plan year: november 1, 2019 october 31, 2020 robstown isd€¦ · by utilizing the section 125 ......

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PLAN YEAR: november 1, 2019 – october 31, 2020

robstown isd

What’s inside? EMPLOYEE BENEFITS CENTER

HOW TO ENROLL

S125 PLAN INFORMATION

FLEXIBLE SPENDING ACCOUNTS

AVAILABLE RESOURCES

BENEFITS AT A GLANCE

CONTACT INFORMATION

EMPLOYEE BENEFITs CENTER HTTP://BENEFITS.FFGA.COM/ROBSTOWNISD

EDELIA TREVINO, ACCOUNT MANAGER 2009 RR 620 N STE 123, AUSTIN TX 78734

OFFICE: 800-672-9666

EMAIL: [email protected]

This guide contains a summary of the benefits offered by your employer. If there is a conflict between the terms of this outline of benefits and the actual contracts, the terms of the contracts will prevail. For a more detailed explanation of benefits you may contact

your Account Manager or First Financial Administrators at 1-800-523-8422 or visit http://benefits.ffga.com.

Employee benefits center NEW employee benefits center - your guide to your benefits! We’ve created a custom site just for you! Find detailed information about current and upcoming benefits, voluntary product offerings and employer programs, Section 125 & Flex Information, important contact numbers and links, and downloadable forms and brochures.

http://benefits.ffga.com/robstownisd

How to Enroll Your First Financial Account Manager will be on site to assist you in enrolling in your benefits. To find out when your Account Manager will be at your location, view the schedule online or contact your site director. You also have the option to enroll online 24/7 through FFenroll during your enrollment period.

To prepare for your enrollment, visit your Employee Benefits Center at http://benefits.ffga.com/robstownisd. Once you have reviewed available benefits for the upcoming plan year, visit FFenroll, https://ffga.benselect.com/enroll, to review currently enrolled benefits and dependent information.

ON SITE ENROLLMENT • What to have ready for your enrollment:• Social Security Numbers for all dependents• Any Status/Life Event or address changes• Questions about available benefits

ONLINE ENROLLMENT To enroll online, log in to FFenroll (https://ffga.benselect.com/enroll). For detailed information on how to enroll, visit the how to enroll tab on your Employee Benefits Center

Login and PIN Your login is your social security number (no dashes) and your PIN is the last four digits of your social security number and the last two digits of your birth year (678977) Once you login you will arrive at the Welcome Screen. Click “Next”, then: Verify your personal information Verify all dependent information (ssn/date of birth) **Very Important** View employment information

USEFUL INFORMATION TO KNOW• Write your PIN number down• Contact First Financial at 855‐523‐8422 with any technical questions• No changes will be permitted until annual enrollment, unless you have an IRS S125 qualified event

Section 125 Plan Information and rules

A Section 125 Plan provides a tax-saving way to pay for eligible medical or dependent care expenses. The

funds are automatically deducted from your paycheck on a pre-tax basis.

Here’s How It Works

A Section 125 Plan reduces your taxes and increases your spendable income by allowing you to deduct the

cost of eligible benefits from your earnings before tax. Plus, the plan is available to you at no cost, and you’re

already eligible. All you have to do is enroll.

Is It Right for Me? The savings you may experience with a Section 125 Plan are outlined below. By utilizing the Section 125

Plan, you would have $70 more every month to apply toward insurance benefits or other needs. That’s a

savings of $840 a year!

Flexible Spending Accounts

Medical FSA Medical Flexible Spending Accounts (FSA) allow you to set aside pre-tax payroll deductions each paycheck to pay for out of pocket medical, dental and vision expenses for you and your family. During open enrollment you will estimate the amount you think you will need during the year. This amount will be taken out of each paycheck. Your full annual election will be available to you at the beginning of the plan year. Your employer has chosen the $500 Roll-Over Option for your plan. This option allows you the opportunity to roll over $500 of unclaimed Medical FSA funds into the following plan year. Any amount in excess of $500 will be forfeited under the use-it-or-lose-it rule.

FSA Plan Year is: November 1, 2019 – October 31, 2020 FSA MAX: The maximum you can set aside each year is $2,700.

DEPENDENT CARE FSA With a Dependent Care Flexible Spending Account (FSA), you can set aside part of your pay on a pre-tax basis to pay for eligible dependent care expenses, such as:

• Day Care Centers • Before/After School Care • Mothers-Day-Out Program • Nursery Schools • Babysitters • Nanny • Au Pair • Day Camps

This account allows you to pay for day care expenses for your qualifying dependent/child with pre-tax dollars while you (and your spouse) are working, seeking employment, and/or attending school as a full time student (for at least five months of the year). Eligible dependents must be children under the age of 13 when care is provided or be an adult dependent incapable of self-care and be claimed as an exemption on your tax return. For full plan details, view the FSA Booklet available on the Employee Benefit Center.

Health Savings Account

Health Savings Account (HSA) through First Financial in conjunction with UMB HSAs were created to help control healthcare costs. They provide a savings vehicle that allows you to set aside money to pay for higher deductibles associated with lower monthly premium High Deductible Health Plans (HDHP). The money you save in monthly insurance premiums may be set aside for eligible medical expenses you incur in the future. High deductibles are not the only requirement for an HDHP to be HSA eligible.

How it works: You choose the payroll deduction contributions up to the maximum allowed by the IRS. Your HSA balance rolls over from year-to-year earning interest along the way. The account is portable. Upon retirement or separation of service, you take the HSA with you because it’s your money and your account. When you want to access the funds, use your benefits card to pay your provider directly or simply request reimbursement or distribution on our online portal or mobile app. Be sure to keep receipts for all of your medical expenses, for which you received a reimbursement, for at least three years for tax-reporting purposes.

HSAs Offer a Triple Tax Advantage • The money you put in to the account is deducted from your paycheck before tax • The interest and earnings you make on the account grow tax free • Distributions for eligible medical expenses are tax free

What are the key advantages of an HSA? • No end-of-year forfeiture of funds • Portable account • Provides an excellent savings vehicle for healthcare expenses • No monthly account fees. • Free eStatements when you opt in for electronic delivery

Minimum Health Insurance Plan Deductible

Amounts for the Qualifying HDHP 2019 Individual Coverage $1,350 Family Coverage $2,700

Annual Maximum Contribution Levels 2019 Individual Coverage $3,500 Family Coverage $7,000

Maximums for HDHP Out-of-Pocket Expenses 2019 Individual Coverage $6,750 Family Coverage $13,500

BENEFITS CARD The Benefits Card is available to all employees that participate in Medical FSA, and/or a Dependent Care FSA. The Benefits Card gives you immediate access to your money at the point of purchase. Cards are available for participating employees, their spouse and eligible dependents that are at least 18 years old. To request a card for your spouse or dependent, login to our secure portal at www.ffga.com. The IRS requires validation of most transactions. You must submit receipts for validation of expenses when requested. If you fail to substantiate by providing a receipt to First Financial within 60 days of the purchase or date of service your card will be suspended until the necessary receipt or explanation of benefits from your insurance provider is received.

Online Portal Get account information from our easy-to-use online portal. View your Flex Account balance, find claim forms and view claim status and history. See your HSA account and investment balances in real time and request distributions. Visit www.ffga.com to set up your online account.

FF FLEX MOBILE APP With the FF Flex Mobile App you can submit claims, view account balance & history, see claim status, view alerts, upload receipts and documentation and more! The FF Flex Mobile App is available for Apple® or AndroidTM devices on the App StoreSM or the Google Play StoreTM.

FSa STORE First Financial has partnered with the FSA store to bring you an easy to use online store to better understand and manage your FSA. For Flex, visit http://www.ffga.com/fsaextras for more details & special deals!

• Shop at FSA Store for eligible items from bandages to wheel chairs and thousands of products in between

• Browse or search for eligible products and services using the FSA Eligibility List • Visit the FSA Learning Center to help find answers to questions you may have about your FSA

FSA RESOURCES

Visit http://benefits.ffga.com/robstownisd for rates and benefit information.

Medical- TRS ActiveCare Aetna is the plan administrator for the TRS-ActiveCare plans.

First Financial Group of America enrolls this product for your district however any product questions or concerns need to be directed to Aetna or your district benefit administrator.

