Companion Life Insurance Company

AdministrativeGuide

ContentsSection.Title

About Your Companion Life Administrative Guide

I. Online Services

II. New Enrollments• WhoisEligibleforinsurance?• Processingnewenrollments• Whenahealthstatementorotherevidenceof insurabilityisrequired

III. Changes for Insured Employees• Changeininsuredemployee’searningsorjob classification• Terminationofanemployee’scoverage• Additionorchangeofadependent’scoverage• Terminationofadependent’scoverage• Changestoanemployee’slifebeneficiary

IV. Billing Statement• Normalgroupchanges• Terminationofdependent’scoverage• Calculatingthepremiumdue• Salaryupdates• Deathofanemployee• WaiverofPremium/ExtendedDeathBenefit• Agereduction• Ageratechangesforvoluntaryproducts

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Continued on next page

ContentsV. Conversion of Insurance• Employees• Dependents• Processingconversion

VI. Portability for Voluntary Life• Applicationandpremiumpayment• Amountofinsurance• Wheninsuranceends• Grouppolicyprovisions• Exclusionsforcontinuationofportability

VII. Claims Procedures• Deathclaims• Dismembermentclaims• Dependentdeathclaims• Waiverofpremium• Acceleratedbenefitsclaims• Shorttermdisabilityclaims• Longtermdisabilityclaims• Dentalclaims• Visionclaims• Importanttaxinformationondisabilityclaims

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About Your Companion LifeAdministrative Guide

ThisadministrativeguidewillprovideyouwiththebasicinstructionsnecessaryfortheproperadministrationofyourCompanionLifeGroupInsurancePlan.AllcoveragesofferedbyCompanionLifearedescribedinthisguide.Youradministrativekitcontainsonlythoseformsapplicabletoyourpolicy.

Wehavetriedtomaketheseinstructionseasytounderstand,simpletouseandasconciseaspossible.TheprovisionsofyourMasterPolicywillapplyindeterminingtherightsandobligationsofallpartiesundertheplan.

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Important Requirements

1.Reviewdocumentsinthewelcomekittoensureaccuracyandcompletenessofallcoverageandbenefits.

2.Developaproceduretofollowsothatenrollmentformsfornew,additionalorchangedemployeeswillbecompletedaccuratelybeforebeingsenttoCompanionLife.Incompleteapplicationswillbereturnedforadditionalinformation.

3.WriteyourCompanionLife10-digitgroupnumber,3-digitdivisionnumber,appropriatedepartmentnumberand/orname(ifapplicable)andemployee’sidentificationnumberonallformsandletterswhensubmittingdocumentationtoCompanionLife.

4.Ensureallgrouprelatedchanges,suchasadditions,deletions,salaryupdates,etc.aremadeinatimelyfashion—preferablythreeweekspriortothenextbillduedate.CompanionLifepolicyforretroactivityisnomorethan60daysfromthecurrentduedate.Anyrequestoutsideofthiswillbesenttounderwritingforapproval.

5.ALLpremiumpaymentsmustbereceivedthreeweekspriortothenextbillduedate,inorderforittobereflectedonthenextbill.Premiumisalwaysappliedtotheoldestunpaidbill.

6.Paymentsmustbesentinwiththeperforatedportionofyourbilltoensureproperallocation.Ifagrouphasmultipledivisionsandonecheckisbeingsubmitted,thenabreakdownofpay-mentsmustbesubmitted.Ifmorethanonecheckisbeingsubmittedthentheperforatedportionofthatbillmustaccompanythecheck.

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Section IOnline Services

Working with Companion Life has never been easier!

Online Tools for Group Administrators

MyBenefitsCompanionSMisasecureonlinebenefitadministrationtooldesignedtomeettheneedsoftoday’sgroupadministrator.

MyBenefitsCompanionisaccessedthroughCompanionLife.com.GroupAdministratorsmayuseMyBenefitsCompanionto:

• Add/changeinsuredemployees• Viewbillhistory(uptosixmonthsprior)• Payabillonline• Add/changeinsuredemployee’scoverage• Viewcurrentbillsummary• Add/changedependent• Viewbillimage(uptotwomonthsprior)• Terminateinsuredemployee• Requestabill• RequestIDcardorcertificate

Use My Benefits Companion to Enroll Groups Online

MyBenefitsCompanionisavailabletonewandexistinggroupswhicharedirectlyadministeredbyCompanionLife.Groupadmin-istratorsmayrequestaccesstoMyBenefitsCompanionbycom-pletingourOnlineEmployeeEnrollmentRequestformwhichis

Section IINew Enrollments

Who is eligible for Insurance?

