.
“How do I figure out my quarterly premium payment?”
The following worksheet will help you determine your quarterly premium payment.
You can calculate your quarterly premium based on a Monthly Benefit up to $4,000
or a Monthly Benefit over $4,000.
8
For a Monthly Benefit up to $4,000, to calculate your quarterly
premium, follow these steps:
1. Indicate the Monthly Benefit you are applying for, equal to the lesser of:
n
The
amount you were covered for under Prudential’s Group LTD plan with your
former employer
n
60%
Monthly Benefit: $____________
of your monthly earnings at the time your coverage under your former plan
terminated, but not more than $4,000
2. Determine the Premium Rate, based on your age, from the chart below:
Premium Rate: $____________
Age
Quarterly Premium Rate
Under age 30
$.0170
30–39
.0250
40–44
.0440
45–49
.0700
50–54
.1120
55–64
.1550
65–69
.1100
3. Multiply your Monthly Benefit (1) by the Premium Rate (2): $____________
This is your quarterly premium amount.
For a Monthly Benefit over $4,000, calculate your quarterly
premium payment as follows*:
Multiply the Premium Rate by $4,000: $____________
Please note that no Monthly Benefit amounts greater than $4,000 will become effective
until approved by Prudential. If you have applied for a Monthly Benefit amount in excess
of $4,000 and it is approved by Prudential, your quarterly premium payment will be
adjusted accordingly.
Examples:
An individual age 40, enrolling for a Monthly Benefit of $2,000:
.0440 x $2,000 = $88.00
The quarterly premium amount would be $88.00.
An individual age 40, enrolling for a Monthly Benefit of $8,000:
.0440 x $4,000 = $176.00
The quarterly premium amount would be $176.00.*
*
Please note that you will only be billed for the first $4,000 of coverage until the additional amount over $4,000 has been
approved. A subsequent bill will reflect the premium amount due for the increased coverage amount and will also include
an outstanding charge for the additional coverage amount from the effective date of the increased coverage to the
beginning of the quarterly bill.
9
“How do I apply?”
To apply for Prudential’s Group LTD Conversion Plan, you must return the attached
Enrollment Form within 60 days of termination of employment. Be sure to:
1. Verify that the Employer Statement portion of the Enrollment Form has been
completed and signed by your former employer. If this was not already completed
when you received the form, please have your former employer complete it
immediately. This _nformation is mandatory for the processing of your application.
i
2. Complete and sign the Employee Statement portion of the Enrollment Form.*
3. Make a copy of your completed Enrollment Form to keep with your important documents.
4. Send your Enrollment Form, completed and signed in its entirety, to:
The Prudential Insurance Company of America
P.O. Box 8769
Philadelphia, PA 19176
* you are applying for a monthly benefit amount in excess of $4,000, you will be mailed an Evidence of Insurability
If
Form to complete, and depending on your age and the amount of coverage requested, we may require an examination
and/or blood test.
10
“Who should I contact if I become disabled?”
Call Prudential at 800-842-1718 as soon as you have been disabled for six weeks. Be
sure to mention the Prudential Group LTD Conversion Plan Control Number—22560—
when calling and on all future correspondence. You will be provided with the forms
needed to submit a disability claim. All claims under Prudential’s Group LTD Conversion
Plan will be administered by:
The Prudential Insurance Company of America
Disability Management Services
P.O. Box 13480
Philadelphia, PA 19176
“When am I considered disabled?”
You are considered disabled when Prudential determines that due to your sickness or injury:
n
You
are unable to perform the material and substantial duties of your regular occupation;
n
You
are under the regular care of a doctor; and
n
You
have a 20% or more loss in your monthly earnings.
After 24 months of payments, you are considered disabled when Prudential determines
that due to the same sickness or injury:
n
You
are unable to perform the duties of any gainful occupation for which you are
reasonably fitted by education, training, or experience; and
n
You
are under the regular care of a doctor.
Prudential will assess your ability and the extent to which you are able to work by
considering the facts and opinions from your doctors and other medical and vocational
experts of our choice.
The Booklet-Certificate you will receive after your insurance becomes effective will provide
you with more details on Prudential’s definition of disability.
“What if I’m partially disabled?”
While you are disabled and receiving benefits, you may recover sufficiently to resume some
employment. If your disability earnings are less than 20% of your pre-disability earnings,
your disability benefit will not be reduced. If your pre-disability earnings are 20% or more
of your pre-disability earnings, the disability benefit will be reduced to the portion of lost
earnings times the adjusted benefit but not less than $50.00 per month.
An employee will not be considered partially disabled while earning more than 80% of
pre-disability earnings during the first 24 months of disability payments or earning more
than 60% of pre-disability earnings after 24 months of disability payments.
“What if I take part in a rehabilitation program?”
While you are disabled and receiving benefits, you may participate in a rehabilitation
program that prepares you to return to full-time employment. Under this provision, some
of the expenses associated with rehabilitation may be paid with Prudential’s approval.
11
Enrollment Form
The Prudential Insurance Company of America
751 Broad Street, Newark, NJ 07102
Prudential Group Long Term
Disability (LTD) Conversion Insurance Trust
Control No.: 22560
Employee Statement
Instructions for Employee: Please be sure to complete all three sections and sign this form on the bottom of the second page. This
form must be submitted within 60 days from your employment’s end. Your employer’s signature is required on page three.