Aetna offers:

• A variety of plan and network options to suit your individual needs

• A Health Concierge available by phone for answers and guidance on care and benefits

• Online services and mobile apps for easy access to health information and tools, wherever you travel.

To get the best view of Aetna resources and plan information, visit www.trsactivecareaetna.com. Please learn about your Aetna medical plan and take advantage of all it offers for your health and well-being.

Dental – ameritas and CC dental Oral care can be a significant financial expense. Having dental insurance can help cover the costs. Help keep your family's smiles healthy with dental insurance.

Vision - ameritas Vision insurance is a way to help cover expenses incurred for eye care services from eye care professionals such as optometrists and ophthalmologists. Regular eye exams can offer more than just measuring your eye sight! They can identify serious eye diseases early, allowing time for treatment. Most people don't realize that eye exams can also reveal the early signs of serious illnesses like diabetes, heart disease and high blood pressure.

Disability – unum Disability insurance pays a cash benefit and is designed to help protect you if you can’t work due to a covered injury or sickness. It pays a monthly benefit amount based on a percentage of your gross income, so you may continue to pay for everyday living expenses.

Benefits at a Glance

CANCER INSURANCE - allstate If cancer touches someone in your family, this plan may help ease the impact on your finances. Benefit payments are made directly to you, allowing you to pay for expenses like copayments, hospital stays, and house and car payments.

Accident Insurance - metlife Accidents are inevitable. Even though you can’t always prepare for unforeseen events, you can plan ahead. Accident Insurance is designed to help cover some of the expenses that can result from a covered accident, and benefit payments are made directly to you.

Hospital indemnity Insurance – Aflac *** NEW ***Even a small trip to the hospital can have a major impact on your finances. Hospital Indemnity Insurance provides financial assistance to help with out-of-pocket expenses that major medical insurance doesn’t cover.

Critical illness Insurance – Aflac *** NEW ***If you experience an event such as a heart attack or stroke, Critical Illness Insurance may help. It pays a lump sum amount to help with expenses that may not be covered by major medical insurance – house payments, everyday expenses, lost income, and more.

Hospital Gap Insurance - sis How will you prepare for out-of-pocket expenses from hospital and doctor bills? Most insurance will only cover a portion of your overall medical expenses. The medical gap plan is designed to help cover your out-of-pocket expenses that can really add up. Supplementing your major medical with Medical Gap Insurance may help you pay for expenses such as deductibles, co-payments, and co-insurance.

Permanent, Portable Life Insurance - TEXAS LIFE Ensuring your family is financially covered in the event of a loss is an important way of showing them you care about their needs. Life Insurance can help. Portable, Individual Life Insurance policies may help your family in the event of your death. The application process is simple. You only have to answer three health questions, and there are no medical exams required.

GROUP LIFE - dearborn Group life insurance allows you to purchase affordable life insurance on yourself, spouse and dependent children. This is term insurance, available as long as you are employed by district. Employees enrolling in the coverage after the first 31 days of their employment will be subject to insurability and must complete a health questionnaire prior to coverage being issued.

Legal - legalshieldPre-paid legal provides access to a variety of legal services for you and your family at an affordable monthly cost. These services include, but are not limited to, advice on unlimited issues, attorney letters or calls made on your behalf, and contract and document review. Simply call an 800 number to access legal counsel and advice from qualified lawyers. This product provides peace of mind in today’s litigious environment.

Aflac Group Critical IllnessINSURANCE – PLAN INCLUDES BENEFITS FOR CANCER AND HEALTH SCREENING

We help take care of your expenses while you take care of yourself.

®

IV (6/19)AGC1802834 R2

The plan does not contain comprehensive adult wellness benefits as defined by law.

What you need, when you need it.

Group critical illness insurance pays

cash benefits that you can use any

way you see fit.

AFLAC GROUP CRITICAL ILLNESS CIG

Aflac can help ease the financial stress of surviving a critical illness.

Chances are you may know someone who’s been diagnosed with a critical

illness. You can’t help notice the difference in the person’s life—both physically

and emotionally. What’s not so obvious is the impact a critical illness may have on

someone’s personal finances.

That’s because while a major medical plan may pay for a good portion of the

costs associated with a critical illness, there are a lot of expenses that may not be

covered. And, during recovery, having to worry about out-of-pocket expenses is the

last thing anyone needs.

That’s the benefit of an Aflac Group Critical Illness plan.

It can help with the treatment costs of covered critical illnesses, such as a heart

attack or stroke.

More importantly, the plan helps you focus on recuperation instead of the

distraction of out-of-pocket costs. With the Critical Illness plan, you receive cash

benefits directly (unless otherwise assigned)—giving you the flexibility to help pay

bills related to treatment or to help with everyday living expenses.

CIG For more than 60 years, Aflac has been dedicated to helping provide individuals and families peace of mind and financial security when they’ve needed it most. The Aflac Group Critical Illness plan is just another innovative way to help make sure you’re well protected.

Here’s why the Aflac Group Critical Illness plan may be right for you.

How it works

Amount payable based on $10,000 Initial Diagnosis Benefit.

Aflac Group Critical Illness

coverage is selected.

You experience chest pains

and numbness in the left arm.

You visit the emergency

room.

A physician determines

that you have suffered a

heart attack.

Aflac Group Critical Illness pays an Initial Diagnosis Benefit of

$10,000

The Aflac Group Critical Illness plan benefits include:

• Critical Illness Benefit payable for:

– Cancer

– Heart Attack (Myocardial Infarction)

– Stroke

– Kidney Failure (End-Stage Renal Failure)

– Major Organ Transplant

– Bone Marrow Transplant (Stem Cell Transplant)

– Sudden Cardiac Arrest

– Coronary Artery Bypass Surgery

– Non-Invasive Cancer

– Skin Cancer

– Severe Burn

– Coma

– Paralysis

– Loss of Sight

– Loss of Hearing

– Loss of Speech

• Health Screening Benefit

But it doesn’t stop there. Having group critical illness insurance from Aflac means that you may have added financial resources to help with medical costs or ongoing living expenses.

For more information, ask your insurance agent/producer, call 1.800.433.3036, or visit aflacgroupinsurance.com.

Features:

• Benefits are paid directly to you, unless otherwise assigned.

• Coverage is available for you, your spouse, and dependent children.

• Coverage may be continued (with certain stipulations). That means you can take it with you if you change jobs or retire.

COVERED CRITICAL ILLNESSES:

CANCER (Internal or Invasive) 100%

HEART ATTACK (Myocardial Infarction) 100%

STROKE (Ischemic or Hemorrhagic) 100%

MAJOR ORGAN TRANSPLANT (25% of this benefit is payable for insureds placed on a transplant list for a major organ transplant) 100%

KIDNEY FAILURE (End-Stage Renal Failure) 100%

BONE MARROW TRANSPLANT (Stem Cell Transplant) 100%

SUDDEN CARDIAC ARREST 100%

SEVERE BURN* 100%

PARALYSIS** 100%

COMA** 100%

LOSS OF SPEECH / SIGHT / HEARING** 100%

NON-INVASIVE CANCER 25%

CORONARY ARTERY BYPASS SURGERY 25%

INITIAL DIAGNOSISWe will pay a lump sum benefit upon initial diagnosis of a covered critical illness when such diagnoses is caused by or solely attributed to an underlying disease. Cancer diagnoses are subject to the cancer diagnosis limitation. Benefits will be based on the face amount in effect on the critical illness date of diagnosis.

ADDITIONAL DIAGNOSISWe will pay benefits for each different critical illness after the first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation.

REOCCURRENCEWe will pay benefits for the same critical illness after the first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation.

CHILD COVERAGE AT NO ADDITIONAL COSTEach dependent child is covered at 50 percent of the primary insured’s benefit amount at no additional charge. Children-only coverage is not available.

SKIN CANCER BENEFITWe will pay $250 for the diagnosis of skin cancer. We will pay this benefit once per calendar year.

Benefits Overview

The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions.

*This benefit is only payable for a burn due to, caused by, and attributed to, a covered accident.**These benefits are payable for loss due to a covered underlying disease or a covered accident.