1.Newemployeeswhohavecompletedthegroup’sservicewait-ingperiodandareeligibleemployees,asdefinedinyourMasterPolicy.

2.Activeemployeesfirstenteringaclassofemployeeseligibleforinsurance.

3.Activeemployeeswhoapplyforinsurancemorethan31daysaftertheireligibilitydateorwhopreviouslywaivedtherighttoinsurancebutnowdesireit.CompanionLifewillrequiresatis-factoryEvidenceofInsurability.Seepage10,When a Health Statement or other Evidence of Insurability is Required.

4.Ifaneligibleemployeeisnotactivelyatworkontheeffectivedateofthepolicyorontheeffectivedateofhis/hercertificate,thencoveragewillnottakeeffectforthatemployeeuntilthedatehe/shereturnstoactivework.

includedinourproposalpackage.Orcall800-753-0404,ext.47525formoreinformation.

Online Tools for Dental Insureds andProfessionals

MyInsuranceCompanionSMisasecureWeb-basedtoolforCompanionLifeDentalinsureds.

DentalprofessionalsmayuseMyInsuranceCompanionto:

• Fileclaimsonline(ADAclaimsentry)• Verifypatienteligibility• Verifypatientbenefits• Checkclaimstatus• Checkthestatusofservicesrenderedusingthegraphical toothdisplay• Viewdentalpre-estimateandorthodonticletters

CompanionLifeDentalInsuredsmayuseMyInsuranceCompanionto:

• Checkclaimstatus• Verifyeligibility• RequestanIDcard• Viewanexplanationofbenefits(EOB)• Receivepre-treatmentestimate• Askcustomerservice

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Processing New Enrollments

Ifanemployee’samountofgrouplifeinsurancerequestedexceedstheGuaranteedIssue(GI)amount,acompletedHealthStatementorEvidenceofInsurabilityformmustbesubmittedtoCompanionLifeforreview.IfnoHealthStatementorEvidenceofInsurabilityformissubmitted,orifCompanionLifedeniestherequestfortheamountovertheGIamount,thentheemployeewillbecoveredfortheGIamountonly.

Anypremiumdueforsuchindividualwillbebasedontheappro-priatepremiumfortheamountofinsuranceintheGuaranteeIssueclass.

Unlessprovisionshavebeenmadetothecontrary,thefullamountofinsurancewilltakeeffectonthefirstpremiumduedatefollow-ingthedateofapproval.

UponapprovaloftheHealthStatementorotherEvidenceofInsur-ability,thepremiumduewillchangeonthefirstofthemonthorthenextpremiumduedate,followingtheeffectivedateoftheap-provedadditionalamountofinsurance.

CheckyourMasterPolicyfortheapplicableprovisionanddetailsonthecoverage.

Companion Life will produce Temporary Vision ID Cards, Certificates of Insurance and or Dental Cards. We will forward these certificates, dental cards or temporary vision ID cards to the Group Administrator or Agent as requested for delivery to the insured employees.Shouldyouneedadditionalcertificatesandordentalcards,pleasecontactusat800-753-0404,ext.45924.All permanent vision ID cards will be mailed directly to each employee’s home address from EyeMed.Shouldyouneedad-ditionalpermanentvisionIDcards,pleasecontactEyeMedVision

Careat866-723-0513tospeakwithanEyeMedrepresentative.

Pleaseensurethatallinformationiscompletedontheenrollmentform(i.e.,Name,SocialSecurityNumber,GroupNumber,Depart-mentNumber,DateofHire,EffectiveDate,Class,Salary,DateofBirth,MaritalStatus,DependentInformationifdental,etc.).Also,besuretoincludeBeneficiaryinformation.

Iftheemployer(policyholder)paysallofthecost,100percentofalleligibleemployeesmustbeenrolledunlessawrittenwaiverisreceived.If,inadditiontoapartialcontributionbytheemployer,theinsuredemployeescontributetothecost,75percentofalleligi-bleemployeesmustbeenrolled.

Fordentalandvisioncoverage,listalldependent(s)(includelastnameifdifferentfrominsured)includingdateofbirth.CompletetheotherDentalInsurancesectionifapplicable.CompanionLifeInsuranceCompanywillcontinuedentalcoverageforunmarrieddependentchildrenuptoage26(orhigheragewhererequiredbystatelaw)regardlessofstudentstatus.Ifadependentisincapaci-tated,pleaseincludemedicaldocumentationforverification.RefertoMasterPolicy.