1
Employee
Information
First Name (Please Print)
MI
Last Name
Date of Birth (mm dd yyyy)
Social Security Number
Gender
M
F
Mailing Address (Street)
City
State
ZIP Code
2
Employment
Information
Employer Name
Your Occupation
Date coverage began under a
Group LTD Plan (mm dd yyyy)
Job Duties
Reason for termination of coverage
Disability
Employment termination date
Employment Terminated (mm dd yyyy)
Retirement
Leave of Absence
3
Conversion
Information
longer a member of an employee
No
class eligible for Group LTD coverage
Monthly earnings at date of termination
Other_______________________
Date coverage terminated under
the Group LTD Plan (mm dd yyyy)
$
.
Are you eligible for coverage under any other Group Long Term Disability Plan?
Yes
No
Are you enrolled for coverage under any other Group Long Term Disability Plan?
Yes
No
Scheduled Monthly Benefit selected equal to 60% of monthly earnings at date of termination not to exceed:
Option 1: a maximum of $4,000.*
Option 2: a maximum of $8,000.* To enroll for this option, you are required
to submit medical evidence of insurability. Depending on your age and the
amount of coverage requested, we may require an examination and/or blood
test. If you choose this option you must complete Section 4 on the following
page (Physician Information). The amount in excess of $4,000 will not become
effective until you are notified of acceptance by Prudential.
Amount of Scheduled Monthly Benefit enrolling for
$
.
*f your Scheduled Monthly Benefit under the group LTD Plan is less than the amount determined under the group LTD
I
Conversion, you are eligible to enroll for the lesser amount. The Scheduled Monthly Benefit may be reduced by other
sources of income. The Booklet-Certificate you will receive after your insurance becomes effective will provide you
with more details.
GL.2007.188 VA
Ed. 0807
Page 1 of 3
4
Physician
Information
If you selected Option 2 in section 3, an Evidence of Insurability Form will be sent to you to complete. In addition, please indicate:
Physician’s First Name (Please Print)
MI
Last Name
Physician’s Address (Street)
Telephone
City
5
[Mail Form to
or Fax Form to]
State
ZIP Code
The Prudential Insurance Company of America, [P.O. Box 8769, Philadelphia, PA 19176
1-800-764-1469]
Important Notice
For residents of all states except the District of Columbia, Florida, Kentucky, New Jersey, New York, Pennsylvania, Utah, Vermont,
Washington and Virginia; WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person,
or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an
insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be
prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition,
an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the
purpose of misleading, information concerning any fact material thereto.
[DISTRICT OF COLUMBIA RESIDENTS— It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer
or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.]
[FLORIDA RESIDENTS— Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.]
[KENTUCKY RESIDENTS — Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime.]
[NEW JERSEY RESIDENTS —Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.]
[NEW YORK RESIDENTS —Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the
stated value of the claim for each such violation. This notice ONLY applies to accident and disability income coverage.]
[PENNSYLVANIA and UTAH RESIDENTS — Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.]
[VERMONT RESIDENTS —Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement
in an application for insurance may be guilty of a criminal offense under state law.]
[WASHINGTON RESIDENTS — Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits.]
VIRGINIA RESIDENTS — Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing
that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing a statement
of claim for payment of a loss or benefit may have violated state law, is guilty of a crime and may be prosecuted and punished under state law. Penalties
may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any
fact material thereto.
Signature
X
Please make a copy of this entire form for your records.
Date (mm dd yyyy)
The Long Term Disability coverage is issued by The Prudential Insurance Company of America, a New Jersey company, [751 Broad Street, Newark,
NJ 07102. Disability Support: 800-290-5903.] Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details,
including any exclusions, limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certificate/
Group Contract issued by Prudential, the terms of the Group Contract will govern. Contract provisions may vary by state. Contract Series: 83500
GL.2007.188 VA
Ed. 0807
Page 2 of 3
Employer Statement
1 Employer
Information
Name of Employer
Control Number
Branch
Employee First Name
MI
Social Security Number
2 Coverage
Information
Coverage is being terminated due to:
Disability
Employment Terminated
Retirement
Employee Last Name
Date coverage began under a
Group Plan (mm dd yyyy)
Date coverage terminated under
the Group Plan (mm dd yyyy)
Leave of Absence
longer a member of an employee class
No
eligible for Group LTD coverage
Employment termination date (mm dd yyyy)
Other____________________________
Was the employee covered under your LTD plan (present plan or
combination of present and prior plans) for 12 months or more?
3 Employment
Information
No
Note to Employer: Please attach a current job description and verification of salary.
Monthly earnings at date of termination
$
4 Plan
Information
Yes
Employee’s Occupation
.
Scheduled Monthly Benefit under the
Group LTD Plan (e.g., 40%, 50%, 60%, 66 2/3%)
%
.
Maximum monthly benefit $
Name of Employer Contact
Employer Address
Street
City
State
ZIP Code
Employer Contact Telephone
Extension
The information provided is correct and complete to the best of my knowledge.
Signature
Date (mm dd yyyy)
X
Prudential and the Rock logo are registered service marks of The Prudential Insurance Company of America
and its affiliates.
GL.2007.188 VA
124115
Ed. 0807
Page 3 of 3
The Long Term Disability coverage is issued by The Prudential Insurance Company of America, a Prudential Financial company, 751 Broad Street, Newark,
NJ 07102. Disability Support: 800-842-1718. Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details,
including any exclusions, limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certificate/
Group Contract issued by Prudential, the terms of the Group Contract will govern. Contract provisions may vary by state. Contract Series: 83500
© 2011 Prudential Financial, Inc. and its related entities.
Prudential, the Prudential logo and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many
jurisdictions worldwide.
124115