WAIVER OF PREMIUMIf you become totally disabled due to a covered critical illness prior to age 65, after 90 continuous days of total disability, we will waive premiums for you and any of your covered dependents. As long as you remain totally disabled, premiums will be waived up to 24 months, subject to the terms of the plan.

SUCCESSOR INSURED BENEFITIf spouse coverage is in force at the time of the primary insured’s death, the surviving spouse may elect to continue coverage. Coverage would continue at the existing spouse face amount and would also include any dependent child coverage in force at the time.

HEALTH SCREENING BENEFIT (Employee and Spouse only)We will pay $100 for health screening tests performed while an insured’s coverage is in force. We will pay this benefit once per calendar year.

This benefit is only payable for health screening tests performed as the result of preventive care, including tests and diagnostic procedures ordered in connection with routine examinations. This benefit is payable for the covered employee and spouse. This benefit is not paid for dependent children.

PROGRESSIVE DISEASE RIDER

AMYOTROPHIC LATERAL SCLEROSIS (ALS OR LOU GEHRIG’S DISEASE) 100%

SUSTAINED MULTIPLE SCLEROSIS 100%

These benefits will be paid based on the face amount in effect on the critical illness date of diagnosis.

OPTIONAL BENEFITS RIDER

BENIGN BRAIN TUMOR 100%

ADVANCED ALZHEIMER’S DISEASE 25%

ADVANCED PARKINSON’S DISEASE 25%

These benefits will be paid based on the face amount in effect on the critical illness date of diagnosis.

LIMITATIONS AND EXCLUSIONS

IF DIAGNOSIS OCCURS AFTER THE AGE OF 70, HALF OF THE BENEFIT IS PAYABLE.

All limitations and exclusions that apply to the critical illness plan also apply to the riders unless amended by the riders.

Cancer Diagnosis Limitation Benefits are payable for cancer and/or non-invasive cancer as long as the insured:

• Is treatment-free from cancer for at least 12 months before the diagnosis date; and

• Is in complete remission prior to the date of a subsequent diagnosis, as evidenced by the absence of all clinical, radiological, biological, and biochemical proof of the presence of the cancer.

EXCLUSIONS We will not pay for loss due to:

• Self-Inflicted Injuries – injuring or attempting to injure oneself intentionally or taking action that causes oneself to become injured;

− In Alaska: injuring or attempting to injure oneself intentionally

• Suicide – committing or attempting to commit suicide, while sane or insane;

− In Missouri: committing or attempting to commit suicide, while sane

− In Illinois and Minnesota: this exclusion does not apply

• Illegal Acts – participating or attempting to participate in an illegal activity, or working at an illegal job:

− In Arizona: participating in or attempting to commit a felony, or being engaged in an illegal occupation;

− In Florida: participating or attempting to participate in an illegal activity, or

working at an illegal occupation;

− In Illinois and Pennsylvania: Illegal Occupation - committing or attempting to commit a felony or being engaged in an illegal occupation;

− In Michigan: Illegal Occupation – the commission of or attempt to commit a felony, or being engaged in an illegal occupation;

− In Nebraska: being engaged in an illegal occupation, or commission of or attempting to commit a felony;

− In Ohio: committing or attempting to commit a felony, or working at an illegal job

• Participation in Aggressive Conflict: − War (declared or undeclared) or military conflicts;

-In Florida: War does not include acts of terrorism

-In Oklahoma: War, or act of war, declared or undeclared when serving in the military service or an auxiliary unit thereto

− Insurrection or riot

− Civil commotion or civil state of belligerence

• Illegal Substance Abuse: − Abuse of legally-obtained prescription medication

− Illegal use of non-prescription drugs

− In Arizona: Being intoxicated or under the influence of any narcotic unless administered on the advice of a physician

− In Michigan, Nevada, and South Dakota: this exclusion does not apply

Diagnosis, treatment, testing, and confinement must be in the United States or its territories.

SPECIFIED DISEASES RIDER Percentage of Face Amount

Addison’s Disease, Cerebrospinal Meningitis, Diphtheria, Huntington’s Chorea, Legionnaire’s Disease, Malaria, Muscular Dystrophy, Myasthenia Gravis, Necrotizing Fasciitis, Osteomyelitis, Poliomyelitis (Polio), Rabies, Sickle Cell Anemia, Systemic Lupus, Systemic Sclerosis (Scleroderma), Tetanus, Tuberculosis

We will pay the benefit shown if an insured is diagnosed with one of the diseases listed and the date of diagnosis is while the rider is in force.

25%

CHILDHOOD CONDITIONS RIDER

CYSTIC FIBROSIS 50%

CEREBRAL PALSY 50%

CLEFT LIP OR CLEFT PALATE 50%

DOWN SYNDROME 50%

PHENYLALANINE HYDROXYLASE DEFICIENCY DISEASE (PKU) 50%

SPINA BIFIDA 50%

TYPE 1 DIABETES 50%

One Time Benefit Amount

AUTISM SPECTRUM DISORDER (ASD) $3,000

Benefits are payable if a dependent child is diagnosed with one of the conditions listed.

IV (8/19)AGC1801293 R2

Aflac Group Hospital Indemnity INSURANCE

Even a small trip to the hospital can have a major impact on your finances.

Here’s a way to help make your visit a little more affordable.

The plan that can help with expenses and protect your savings.

Does your major medical insurance cover all of your bills?

Even a minor trip to the hospital can present you with unexpected expenses and medical bills. And even with major medical insurance, your plan may only pay a portion of your entire stay.

That’s how the Aflac Group Hospital Indemnity plan can help.

It provides financial assistance to enhance your current coverage. So you may be able to avoid dipping into savings or having to borrow to address out-of-pocket-expenses major medical insurance was never intended to cover. Like transportation and meals for family members, help with child care, or time away from work, for instance.

The Aflac Group Hospital Indemnity plan benefits include the following:

• Hospital Confinement Benefit

• Hospital Admission Benefit

• Hospital Intensive Care Benefit and more

AFLAC GROUP HOSPITAL INDEMNITY HIG

Policy Series C80000

How it works

The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions.

The Aflac Group

Hospital Indemnity High plan is

selected.

The insured has a high fever and

goes to the emergency

room.

The physician admits the insured into the hospital.

The insured is released after two

days.

The Aflac Group Hospital Indemnity High plan pays

$2,400 Amount payable was generated based on benefit amounts for: Hospital Admission ($2,000), and Hospital Confinement ($200 per day).

Benefits OverviewHIGH MID

HOSPITAL ADMISSION BENEFIT per confinement (once per covered sickness or accident per calendar year for each insured)Payable when an insured is admitted to a hospital and confined as an in-patient because of a covered accidental injury or covered sickness. We will not pay benefits for confinement to an observation unit, or for emergency room treatment or outpatient treatment. We will not pay benefits for admission of a newborn child following his birth; however, we will pay for a newborn’s admission to a Hospital Intensive Care Unit if, following birth, he is confined as an inpatient as a result of a covered accidental injury or covered sickness (including congenital defects, birth abnormalities, and/or premature birth).

$2,000 $1,000

HOSPITAL CONFINEMENT per day (maximum of 31 days per confinement for each covered sickness or accident for each insured)Payable for each day that an insured is confined to a hospital as an in-patient as the result of a covered accidental injury or covered sickness. If we pay benefits for confinement and the insured becomes confined again within six months because of the same or related condition, we will treat this confinement as the same period of confinement. This benefit is payable for only one hospital confinement at a time even if caused by more than one covered accidental injury, more than one covered sickness, or a covered accidental injury and a covered sickness.

$200 $150

HOSPITAL INTENSIVE CARE BENEFIT per day (maximum of 10 days per confinement for each covered sickness or accident for each insured) Payable for each day when an insured is confined in a Hospital Intensive Care Unit because of a covered accidental injury or covered sickness. We will pay benefits for only one confinement in a Hospital's Intensive Care Unit at a time. Once benefits are paid, if an insured becomes confined to a Hospital's Intensive Care Unit again within six months because of the same or related condition, we will treat this confinement as the same period of confinement.

This benefit is payable in addition to the Hospital Confinement Benefit.