Employer must maintain copies of Enrollment forms and cur-rent Beneficiary Designations to submit at time of death claim. Employee Enrollment forms may be found on our website, CompanionLife.com. Click on Agent Information and then select Group Enrollment Guide.

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When a Health Statement or Other Evidence of Insurability is Required

Generally,anytimeanemployeeelectstoaddorincreasecoverageforwhichheorshewaspreviouslyeligible,butdidnotchoosetoenroll,aHealthStatementorotherEvidenceofInsurabilityisre-quired.Thisistrueevenifheorsheelectscoverageonthegroup’sanniversarydate.Thisisnotapplicablefordentalbuttheemployeemustsatisfythegroup’swaitingperiod.Theeffectivedateforcov-erageonthepersonwhohassubmittedEvidenceofInsurabilityisthefirstofthemonth,orthenextpremiumduedate,followingthedatethecoveragewasapprovedbyCompanionLife.ThepremiumwillbereflectedonthesubsequentBillingStatement.Anactiveemployeewhocancelstheirdentalcoveragemayre-enrollasaonetimecourtesy.Allenrollmentwaitingperiodswillapplyandbenefits,deductiblesandwaitingperiodcreditswillnotbecarriedforward.

Note: Companion Life reserves the right to issue a lower Voluntary Life & AD&D benefit amount based on underwriting guidelines.

Forpoliciesthatincludedependentlifeinsurance,anemployeeiseligiblefordependentlifecoverageonhisorheroriginaleligibilitydateorwhenmarriage,birth,adoption,etc.occurs.Iftheemploy-eedoesnotelecttotakethecoveragewithin31daysofbecom-ingeligible,completionofaHealthStatementontheemployee’sspouseanddependentchildrenwillberequiredbeforecoveragecanbemadeeffective.

AHealthStatementwillberequiredwhenanemployeeelectstotakeeitherEmployerPaidorVoluntaryShortTermorLongTermDisabilityinsurancemorethan31daysaftertheiroriginaleligibil-itydate.ApplicantswhosubmitincompleteHealthStatementswillbedeclinedforcoverage.

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Section IIIChanges for

Insured EmployeesAll changes must be requested in writing.

1. Change in an insured employee’s earnings or job classification.

Ifaninsuredemployeeisnotactivelyatworkonthedate whenanincreaseintheamountofinsuranceistotake effect,thentheincreasewillnottakeeffectuntilthe employeereturnstoactivework.

Decreasesintheamountofaninsuredemployee’s insurancewilltakeeffectonthefirstofthemonth,orthe nextpremiumduedate,followingthedateofchange.

Note: Salary updates are extremely important on groups with salary based benefits. Death and disability claims will be adjudicated using the latest reported salary, prior to loss. No salary updates will be permitted at claim time.

2. Termination of an employee’s coverage. Report the termination of an employee’s coverage when:

a.Theemployeeceasesemployment.

b.Theemployeeisnolongereligibleanddoesnotmeet therequirementsofanActiveEmployeeasdefinedin SectionI.

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c.Theemployeeisdeceased.

3. Addition or change of a dependent’s coverage.

Ifaninsuredemployeedesiresdependentcoverageafter becominginsured,andsuchrequestismadewithin31days fromthedatethataneligibledependentwasacquired(i.e., marriage),pleasenotethedateofchangeontheBilling Statement.

4. Termination of a dependent’s coverage.

Reporttheterminationofdependentcoverageonlyin situationsaffectingpremiumssuchas:

a.Aninsureddependentchildorspouseshoulddieandno eligibledependentremains.

b.Insuredemployeeandinsuredspousearelegally separatedordivorcedandtherearenodependent childrentobeinsured.

c.Ifadependentchildisnolongereligible,orreaches terminationage,andthereisnoinsuredspouse.Refer toMasterPolicy.

d.Iftheemployercancelsdependentcoveragefrom theMasterPolicy.

Note: Please ensure that all changes are made in a timely fashion so that billing and group information are correct. We limit retroactivity to no more than 60 days.

Uponterminationofanemployee’sdentalorvisioncoverage,theemployeeandcovereddependentsmaybeeligibleforcontinuation

ofcoverageunderCOBRA.ThegroupadministratorisresponsibleforprovidingCOBRANoticesthatmayberequiredunderfederallaw,andmustcontacttheCompanionLifeservicedepartmentat800-753-0404,ext.45924regardingCOBRArights.

5. Changes to an Employees’ Life Beneficiary.

Ifanemployeechangeshisbeneficiaryforlifecoverage, itshouldbedoneusingtheBeneficiaryElectionform, orEnrollmentApplication,thensignedanddatedbythe employee.

It is the responsibility of the group to keep all Beneficiary Election forms. These must be provided when a death claim is filed.

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Section IVBilling Statement

1. Normal group changes.

Regularchanges(i.e.,deletions,nameandidentification numberchanges)shouldbemadeontheBillingStatement. ThereisacodekeyatthebottomoftheBillingStatement whichshouldbeusedforchanges:LE=leftemployment, FE=futureeffective,REF=refusalofcoverage, DEC=deceased.TosubmitchangesontheBillingState- ment,simplyplacetheappropriatecodebythegroup member’snameandmakethenecessarycorrection.For terminations,pleasebesuretonotetheeffectivedateof terminationorwewillusetheduedateoftheBillingState ment.

2. Termination of a dependent’s coverage.

Shouldaninsuredemployeenolongerhaveeligibledepen- dents(spouseordependentchildren),indicatethedatethe coverageistobecancelled.

3. Calculating the premium due.

Pleasepayasbilled.Changes(additions,deletions,salary updates,etc.)willbereflectedinthenextmonth’sBilling Statement.

4. Salary Updates.

SalarychangesmaybemadeontheBillingStatementor

submitachangerequestenrollmentform.Ifachangeis beingmadeontheBillingStatementthengivetheeffec- tivedateofthechange/updatenexttothenameofthe employee.Salaryupdatesonsalarybasedbenefitsare extremelyimportant.Deathanddisabilityclaimswillbe adjudicatedusingthelatestreportedsalary.No salary updates will be permitted at claim time.

5. Death of an employee.

Normallywewouldautomaticallyterminatetheinsured employeewhennotifiedofthedeathclaim;however,there aremanytimeswhentheBillingStatementwillbegener- atedpriortoourofficebeingnotifiedofaclaim.You shouldplacetheappropriatecode“DEC”bythedeceased employee’snameandthedateofdeath.

6. Waiver of Premium/Extended Death Benefit.

AlllifepolicieswillincludeeitheraWaiverofPremium provisionoranExtendedDeathBenefitprovision.

a.WaiverofPremium,whenapprovedbyCompanionLife, waivesthelifepremiumforaneligibledisabledemploy- ee.RefertoyourMasterPolicy.Uponwrittennoticeof approval,theemployeecanberemovedfromthebill. Thiswillbedoneautomatically.However,ifyou receiveabillthatstillincludestheemployeeafteryou havereceivedwrittenapprovalthenyoushouldplace theappropriatecode“WOP”bytheemployee’sname andthedateoftheapprovalnotice.

In order to be eligible for the Waiver of Premium, the claim must be filed within 12 months of the date of Total Disability.

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Refertopage24forinformationregardinghowtofilefor WaiverofPremiumBenefits.

b.ExtendedDeathBenefitwaivesthelifepremiumsforan eligibledisabledemployeeforoneyearfromthedateof totaldisability.

7. Age reduction.

Agereductionswilloccurontheinsuredemployee’sbirth date.Aproratedpremiumwillbereflectedonthatmonth’s BillingStatement.RefertoyourMasterPolicyforthis provision,ifapplicable.

8. Age rate changes for voluntary products.

a.RatechangesforVoluntaryLifeandLTDareonan annualbasis.Anemployeewho’sagechangewarrantsa ratechangewillbereflectedonthenextanniversary date.

b.VoluntarySTDwillalwaysbebaseduponthe employee’sageatthetimeofenrollment.

c.Areportisgeneratedthreemonthsinadvanceinorder toadvisethegroupofthenecessaryupdates.

Note: Retroactive changes will be made for no more than 60 days.

Section VConversion of Insurance

Employees

Aninsuredemployeeisentitledtotheconversionprivilegeforthebasiclifeinsurance(noAD&D)whenallorpartofaninsuredemployee’sbasiclifeinsuranceendsdueto:

1.Terminationofemployment.

2.Terminationofmembershipinaclassofeligible employees(i.e.,changetoajobclassificationnot covered).

3.Reductionincoverageduetoage.

4.TerminationoftheMasterPolicyorInsuranceonany class.The condition pertaining to employment must be met. See your Master Policy.

Theinsuredemployeemustconvertinsurancewithin31daysafterthegroupinsuranceendsortheconversionprivilegewillceasetoapply.