$200 $150

INTERMEDIATE INTENSIVE CARE STEP-DOWN UNIT per day (maximum of 10 days per confinement for each covered sickness or accident for each insured)Payable for each day when an insured is confined in an Intermediate Intensive Care Step-Down Unit because of a covered accidental injury or covered sickness. We will pay benefits for only one confinement in an Intermediate Intensive Care Step-Down Unit at a time.

Once benefits are paid, if an insured becomes confined to a Hospital's Intermediate Intensive Care Step-Down Unit again within six months because of the same or related condition, we will treat this confinement as the same period of confinement.

This benefit is payable in addition to the Hospital Confinement Benefit.

$100 $75

LIMITATIONS AND EXCLUSIONS

EXCLUSIONS (in Montana: LIMITATIONS)

We will not pay for loss due to:

• War – voluntarily participating in war, any act of war, or military conflicts, declared or undeclared, or voluntarily participating or serving in the military, armed forces, or an auxiliary unit thereto, or contracting with any country or international authority. (We will return the prorated premium for any period not covered by the certificate when the insured is in such service.) War also includes voluntary participation in an insurrection, riot, civil commotion or civil state of belligerence. War does not include acts of terrorism (except in Illinois).

− In Connecticut: a riot is not excluded.

− In Oklahoma: War, or any act of war, declared or undeclared, when serving in the military, armed forces, or an auxiliary unit thereto. (We will return the prorated premium for any period not covered by the certificate when the insured is in such service.) War does not include acts of terrorism.

• Suicide – committing or attempting to commit suicide, while sane or insane.

− In Missouri, Montana, and Vermont: committing or attempting to commit suicide, while sane.

− In Minnesota: this exclusion does not apply.

• Self-Inflicted Injuries – injuring or attempting to injure oneself intentionally.

− In Missouri: injuring or attempting to injure oneself intentionally which is obviously not an

HIG

In order to receive benefits for accidental injuries due to a covered accident, an insured must be admitted within six months of the date of the covered accident (in Washington, twelve months).

SUCCESSOR INSURED BENEFITIf spouse coverage is in force at the time of the employee’s death, the surviving spouse may elect to continue coverage. Coverage would continue according to the existing plan and would also include any dependent child coverage in force at the time.

Robstown ISD

ACCIDENT INSURANCE BENEFITS With MetLife, you’ll have a choice of two comprehensive plans which provide payments in addition to any other insurance payments you may receive. Here are just some of the covered events/services.

Benefit Type1 Low Plan MetLife Accident Insurance Pays YOU

High Plan MetLife Accident Insurance Pays YOU

Injuries

Fractures2 $50 – $3,000 $100 – $6,000

Dislocations2 $50 – $3,000 $100 – $6,000

Second and Third Degree Burns $50 – $5,000 $100 – $10,000

Skin Graft Benefit 50% of Burn Benefit 50% of Burn Benefit

Concussions $200 $400

Coma Benefit $5,000 $10,000

Ruptured Disk with Surgical Repair Benefit $500 $1,000

Torn Cartiage in Knee Benefit – with or without surgical repair $100 or $500 $150 or $750

Cuts/Lacerations $25 – $200 $50 – $400

Torn/Ruptred/Severed Tendon/Ligament/Rotator Cuff Benefit $100-$750 $150-$1,000

Broken Tooth Benefit $25-$100 $50-$200

Eye Injuries $200 $300

Medical Services & Treatment

Ground Ambulance $200 $300

Air Ambulance $750 $1,000

Emergency Care $25 – $50 $50 – $100

Non-Emergency Care $25 $50

Medical Testing Benefit $100 $200

Physician Follow-Up $50 $75

Transportation Benefit $200 $400

Therapy Services (including physical therapy) $15 $25

Pain Management Benefit for Epidural Anesthesia $50 $100

Prosthetic Device Benefit $500 or $1,000 $750 or $1,500

Medical Appliances $50 – $500 $100 – $1,000

Modification Benefit $500 $1,000

Blood/Plasma/Platelets Benefit $300 $400

Inpatient Surgery $100 – $1,000 $200 – $2,000

MetLife Accident Insurance Plan Summary

Outpatient Ambulatory Surgery Benefit $150 $300

Hospital3 Coverage (Accident)

Admission $500 or $1,000 $1,000 or $2,000

Confinement (non-ICU confinement paid for up to 365 days. ICU confinement paid for 30 days)

$100 (non-ICU) – $200 (ICU) a day $200 (non-ICU) – $400 (ICU) a day

Inpatient Rehab (paid per accident) $100 a day $200 a day

Benefit Type1 Low Plan MetLife Accident Insurance Pays YOU

High Plan MetLife Accident Insurance Pays YOU

Basic Accidental Death

Employee $25,000 $50,000

Spouse $12,500 $25,000

Child(ren) $5,000 $10,000

Accidental Death – Common Carrier Benefit

Employee $75,000 $150,000

Spouse $37,500 $75,000

Child(ren) $15,000 $30,000

Dismemberment, Loss & Paralysis

Basic Dismemberment Benefit $250 – $2,500 $500 - $10,000

Catastrophic Dismemberment/Functional Loss Benefit $10,000 $50,000

Paralysis Benefit $5,000 or $10,000 $25,000 or $50,000

Other Benefits

Lodging – for accompanying companion’s lodging more than 50 miles from the insured's primary residence during insured’s hospitalization due to an accident

$100 per day

$200 per day

BENEFIT PAYMENT EXAMPLE

Covered Event1 Benefit Amount8

Ambulance (ground) $300

Emergency Care $100

Physician Follow-Up ($75 x 2) $150 Medical Testing $200 Concussion $400

Broken Tooth (repaired by crown) $200

Benefits paid by MetLife Group Accident Insurance $1,350

Kathy’s daughter, Molly, plays soccer on the varsity high school team. During a recent game, she collided with an opposing player, was knocked unconscious and taken to the local emergency room by ambulance for treatment. The ER doctor diagnosed a concussion and a broken tooth. He ordered a CT scan to check for facial fractures too, since Molly’s face was very swollen. Molly was released to her primary care physician for follow-up treatment, and her dentist repaired her broken tooth with a crown. Depending on her health insurance, Kathy’s out-of-pocket costs could run into hundreds of dollars to cover expenses like insurance co-payments and deductibles. MetLife Group Accident Insurance payments can be used to help cover these unexpected costs.

INSURANCE RATES

MetLife offers competitive group rates and convenient payroll deduction so you don’t have to worry about writing a check or missing a payment! Your employee rates are outlined below.

Rates – Low Plan Type Monthly Employee $7.46 Employee +Spouse $11.58

Employee +Children $13.51

Employee + Spouse/Children $18.00

Rates – High Plan Type Monthly

Employee $14.26 Employee +Spouse $22.11

Employee +Children

$25.76

Employee + Spouse/Children $34.33

QUESTIONS & ANSWERS

Who is eligible to enroll for this accident coverage? You are eligible to enroll yourself and your eligible family members!9 You need to enroll during your Enrollment Period and be actively at work for your coverage to be effective. How do I pay for my accident coverage? Premiums will be conveniently paid through payroll deduction, so you don’t have to worry about writing a check or missing a payment. What happens if my employment status changes? Can I take my coverage with me? Yes, you can take your coverage with you. You will need to continue to pay your premiums to keep your coverage in force. Your coverage will only end if you stop paying your premium or if your employer offers you similar coverage with a different insurance carrier. Who do I call for assistance? Please call MetLife directly at 1-800-GET-MET8 (1-800-438-6388) and talk with a benefits consultant. Or visit our website: mybenefits.metlife.com

ROBSTOWN INDEPENDENT SCHOOL DISTRICT Dental Highlight Sheet

Low Plan: Dental Plan Summary Policy # 400360 Effective Date: 11/1/2019

Plan Benefit Type 1 MCE Type 2 MCE Type 3 MCE

Deductible $50/Calendar Year Type 2 & 3 Waived Type 1 3 Family Maximum Maximum (per person) $1,000 per calendar year Allowance MCE Waiting Period Type 3 – 12 months

Orthodontia Summary - Child Only Coverage

Allowance U&C Plan Benefit 50% Lifetime Maximum (per person) $750 Waiting Period 12 months

Sample Procedure Listing (Current Dental Terminology © American Dental Association.)