It is the responsibility of the group and/or the employee to re-quest conversion from us within the 31 day time frame.

Dependents

Aninsureddependentmayconvertbasicdependentlifeinsurancecoveragewhenallorpartofthedependent’sbasiclifeinsurance

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underthispolicyendsdueto:

1.Theemployee’sterminationofemployment.

2.Theemployee’sterminationofmembershipina classofeligibleemployees.

3.Theemployee’sdeath.

4.Thedependent’schangeofstatus.

5.Theterminationofthepolicyorterminationofthe dependentprovisionsunderthepolicy.The dependent must meet the conditions shown in the Master Policy.

Theinsureddependentmustconvertinsurancewithin31daysafterthegroupinsuranceendsortheconversionprivilegewillceasetoapply.

It is the responsibility of the group and/or the employee to re-quest conversion from Companion Life within the 31 day time frame.

Processing Conversion

Iftheinsuredisinterestedinconvertingtheirinsurance,pleasehavethemcallCompanionLife’shomeofficeat800-753-0404,ext.47207toreceivefurtherinformationandtoobtainaLifeCon-versionInformationRequestForm.

Itistheobligationofthegroupadministratortolettheinsuredemployeeknowoftheconversionbenefituponterminationoftheindividual’scoverage.

Itisalsotheresponsibilityofthegroupand/oremployeetorequestconversionfromuswithinthe31daytimeframe.

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Section VIPortability forVoluntary Life

Portability for Voluntary Life

TheinsuredemployeeisentitledtotheportabilityorconversionprivilegeforVoluntaryLifecoverage(forinformationregardingconversion,refertopage18).

Application and Premium Payment

Asagroupadministrator,pleaseinforminsured(s)ofthefollow-ing:

YoumustapplyinwritingtoCompanionLifewithin31daysafterthedateofemploymentends.

YoumustpaytherequiredpremiumdirectlytoCompanionLife.Thepremiumratewillbethesamerateapplicabletoanactiveemployee.Anyratechangeswhichbecomeeffectiveforyouremployerwillbecomeeffectiveforyouonthesamedate.Thefirstpremiumpaymentmustbemadenolaterthan31daysafterthedatetheinsurancewouldotherwiseterminate.

Amount of Insurance

Themaximumamountofinsuranceyoumaycontinueistheamountineffectonthedateemploymentterminates.Youmaycontinueanylesseramountinincrementsavailabletoactive

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employees(forthespouse,inincrementsavailableforspousestoactiveemployees).Theamountyoucontinueforyourspousemaynotexceed50percentofyouramount,uptomaximumbenefitof$50,000.

Dependentchildrenwillnotbeeligibleforthisprovisionalthoughyoumayapplytoconvertthechildbenefitamount.

Youmaynotchangetheelectedamountsoninsurancecontinuedundertheseprovisions.ThereductionandterminationprovisionstatedontheScheduleofInsuranceineffectonthedateemploy-mentterminateswillstillapplytothisinsurance.

When Insurance Ends

Insurancecontinuedunderthisprovisionendsautomaticallyontheearliestof:

1.Thedatethelastperiodendsforwhichyoumadea premiumpayment.

2.Thedatethegrouppolicyterminates.

3.Thedateyouremployer’sparticipationunderthisgroup policyends.

4.Thedateyoubecomeafull-timememberofthearmed forcesofanycountry.

Whenyourinsuranceunderthisprovisionends,youandyourspousemaybeeligibletoconvertthisinsurancetoanindividualpolicyundertheConversionProvisionofthisgrouppolicy.RefertoyourGroupCertificate.

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Group Policy Provisions

TheWaiverofPremiumprovisionswillnotapplytoinsurancecontinuedundertheseprovisions.Insurancecontinuedundertheseprovisionsissubjecttoallothertermsofthegrouppolicy,exceptasprovidedabove.

TheemployeeisrequiredtoprovideanynoticetoCompanionLifethatisrequiredbytheemployerunderotherprovisionsofthegrouppolicywhiletheinsuranceiscontinued.

Exclusions for Continuation of Portability

Insurancecannotbecontinuedunderthisprovisionifyourinsur-anceterminatesbecauseofoneofthefollowing:

1.Thegrouppolicyterminates.

2.Youremployer’sparticipationunderthegrouppolicy terminates.

3.Retirement.Retireescan,however,converttheir policies.

4.Youbecomeafull-timememberofthearmed forcesofanycountry.

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Section VIIClaims Procedures

ItisimportantthatyouimmediatelynotifytheCompanionLifeClaimsDepartmentoftheexistenceofaclaim.Claimformsmustbefilledoutcompletelyandaccurately.

Processing Death Claims

Thefollowinginformationisnecessarytoprocessadeathclaim:

1.Claimformcompletedbytheemployerandthe claimant.

2.Certified(raisedseal)copyoftheDeathCertificate.

3.Originalenrollmentformandanyenrollmentforms withbeneficiarychanges.All beneficiary updates or changes must be maintained by the group.

4.ForAccidentalDeathclaims,acopyofthe accidentreport,investigatingofficer’sreportanda coroner’sreport,ifapplicable.

5.Payrollrecordswillberequiredonallemployeesatthe timeoftheclaimunlessaspecialprovisionor arrangementhasbeenapprovedduringtheinitial enrollmentofthegroup.

AlloftheabovedocumentsshouldbedirectedtotheCompanionLifeClaimsDepartment.Incompleteinformationwill

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causedelays.TheClaimsDepartmentwilldirectallrequestsformissinginformationtoyouand/orthebeneficiary.

Anybenefitbecomingduebyreasonofdeathofaninsuredem-ployeewillbepaidtothebeneficiarydesignatedbytheinsured.Iftheinsuredemployeehasdiedandnobeneficiaryislivingornamed,CompanionLifecanelecttopaytheamountshownintheapplicationtothemember(s)ofthefirstsurvivingclassinthefol-lowingorderlistedbelow.

Theinsuredemployee’s:

1.Spouse 2.Child(ren) 3.Parent(s) 4.Brother(s)andsister(s) 5.Executorsandadministrators

CompanionLifewillnotbeliabletotheextentofanypaymentsomade,unlesswereceivewrittennoticeofavalidclaimbysomeotherpersonbeforepaymentismade.Paymentmadeonbehalfofaminorisconditionaluponreceiptofguardianshippapers.Incom-munitypropertystates,thespousemaybeentitledto50percentoftheproceedsfromtheinsurancepolicyunlesshe/shewaivedhis/herrightstotheproceeds.

CompanionLifewillmailyounotificationwhentheclaimispaid.

Note: Death and disability claims on groups with salary based benefits will be adjudicated using the latest reported salary, prior to loss. No salary updates will be permit- ted at claim time.

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Processing Dismemberment Claims

Whentheclaimformhasbeenfullycompleted,itmustthenbesubmittedtoCompanionLifeforprocessing.CompanionLifewillreturnincompleteformstotheinsuredemployeeoremployerforcompletion.Thiswilldelayprocessingoftheclaim.

Processing Dependent Death Claims

DependentDeathclaimsaresubmittedonthesameclaimformasanEmployeeDeathclaim.Acertified(raisedseal)copyoftheDeathCertificateandacopyoftheemployee’sEnrollmentFormarealsoneeded.Theinsuredemployeeisthedesignatedbenefici-aryforthisbenefit.

Processing Waiver of Premium

Ifaninsuredbecomestotallydisabled,priortoage60,CompanionLifewillwaivepremiumfortheBasicTermLifeInsuranceBen-efit.TheWaiverofPremiumwillbeginonthefirstofthemonthfollowing12consecutivemonthsoftotaldisability.

The insured must file a written notice within 12 months after the date of total disability to be eligible for this benefit.

Thewrittennoticeincludesathree-partformcompletedbytheinsuredemployee,employerandattendingphysician.

Processing Accelerated Benefit Claims

AcceleratedBenefitclaimsaresubmittedonaseparateclaimformdesignedforthisbenefit.ProofofTerminalIllnesscertifiedbytheattendingphysicianandoneotherphysicianmustbeprovidedaswell.Terminalillnesswouldbedefinedaslifeexpectancyof12monthsorlessasdeemedbytheattendingphysician.

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Processing Short Term Disability Claims

Atthebeginningofthedisabilityperiod,theinsuredemployeemustsubmittheShortTermDisabilityAccidentorSicknessClaimform.Payrollrecordsarerequiredonallemployees65yearsorolder.Theemployershouldprovideonlytheinitialclaimformtotheinsuredemployee.Periodicphysiciansstatementswouldbeneededbytheinsuredtocontinuebenefits.

1.TheinsuredemployeemustcompletePartIandsignthe AuthorizationtoReleaseInformation.

2.Theinsuredemployeemusthavetheattending physiciancompleteandsignPartII.