Type 1 Type 2 Type 3

⚫ Routine Exam

(1 in 6 months)

⚫ Bitewing X-rays

(1 in 12 months)

⚫ Full Mouth/Panoramic X-rays

(1 in 5 years)

⚫ Periapical X-rays

⚫ Cleaning

(1 in 6 months)

⚫ Fluoride for Children 13 and under

(1 in 12 months)

⚫ Sealants (age 13 and under)

⚫ Space Maintainers

⚫ Restorative Amalgams

⚫ Restorative Composites

(anterior and posterior teeth)

⚫ Denture Repair

⚫ Simple Extractions

⚫ Complex Extractions

⚫ Anesthesia

⚫ Onlays

⚫ Crowns

(1 in 10 years per tooth)

⚫ Crown Repair

⚫ Endodontics (nonsurgical)

⚫ Endodontics (surgical)

⚫ Periodontics (nonsurgical)

⚫ Periodontics (surgical)

⚫ Prosthodontics (fixed bridge; removable

complete/partial dentures)

(1 in 10 years)

Monthly Rates

Employee Only (EE) $23.56 EE + 1 Dependent $43.04 EE + 2 or more Dependents $66.84

Ameritas Information

We're Here to Help This plan was designed specifically for the associates of ROBSTOWN INDEPENDENT SCHOOL DISTRICT. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritas.com.

Rx Savings

Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card.

ROBSTOWN INDEPENDENT SCHOOL DISTRICT Dental Highlight Sheet

High Plan: Dental Plan Summary Policy # 400360 Effective Date: 11/1/2019

Plan Benefit Type 1 100% Type 2 80% Type 3 50%

Deductible $50/Calendar Year Type 2 & 3 Waived Type 1 3 Family Maximum Maximum (per person) $1,000 per calendar year Allowance Ameritas U&C Dental Rewards® Included Waiting Period Type 3 – 12 months

Orthodontia Summary - Child Only Coverage

Allowance U&C Plan Benefit 50% Lifetime Maximum (per person) $1,000 Waiting Period 12 months

Sample Procedure Listing (Current Dental Terminology © American Dental Association.)

Type 1 Type 2 Type 3

⚫ Routine Exam

(1 in 6 months)

⚫ Bitewing X-rays

(1 in 12 months)

⚫ Full Mouth/Panoramic X-rays

(1 in 5 years)

⚫ Periapical X-rays

⚫ Cleaning

(1 in 6 months)

⚫ Fluoride for Children 13 and under

(1 in 12 months)

⚫ Sealants (age 13 and under)

⚫ Space Maintainers

⚫ Restorative Amalgams

⚫ Restorative Composites

(anterior and posterior teeth)

⚫ Denture Repair

⚫ Simple Extractions

⚫ Complex Extractions

⚫ Anesthesia

⚫ Onlays

⚫ Crowns

(1 in 10 years per tooth)

⚫ Crown Repair

⚫ Endodontics (nonsurgical)

⚫ Endodontics (surgical)

⚫ Periodontics (nonsurgical)

⚫ Periodontics (surgical)

⚫ Prosthodontics (fixed bridge; removable

complete/partial dentures)

(1 in 10 years)

Monthly Rates

Employee Only (EE) $30.92 EE + 1 Dependent $55.16 EE + 2 or more Dependents $86.76

Ameritas Information

We're Here to Help This plan was designed specifically for the associates of ROBSTOWN INDEPENDENT SCHOOL DISTRICT. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritas.com.

Rx Savings


ROBSTOWN INDEPENDENT SCHOOL DISTRICT Eye Care Highlight Sheet

Plan 1: EyeChoice ViewPointe® Plan H Summary Policy # 400360 Effective Date: 11/1/2019

EyeMed Access Network Out of Network Deductibles

$10 Exam No deductible $25 Eye Glass Lenses

Annual Eye Exam Covered in full Up to $35 Lenses (per pair)

Single Vision Covered in full Up to $25 Bifocal Covered in full Up to $40 Trifocal Covered in full Up to $55 Lenticular 20% discount No benefit Progressive See lens options NA

Contacts Fit & Follow Up Exams

Standard Standard: Member cost up to $55 No benefit Premium (Allowance) Premium: 10% off of retail No benefit

Elective Up to $115 Up to $100 Medically Necessary Covered in full Up to $200

Frames $100 Up to $45 Frequencies (months)

Exam/Lens/Frame 12/12/24 12/12/24 Based on date of service Based on date of service

Lens Options (member cost)

EyeMed Access Network Out of Network Progressive Lenses No benefit

Standard Standard: $65 + lens deductible Premium Premium: lens cost

- 20% discount - $120 allowance

+ Standard Progressive cost

Std. Polycarbonate $40 No benefit Tint (solid and gradient) $15 No benefit Scratch Resistant Coating $15 No benefit Anti-Reflective Coating $45 No benefit Ultraviolet Coating $15 No benefit Lasik or PRK Average discount of 15% off retail price or 5% off

promotional price at US Laser Network participating providers.

No benefit

Monthly Rates

Employee Only (EE) $6.52 EE + Spouse $14.04 EE + Child(ren) $11.40 EE + Family $18.88

ROBSTOWN INDEPENDENT SCHOOL DISTRICT Eye Care Highlight Sheet

Additional ViewPointe® H Features

EyeMed In-Network Discounts 15% discount off the remaining balance in excess of the conventional contact lens allowance. 20% discount off the remaining balance in excess of the frame allowance. 20% discount on items not covered by the plan at network providers, which may not be combined with any other discounts or promotional offers. This discount does not apply to EyeMed Provider's professional services, or contact lenses.

EyeMed In-Network Secondary Purchase Plan Members receive a 40% discount on a complete pair of glasses once the funded benefit has been exhausted. Members receive a 15% discount off the retail price on conventional contact lenses once the funded benefit has been exhausted. Discount applies to materials only.

Contact Lens Replacement by Mail Program After exhausting the contact lens benefit, replacement lenses may be obtained at significant discounts on-line. Visit EyeMedvisioncare.com for details.

Rx Savings


Eye Care Plan Member Service

ViewPointe eye care from Ameritas Group features the money-saving eye care network of EyeMed Vision Care. Customer service is available to plan members through EyeMed's well-trained and helpful service representatives. Call or go online to locate the nearest EyeMed Access network provider, view plan benefit information and more. EyeMed Customer Care Center: 1-866-289-0614 ⚫ Service representative hours: 8 a.m. to 11 p.m. ET Monday through Saturday, 11 a.m. to 8 p.m. ET Sunday ⚫ Interactive Voice Response available 24/7 Locate an EyeMed provider at: ameritas.com View plan benefit information at: eyemedvisioncare.com

Section 125

This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period.

Worldwide Support

When our members travel abroad, they’ll have peace of mind knowing that should a dental or vision need arise, help is just a phone call away. Through AXA Assistance, Ameritas offers its dental and vision plan members 24-hour access to dental or vision provider referrals when traveling outside the U.S. Immediately after a call is made to AXA, an assistance coordinator assesses the situation, provides credible provider referrals and can even assist with making the appointment. Within 48 hours following the appointment, the coordinator calls the member to find out if additional assistance is needed. If all is well, the case is closed. Then, the plan member may submit a claim to Ameritas for reimbursement consideration based on applicable plan benefits. Contact AXA Assistance USA toll free by calling 866-662-2731, or call collect from anywhere in the world by dialing 1-312-935-3727.

Language Services

We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance.