3.TheemployermustcompletePartIII.

Note:• If employee is eligible for salary continuation, PTO, sick leave, vacation, etc., disability will not begin until exhaustion of the elimination period or such employer paid benefit, whichever is later.• If employee is subject to child support withholdings, attached documentation with claim.• If period of disability is due to a workers’ compensation liability, disability benefits are not payable.

Oncethisformhasbeenfullycompleted,theemployermustsubmitittoCompanionLifeforprocessing.Incompleteformswillbereturnedtotheemployerforcompletionandthiswilldelaytheprocessingoftheclaim.

Premium payments must be paid during any period for which Short Term Disability benefits are payable. There is no Waiver of Premium for Short Term Disability.

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TheemployermustnotifyCompanionLifewhenadisabledin-suredemployeereturnstoworkonapart-timeorfull-timebasis.

TheReturnToWorkNoticeiscompletedbytheemployer/groupadministratorandmustbemailed,faxedorphonedtoCompanionLife.Weekly disability checks are mailed to the employer’s ad-dress.

PleaserefertoImportant Tax Informationregardingdisabilityclaimsonpage29.

Note: Death and disability claims on groups with salary based benefits will be adjudicated using the latest reported salary, prior to loss. No salary updates will be permitted at claim time.

ShortTermDisabilityclaimsstatusandbenefitpaymentstatusmayalsobeobtainedbycallingtheCompanionLifeVoiceResponseUnit(VRU).

Theautomatedtelephonesystemprovidesinformationtooursubscribersoncurrentclaimsstatus,benefitpaymentstatus(benefitchecknumbers,dateofbenefitcheckissue,benefitcheckamountandthedisabilitybenefitperiodforwhichthebenefitisbeingpaid).IftheinformationneededcannotbeprovidedbytheVRU,thecallermaytransferatanytimetoaclaimsrepresentative.

ThetelephonenumberfortheCompanionLifeVoiceResponseUnitforShortTermDisabilityis800-753-0404,ext.45922.

Processing Long Term Disability Claims

LongTermDisabilityclaimsmustbesubmittedatleasthalfwaythroughtheeliminationperiod.LTDclaimsshouldbesentto:

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CompanionLifeInsuranceCompany POBox2993 Hartford,CT06104-2993

Toexpeditethehandlingofnewclaims,formsmayalsobefaxedto:860-392-3672.Originalsmustfollowbyregularmail.

ForquestionsregardingLongTermDisabilityclaimscall:800-892-0430orfax860-843-4716.

1.Theinsuredemployeemustcompleteallquestions,sign anddatethetopportionoftheclaimform.

2.Theinsuredemployeemusthavethephysician complete,signanddatethebackoftheclaimform.

3.Theemployermustcompleteallquestions,signand datethebottomportionoftheclaimform.

Whensubmittingtheformpleasebesurethateachpartyfullycom-pletestheirportion.Thiswillhelppreventanyunnecessarydelays.

LongTermDisabilityclaimsapproval/denialcantakeupto60daysorlongertoprocess.CompanionLifeencouragesclaimantstoprovidenecessaryinformationassoonasthedisabilityisdeter-minedtoavoiddelayinthepaymentofbenefits.OnceCompanionLifedeterminesthattheinsuredemployeequalifiesforLongTermDisabilitybenefitstheLTDpremiumwillbewaived.Youwillreceivewrittennotificationofapprovalordenial.

Aftertheinitialapproval,monthlybenefitpaymentsaretimedtobereceivedbytheendofthemonthforwhichbenefitsaredue.AnindividualmayrequestpaymentstobemadeelectronicallythroughourElectronicFundTransferprocess.

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Benefitsarenotintegratedwithanyindividuallyownedpoliciesorindividualretirementbenefits.

Note: Death and disability claims on groups with salary based benefits will be adjudicated using the latest reported salary. No salary updates will be permitted at claim time.

Approval of LTD benefits does not constitute approval for Waiver of Premium. The employee must file sepa- rately for life insurance premium to be waived. Refer to pages 15 and 24 for additional information.

Processing Dental Claims

DentalclaimsmaybesubmittedontheCompanionLifeDentalClaimformoranyclaimformapprovedbytheAmericanDentalAssociation.

Dentalclaimstatusmaybeobtainedbytheemployeeortheden-talproviderbycallingtheCompanionLifeVoiceResponseUnit(VRU).Thisisanautomatedtelephonesystemthatallowsyouac-cesstoourcomputer24hoursadaywithallinformationondentalclaims,dentalbenefitsandeligibilityforourdentalsubscribers.Ifacallismadeduringourregularofficehoursandtheinquirycan-notbehandledthroughtheVRUthenthecallwillbetransferredtoaphonerepresentative.