This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

ROBSTOWN I S D Costs Effective as of November 1, 2006

Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year)

Product: Renewal Rates WITH New Line of Coverage

Educator Select Income Protection Plan

ADEA II Duration of Benefits

Elimination Period (Days)

Injury (Days) 0* 7* 14* 30* 90 180

Sickness (Days) 7* 7* 14* 30* 90 180 Annual

Earnings Monthly Earnings

Maximum Monthly

Benefit

3600 300 200 9.66 9.50 6.20 5.36 2.04 1.42

5400 450 300 14.49 14.25 9.30 8.04 3.06 2.13

7200 600 400 19.32 19.00 12.40 10.72 4.08 2.84

9000 750 500 24.15 23.75 15.50 13.40 5.10 3.55

10800 900 600 28.98 28.50 18.60 16.08 6.12 4.26

12600 1050 700 33.81 33.25 21.70 18.76 7.14 4.97

14400 1200 800 38.64 38.00 24.80 21.44 8.16 5.68

16200 1350 900 43.47 42.75 27.90 24.12 9.18 6.39

18000 1500 1000 48.30 47.50 31.00 26.80 10.20 7.10 19800 1650 1100 53.13 52.25 34.10 29.48 11.22 7.81

21600 1800 1200 57.96 57.00 37.20 32.16 12.24 8.52

23400 1950 1300 62.79 61.75 40.30 34.84 13.26 9.23

25200 2100 1400 67.62 66.50 43.40 37.52 14.28 9.94

27000 2250 1500 72.45 71.25 46.50 40.20 15.30 10.65

28800 2400 1600 77.28 76.00 49.60 42.88 16.32 11.36

30600 2550 1700 82.11 80.75 52.70 45.56 17.34 12.07

32400 2700 1800 86.94 85.50 55.80 48.24 18.36 12.78

34200 2850 1900 91.77 90.25 58.90 50.92 19.38 13.49 36000 3000 2000 96.60 95.00 62.00 53.60 20.40 14.20

37800 3150 2100 101.43 99.75 65.10 56.28 21.42 14.91

39600 3300 2200 106.26 104.50 68.20 58.96 22.44 15.62

41400 3450 2300 111.09 109.25 71.30 61.64 23.46 16.33

43200 3600 2400 115.92 114.00 74.40 64.32 24.48 17.04

45000 3750 2500 120.75 118.75 77.50 67.00 25.50 17.75

46800 3900 2600 125.58 123.50 80.60 69.68 26.52 18.46

48600 4050 2700 130.41 128.25 83.70 72.36 27.54 19.17

50400 4200 2800 135.24 133.00 86.80 75.04 28.56 19.88

52200 4350 2900 140.07 137.75 89.90 77.72 29.58 20.59 54000 4500 3000 144.90 142.50 93.00 80.40 30.60 21.30

55800 4650 3100 149.73 147.25 96.10 83.08 31.62 22.01

57600 4800 3200 154.56 152.00 99.20 85.76 32.64 22.72

59400 4950 3300 159.39 156.75 102.30 88.44 33.66 23.43

61200 5100 3400 164.22 161.50 105.40 91.12 34.68 24.14

63000 5250 3500 169.05 166.25 108.50 93.80 35.70 24.85

64800 5400 3600 173.88 171.00 111.60 96.48 36.72 25.56

66600 5550 3700 178.71 175.75 114.70 99.16 37.74 26.27

68400 5700 3800 183.54 180.50 117.80 101.84 38.76 26.98 70200 5850 3900 188.37 185.25 120.90 104.52 39.78 27.69

72000 6000 4000 193.20 190.00 124.00 107.20 40.80 28.40

73800 6150 4100 198.03 194.75 127.10 109.88 41.82 29.11

75600 6300 4200 202.86 199.50 130.20 112.56 42.84 29.82

77400 6450 4300 207.69 204.25 133.30 115.24 43.86 30.53

79200 6600 4400 212.52 209.00 136.40 117.92 44.88 31.24

81000 6750 4500 217.35 213.75 139.50 120.60 45.90 31.95

82800 6900 4600 222.18 218.50 142.60 123.28 46.92 32.66

84600 7050 4700 227.01 223.25 145.70 125.96 47.94 33.37

86400 7200 4800 231.84 228.00 148.80 128.64 48.96 34.08 88200 7350 4900 236.67 232.75 151.90 131.32 49.98 34.79

90000 7500 5000 241.50 237.50 155.00 134.00 51.00 35.50

91800 7650 5100 246.33 242.25 158.10 136.68 52.02 36.21

93600 7800 5200 251.16 247.00 161.20 139.36 53.04 36.92

REF #: 2857442 * If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Find your Annual/Monthly Earnings above to determine your Maximum Monthly Benefit. If your Annual/Monthly Earnings are not shown, use the next lower Annual/Monthly Earnings and corresponding Maximum Monthly Benefit. Or, you may refer to the Plan Highlights to calculate your Maximum Monthly Benefit based on your earnings.

ROBSTOWN I S D

Costs Effective as of November 1, 2006 Costs below are based on a Monthly payroll deduction

(Employer billing mode is based on 12 Payments per year)

Product: Renewal Rates WITH New Line of Coverage

Educator Select Income Protection Plan

ADEA II Duration of Benefits

Elimination Period (Days)

Injury (Days) 0* 7* 14* 30* 90 180

Sickness (Days) 7* 7* 14* 30* 90 180 Annual

Earnings Monthly Earnings

Maximum Monthly

Benefit

95400 7950 5300 255.99 251.75 164.30 142.04 54.06 37.63

97200 8100 5400 260.82 256.50 167.40 144.72 55.08 38.34

99000 8250 5500 265.65 261.25 170.50 147.40 56.10 39.05

100800 8400 5600 270.48 266.00 173.60 150.08 57.12 39.76

102600 8550 5700 275.31 270.75 176.70 152.76 58.14 40.47

104400 8700 5800 280.14 275.50 179.80 155.44 59.16 41.18

106200 8850 5900 284.97 280.25 182.90 158.12 60.18 41.89

108000 9000 6000 289.80 285.00 186.00 160.80 61.20 42.60

109800 9150 6100 294.63 289.75 189.10 163.48 62.22 43.31 111600 9300 6200 299.46 294.50 192.20 166.16 63.24 44.02

113400 9450 6300 304.29 299.25 195.30 168.84 64.26 44.73

115200 9600 6400 309.12 304.00 198.40 171.52 65.28 45.44

117000 9750 6500 313.95 308.75 201.50 174.20 66.30 46.15

118800 9900 6600 318.78 313.50 204.60 176.88 67.32 46.86

120600 10050 6700 323.61 318.25 207.70 179.56 68.34 47.57

122400 10200 6800 328.44 323.00 210.80 182.24 69.36 48.28

124200 10350 6900 333.27 327.75 213.90 184.92 70.38 48.99

126000 10500 7000 338.10 332.50 217.00 187.60 71.40 49.70 127800 10650 7100 342.93 337.25 220.10 190.28 72.42 50.41

129600 10800 7200 347.76 342.00 223.20 192.96 73.44 51.12

131400 10950 7300 352.59 346.75 226.30 195.64 74.46 51.83

133200 11100 7400 357.42 351.50 229.40 198.32 75.48 52.54

135000 11250 7500 362.25 356.25 232.50 201.00 76.50 53.25

REF #: 2857442 * If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Find your Annual/Monthly Earnings above to determine your Maximum Monthly Benefit. If your Annual/Monthly Earnings are not shown, use the next lower Annual/Monthly Earnings and corresponding Maximum Monthly Benefit. Or, you may refer to the Plan Highlights to calculate your Maximum Monthly Benefit based on your earnings.

Accelerated Death Benefit for Chronic Illness Rider Form ICC15-ULABR-CI-15 or ULABR-CI-15Accidental Death Benefit Form ICC 07-ULCL-ADB-07 or Form Series ULCL-ADB-07

MONTHLY NON-TOBACCO PREMIUMSEmployee Only with Accidental Death and Chronic Illness Riders

Non

-Tob

acco

Employee monthly p r e m i u m s

PureLife-plus — Standard Risk Table Premiums — Non-Tobacco — Express IssueGUARANTEED

Monthly Premiums for Life Insurance Face Amounts Shown PERIOD

Includes Added Cost for Age to Which

Issue Accidental Death Benefit (Ages 17-59) Coverage is

Age and Accelerated Death Benefit for Chronic Illness (All Ages) Guaranteed at

(ALB) $10,000 $25,000 $50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 Table Premium

15D-1 83

2-3 83

4-10 79

11-16 75

17-20 11.40 20.55 29.70 38.85 57.15 75.45 93.75 112.05 73

21-22 11.68 21.10 30.53 39.95 58.80 77.65 96.50 115.35 73

23-25 11.95 21.65 31.35 41.05 60.45 79.85 99.25 118.65 71

26 12.23 22.20 32.18 42.15 62.10 82.05 102.00 121.95 72

27 12.50 22.75 33.00 43.25 63.75 84.25 104.75 125.25 72

28 12.50 22.75 33.00 43.25 63.75 84.25 104.75 125.25 71

29 12.78 23.30 33.83 44.35 65.40 86.45 107.50 128.55 71

30-31 13.05 23.85 34.65 45.45 67.05 88.65 110.25 131.85 70

32 13.60 24.95 36.30 47.65 70.35 93.05 115.75 138.45 70

33 14.15 26.05 37.95 49.85 73.65 97.45 121.25 145.05 71

34 14.70 27.15 39.60 52.05 76.95 101.85 126.75 151.65 72

35 15.53 28.80 42.08 55.35 81.90 108.45 135.00 161.55 73

36 16.08 29.90 43.73 57.55 85.20 112.85 140.50 168.15 73

37 16.63 31.00 45.38 59.75 88.50 117.25 146.00 174.75 73

38 17.45 32.65 47.85 63.05 93.45 123.85 154.25 184.65 74

39 18.55 34.85 51.15 67.45 100.05 132.65 165.25 197.85 75

40 9.21 19.65 37.05 54.45 71.85 106.65 141.45 176.25 211.05 76

41 9.76 21.03 39.80 58.58 77.35 114.90 152.45 190.00 227.55 77

42 10.53 22.95 43.65 64.35 85.05 126.45 167.85 209.25 250.65 78

43 11.30 24.88 47.50 70.13 92.75 138.00 183.25 228.50 273.75 80

44 12.07 26.80 51.35 75.90 100.45 149.55 198.65 247.75 296.85 81

45 12.95 29.00 55.75 82.50 109.25 162.75 216.25 269.75 323.25 82

46 13.83 31.20 60.15 89.10 118.05 175.95 233.85 291.75 349.65 83

47 14.60 33.13 64.00 94.88 125.75 187.50 249.25 311.00 372.75 83

48 15.48 35.33 68.40 101.48 134.55 200.70 266.85 333.00 399.15 84

49 16.47 37.80 73.35 108.90 144.45 215.55 286.65 357.75 428.85 85

50 17.68 40.83 79.40 117.98 156.55 86

51 19.11 44.40 86.55 128.70 170.85 87

52 20.87 48.80 95.35 141.90 188.45 88

53 22.63 53.20 104.15 155.10 206.05 90

54 23.84 56.23 110.20 164.18 218.15 90

55 24.94 58.98 115.70 172.43 229.15 91

56 26.04 61.73 121.20 180.68 240.15 91

57 27.25 64.75 127.25 189.75 252.25 91

58 28.57 68.05 133.85 199.65 265.45 91

59 29.78 71.08 139.90 208.73 277.55 91

60 30.63 73.20 144.15 215.10 286.05 91

61 32.28 77.33 152.40 227.48 302.55 91

62 34.04 81.73 161.20 240.68 320.15 92

63 35.91 86.40 170.55 254.70 338.85 92

64 37.89 91.35 180.45 269.55 358.65 92

65 39.98 96.58 190.90 285.23 379.55 92

66 42.29 92

67 44.82 92

68 47.57 92

69 50.43 93

70 53.29 93

PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the

Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.

Form: 18M049-ICC EXP-K-M-3AD

19M022-C-ADB-CI NT 1097 (exp0221) Policy Form ICC18-PRFNG-NI-18 or Form Series PRFNG-NI-18

PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After theGuaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under “Permanent Coverage”.

Tob

acco

Employee monthly p r e m i u m s

PureLife-plus — Standard Risk Table Premiums — Tobacco — Express IssueGUARANTEED

M ont h l y Pr emi ums for L i fe I nsu r ance Face Amoun t s Show n PERI OD



Age and Accelerated Death Benefit for Chronic Illness (All Ages) Guaranteed at

(ALB) $10,000 $25,000 $50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 Table Premium15D-1 832-3 834-10 7911-16 7517-20 16.08 29.90 43.73 57.55 85.20 112.85 140.50 168.15 7021-22 16.63 31.00 45.38 59.75 88.50 117.25 146.00 174.75 7023-25 17.45 32.65 47.85 63.05 93.45 123.85 154.25 184.65 69

26 17.73 33.20 48.68 64.15 95.10 126.05 157.00 187.95 6927 18.00 33.75 49.50 65.25 96.75 128.25 159.75 191.25 6828 18.28 34.30 50.33 66.35 98.40 130.45 162.50 194.55 6829 18.55 34.85 51.15 67.45 100.05 132.65 165.25 197.85 68

30-31 20.75 39.25 57.75 76.25 113.25 150.25 187.25 224.25 6932 21.30 40.35 59.40 78.45 116.55 154.65 192.75 230.85 6933 21.58 40.90 60.23 79.55 118.20 156.85 195.50 234.15 6934 21.85 41.45 61.05 80.65 119.85 159.05 198.25 237.45 6835 23.23 44.20 65.18 86.15 128.10 170.05 212.00 253.95 6936 24.05 45.85 67.65 89.45 133.05 176.65 220.25 263.85 6937 25.43 48.60 71.78 94.95 141.30 187.65 234.00 280.35 7038 26.25 50.25 74.25 98.25 146.25 194.25 242.25 290.25 7039 27.90 53.55 79.20 104.85 156.15 207.45 258.75 310.05 7040 13.50 30.38 58.50 86.63 114.75 171.00 227.25 283.50 339.75 7241 14.27 32.30 62.35 92.40 122.45 182.55 242.65 302.75 362.85 7342 15.26 34.78 67.30 99.83 132.35 197.40 262.45 327.50 392.55 7443 16.80 38.63 75.00 111.38 147.75 220.50 293.25 366.00 438.75 7644 17.68 40.83 79.40 117.98 156.55 233.70 310.85 388.00 465.15 7745 18.89 43.85 85.45 127.05 168.65 251.85 335.05 418.25 501.45 7846 19.99 46.60 90.95 135.30 179.65 268.35 357.05 445.75 534.45 7947 21.09 49.35 96.45 143.55 190.65 284.85 379.05 473.25 567.45 7948 22.19 52.10 101.95 151.80 201.65 301.35 401.05 500.75 600.45 8049 23.95 56.50 110.75 165.00 219.25 327.75 436.25 544.75 653.25 8250 25.16 59.53 116.80 174.08 231.35 8251 27.03 64.20 126.15 188.10 250.05 8352 29.34 69.98 137.70 205.43 273.15 8553 31.21 74.65 147.05 219.45 291.85 8754 32.75 78.50 154.75 231.00 307.25 8755 34.29 82.35 162.45 242.55 322.65 8756 36.05 86.75 171.25 255.75 340.25 8757 37.70 90.88 179.50 268.13 356.75 8758 39.68 95.83 189.40 282.98 376.55 8759 41.33 99.95 197.65 295.35 393.05 8760 42.51 102.90 203.55 304.20 404.85 8761 45.37 110.05 217.85 325.65 433.45 8862 48.01 116.65 231.05 345.45 459.85 8863 50.54 122.98 243.70 364.43 485.15 8864 53.07 129.30 256.35 383.40 510.45 8965 55.71 135.90 269.55 403.20 536.85 8966 58.57 8967 61.65 8968 64.84 8969 68.25 8970 71.88 90

PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After theGuaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.