ThetelephonenumberfortheCompanionLifeVoiceResponseUnitfordentalis800-765-9603.

Or,contactusbywritingat:

CompanionLifeInsuranceCompany POBox100102 Columbia,SC29202-3102

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WrittenHIPAAAuthorizationmustbeonfilefromthesubscriberinorderforagroupadministrator,agentorbrokertodiscussdentalclaimsinformation.

Processing Vision Claims

Visionclaimsshouldbesentto:

EyeMedVisionCare Attn:OONClaims POBox8504 Mason,OH45040-7111

TospeakwithanEyeMedrepresentative,call866-723-0513.

TolocateanEyeMedProvider,call866-723-0596.Toexpeditethehandlingofnewclaims,Faxto866-293-7373,ore-mailformandreceiptstooonclaims@eyemedvisioncare.com.

Theinsuredemployeemustcompleteallrequestedinformationontheclaimformandattachedallitemized paid receiptsthatindicateservicesprovidedandtheamountchargedforeachserv-icepriortosubmittingtheclaimformtoEyeMed.Anymissingorincompleteinformationmayresultindelayofpaymentortheformbeingreturned.

Theinsuredemployeemustmakesuretheclaimformhasbeensignedanddated.

Important Tax Information

Please note: The following is a simplified summary of the current tax law. Companion Life does not provide legal or tax advice; therefore, we encourage you to review the complete text of the law to establish its full application to your situation. We also encour-

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age you to consult your tax advisor, attorney, or accountant re-garding your specific responsibilities as an employer.

CompanionLifeisnotyouragentwithrespecttodisabilityclaimpayments.Accordingly,undercurrenttaxlaw,CompanionLifeisonlyresponsibleforwithholdingtheemployee’sportionofFICAandmakingtimelydepositsoftheamountswithheld.Theemploy-er’sshareoftheFICAispayablebyeachemployeruponnotifica-tionfromCompanionLifeoftheamountofdisabilitybenefitspaidtotheinsuredemployee.

ThelawfurtherprovidesthatcertainpaymentsarenotsubjecttoFICA,includingpaymentsattributabletoemployeecontributions,paymentsthatwhencombinedwiththeregularwagesandsickpaypreviouslypaidtotheemployeeduringtheyearexceedtheappli-cablewagebase,andpaymentsafter6monthsabsencefromwork.Therefore,itisnecessarywhensubmittingdisabilityclaimsthatyouadviseusofthefollowing:

•Theemployeecontributionstotheplanmadewithafter taxdollars •Thetotalwagespaidtotheemployeeduringthecalendar year •Thelastmonthinwhichtheemployeeworked

AlthoughdisabilitybenefitspaidbyCompanionLifearenotsub-jecttomandatoryfederalincometaxwithholding,anemployeemayelecttohavefederalincometaxwithheldbysubmittingformW-4StoCompanionLife.IftheinsuredemployeedoesnotsubmitaFormW-4S,federalincometaxwillnotbewithheldfromthebenefitpayments.

Tofacilitaterecordkeepingforyourcompliancewiththelaw,CompanionLifewillprovideyou,onaweeklyandquarterlybasis,withalistingofamountspaidandtaxeswithheld.Thisreportwill

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giveyousufficientinformationtocompleteyourownFICAreport-ing.Inaddition,CompanionLifewillprovideyouanannualreportpriortoJanuary15thofeachyearfollowingtheyearinwhichthedisabilitybenefitsarepaid.YoushouldusethisreporttoprepareFormsW-2foryourinsuredemployees.Companion Life does not prepare Forms W-2.Theannualreportwillincludethefollowinginformation:

•Theemployee’sname •Theemployee’sSSN(iftaxeswerewithheld) •Thedisabilitybenefitspaidtotheemployee •Anyfederalincometaxwithheld •Anyemployeesocialsecuritytaxwithheld •AnyemployeeMedicaretaxwithheld

Ifyouhaveanyquestionsorconcernsabouttheaboveinformation,orifwemaybeofservicetoyou,pleasecontactCompanionLifeClaimsat800-753-0404,ext.45922.

Notes

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95335 Rev.5/11

P.O.Box100102Columbia,SC29202-3102

800-753-0404|800-836-5433FaxCompanionLife.com