Non

-Tob

acco

Spouse/Child monthly p r e m i u m s

PureLife-plus — Standard Risk Table Premiums — Non-Tobacco — Express IssueGUARANTEED




Age Guaranteed at

(ALB) $10,000 $25,000 $50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 Table Premium15D-1 8.00 13.75 832-3 8.25 14.25 834-10 8.50 14.75 7911-16 8.75 15.25 7517-20 10.75 19.25 27.75 36.25 53.25 70.25 87.25 104.25 7321-22 11.00 19.75 28.50 37.25 54.75 72.25 89.75 107.25 7323-25 11.25 20.25 29.25 38.25 56.25 74.25 92.25 110.25 71

26 11.50 20.75 30.00 39.25 57.75 76.25 94.75 113.25 7227 11.75 21.25 30.75 40.25 59.25 78.25 97.25 116.25 7228 11.75 21.25 30.75 40.25 59.25 78.25 97.25 116.25 7129 12.00 21.75 31.50 41.25 60.75 80.25 99.75 119.25 71

30-31 12.25 22.25 32.25 42.25 62.25 82.25 102.25 122.25 7032 12.75 23.25 33.75 44.25 65.25 86.25 107.25 128.25 7033 13.25 24.25 35.25 46.25 68.25 90.25 112.25 134.25 7134 13.75 25.25 36.75 48.25 71.25 94.25 117.25 140.25 7235 14.50 26.75 39.00 51.25 75.75 100.25 124.75 149.25 7336 15.00 27.75 40.50 53.25 78.75 104.25 129.75 155.25 7337 15.50 28.75 42.00 55.25 81.75 108.25 134.75 161.25 7338 16.25 30.25 44.25 58.25 86.25 114.25 142.25 170.25 7439 17.25 32.25 47.25 62.25 92.25 122.25 152.25 182.25 7540 8.65 18.25 34.25 50.25 66.25 98.25 130.25 162.25 194.25 7641 9.15 19.50 36.75 54.00 71.25 105.75 140.25 174.75 209.25 7742 9.85 21.25 40.25 59.25 78.25 116.25 154.25 192.25 230.25 7843 10.55 23.00 43.75 64.50 85.25 126.75 168.25 209.75 251.25 8044 11.25 24.75 47.25 69.75 92.25 137.25 182.25 227.25 272.25 8145 12.05 26.75 51.25 75.75 100.25 149.25 198.25 247.25 296.25 8246 12.85 28.75 55.25 81.75 108.25 161.25 214.25 267.25 320.25 8347 13.55 30.50 58.75 87.00 115.25 171.75 228.25 284.75 341.25 8348 14.35 32.50 62.75 93.00 123.25 183.75 244.25 304.75 365.25 8449 15.25 34.75 67.25 99.75 132.25 197.25 262.25 327.25 392.25 8550 16.35 37.50 72.75 108.00 143.25 8651 17.65 40.75 79.25 117.75 156.25 8752 19.25 44.75 87.25 129.75 172.25 8853 20.85 48.75 95.25 141.75 188.25 9054 21.95 51.50 100.75 150.00 199.25 9055 22.95 54.00 105.75 157.50 209.25 9156 23.95 56.50 110.75 165.00 219.25 9157 25.05 59.25 116.25 173.25 230.25 9158 26.25 62.25 122.25 182.25 242.25 9159 27.35 65.00 127.75 190.50 253.25 9160 28.05 66.75 131.25 195.75 260.25 9161 29.55 70.50 138.75 207.00 275.25 9162 31.15 74.50 146.75 219.00 291.25 9263 32.85 78.75 155.25 231.75 308.25 9264 34.65 83.25 164.25 245.25 326.25 9265 36.55 88.00 173.75 259.50 345.25 9266 38.65 9267 40.95 9268 43.45 9269 46.05 9370 48.65 93



Tob

acco

Spouse/Child monthly p r e m i u m s

PureLife-plus — Standard Risk Table Premiums — Tobacco — Express IssueGUARANTEED




Age Guaranteed at

(ALB) $10,000 $25,000 $50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 Table Premium15D-1 832-3 834-10 7911-16 7517-20 15.00 27.75 40.50 53.25 78.75 104.25 129.75 155.25 7021-22 15.50 28.75 42.00 55.25 81.75 108.25 134.75 161.25 7023-25 16.25 30.25 44.25 58.25 86.25 114.25 142.25 170.25 69

26 16.50 30.75 45.00 59.25 87.75 116.25 144.75 173.25 6927 16.75 31.25 45.75 60.25 89.25 118.25 147.25 176.25 6828 17.00 31.75 46.50 61.25 90.75 120.25 149.75 179.25 6829 17.25 32.25 47.25 62.25 92.25 122.25 152.25 182.25 68

30-31 19.25 36.25 53.25 70.25 104.25 138.25 172.25 206.25 6932 19.75 37.25 54.75 72.25 107.25 142.25 177.25 212.25 6933 20.00 37.75 55.50 73.25 108.75 144.25 179.75 215.25 6934 20.25 38.25 56.25 74.25 110.25 146.25 182.25 218.25 6835 21.50 40.75 60.00 79.25 117.75 156.25 194.75 233.25 6936 22.25 42.25 62.25 82.25 122.25 162.25 202.25 242.25 6937 23.50 44.75 66.00 87.25 129.75 172.25 214.75 257.25 7038 24.25 46.25 68.25 90.25 134.25 178.25 222.25 266.25 7039 25.75 49.25 72.75 96.25 143.25 190.25 237.25 284.25 7040 12.55 28.00 53.75 79.50 105.25 156.75 208.25 259.75 311.25 7241 13.25 29.75 57.25 84.75 112.25 167.25 222.25 277.25 332.25 7342 14.15 32.00 61.75 91.50 121.25 180.75 240.25 299.75 359.25 7443 15.55 35.50 68.75 102.00 135.25 201.75 268.25 334.75 401.25 7644 16.35 37.50 72.75 108.00 143.25 213.75 284.25 354.75 425.25 7745 17.45 40.25 78.25 116.25 154.25 230.25 306.25 382.25 458.25 7846 18.45 42.75 83.25 123.75 164.25 245.25 326.25 407.25 488.25 7947 19.45 45.25 88.25 131.25 174.25 260.25 346.25 432.25 518.25 7948 20.45 47.75 93.25 138.75 184.25 275.25 366.25 457.25 548.25 8049 22.05 51.75 101.25 150.75 200.25 299.25 398.25 497.25 596.25 8250 23.15 54.50 106.75 159.00 211.25 8251 24.85 58.75 115.25 171.75 228.25 8352 26.95 64.00 125.75 187.50 249.25 8553 28.65 68.25 134.25 200.25 266.25 8754 30.05 71.75 141.25 210.75 280.25 8755 31.45 75.25 148.25 221.25 294.25 8756 33.05 79.25 156.25 233.25 310.25 8757 34.55 83.00 163.75 244.50 325.25 8758 36.35 87.50 172.75 258.00 343.25 8759 37.85 91.25 180.25 269.25 358.25 8760 38.85 93.75 185.25 276.75 368.25 8761 41.45 100.25 198.25 296.25 394.25 8862 43.85 106.25 210.25 314.25 418.25 8863 46.15 112.00 221.75 331.50 441.25 8864 48.45 117.75 233.25 348.75 464.25 8965 50.85 123.75 245.25 366.75 488.25 8966 53.45 8967 56.25 8968 59.15 8969 62.25 8970 65.55 90



IMPORTANT CONTACTS

Benefit Vendor Phone Website Medical TRS ActiveCare Aetna 800-222-9205 www.trsactivecareaetna.com

Dental Ameritas 800-487-5553 www.ameritas.com

Dental CC Dental 877-242-1463

Vision Ameritas 800-487-5553 www.ameritas.com

Disability UNUM 866-679-3054 www.UNUM.com

Cancer Allstate 800-521-3535 www.allstatebenefits.com

Accident Metlife 800-438-6388 www.metlife.com

Critical Illness AFLAC 800-992-3522 www.AFLAC.com

Hospital Indemnity AFLAC 800-992-3522 www.AFLAC.com

Gap SIS Link 800-767-6811 www.specialink.com

Legal LegalShield 800-654-7757 www.legalshield.com

Life Texas Life 800-283-9233 www.texaslife.com

Group Life Dearborn 800-348-4512 www.dearbornnational.com

Medical FSA and Dependent Care First Financial 800-523-8422 www.ffga.com

HSA (Health Savings Account) First Financial 800-523-8422 www.ffga.com

Limited Purpose Flex First Financial 800-523-8422 www.ffga.com

Edelia Trevino, ACCOUNT MANAGER 2009 RR 620 N STE 123, AUSTIN TX 78734

OFFICE: 800-672-9666 | EMAIL: [email protected]

http://www.ameritas.com/

http://www.ameritas.com/

http://www.unum.com/

http://www.allstatebenefits.com/

http://www.metlife.com/

http://www.aflac.com/

http://www.aflac.com/

http://www.specialink.com/

http://www.legalshield.com/

http://www.texaslife.com/

http://www.dearbornnational.com/

http://www.ffga.com/



plan year: november 1, 2019 october 31, 2020 robstown isd€¦ · by utilizing the section 125 ......

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