Cover sheet Date: March 30, 2012 To: From: Group Insurance Services, Inc. Tom Weibel Contact information Regional group sales office Service Office Tom Weibel 475 N. Martingale Road Ste. 520 Schaumburg, IL 60173 Office: 847-413-9600 Toll-free: 800-847-5852 Fax: 847-413-9150 8801 Indian Hills Drive Omaha, NE 68114 Office: 800 423-2765 Fax: 877 573-6177 Home Office: Fort Wayne, IN Why LFG for Worksite Benefits? Maximize the value of your employee benefits package with flexible, easy-to-use voluntary benefits from Lincoln Financial Group. We offer flexible service and enrollment options, and a variety of products to cover you and your employees. ■ ■ ■ ■ ■ Employees are able to keep their coverage should they leave their employer Coverage that is Guaranteed Renewable No physical exams are required Flexibility to design a plan that’s just right for your employees Tools to help educate and empower your employees to make the right choices with confidence LFG offers a full suite of products to meet your insurance needs ■ Universal Life ■ Critical Illness ■ Accident ■ Short and Long Term Disability ■ Term Life Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates, including insurance company affiliates The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so; and Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group® companies. Product availability and/or features may vary by state. Limitations and exclusions may apply. Affiliates are separately responsible for their own financial and contractual obligations. Prepared For: GIS Client Group ID: Quote Sequence: Proposed Effective Date: 4/1/2012 or later Lincoln Voluntary Accident Plan Highlights With Voluntary Accident Benefits from Lincoln Financial Group, employees are empowered to protect their income from unexpected expenses related to an accident. Why choose Lincoln for Voluntary Accident Protection? ■ Coverage is Guarantee Issue. ■ Coverage is Guarantee Renewable. ■ The option to continually build participation through annual enrollment. ■ Benefits are paid directly to the covered employee. ■ Benefits are paid for multiple injuries related to a single accident. ■ Attractive group rates are offered. ■ Employees may keep their Accident coverage after separation from their employer. ■ Premiums can be paid by employee on a pre-tax or post-tax basis. COST SUMMARY Rates shown are Weekly and guaranteed renewable 2SWLRQ &KRLFH3ODQ Accident Base Coverage Employee Only Employee + Spouse Employee + Child(ren) Employee + Family $3.91 $5.47 $6.62 $8.76 GROUP LEVEL BENEFIT OPTIONS $GGLWLRQDOEHQHILWVVHOHFWHGE\HPSOR\HUIRUDOOHQUROOHGHPSOR\HHVFRVWLQFOXGHGLQEDVHFRYHUDJHUDWHVDERYH On-the-job Accident Coverage included EMPLOYEE LEVEL BENEFIT OPTIONS (PSOR\HHVPD\HOHFWWKHIROORZLQJFRYHUDJHVLQDGGLWLRQWR%DVH&RYHUDJHDQG*URXS/HYHO%HQHILW2SWLRQV Health Assessment (Wellness) Benefit Available for Employee Election at displayed rate Employee Only Employee + Spouse Employee + Child(ren) Employee + Family $0.51 $1.02 $0.64 $1.17 Proposal assumptions ■$PLQLPXPRIHQUROOHHVLVUHTXLUHGWRHVWDEOLVKFRYHUDJHIRUWKHJURXS ■7KHUHLVQRPLQLPXPHQUROOPHQWUHTXLUHPHQWIRUGHSHQGHQWFRYHUDJH ■(PSOR\HHVPXVWEHDFWLYHO\DWZRUNRQWKHHIIHFWLYHGDWHRIFRYHUDJH ■7UHDWPHQWPXVWEHUHFHLYHGZLWKLQWKHUHTXLUHGWLPHOLQHVVHWIRUWKLQWKHSROLF\ ■%DVHFRYHUDJHLVUHTXLUHGIRUHYHU\LQVXUHGHOHFWLQJRSWLRQDOEHQHILWV ■%HQHILWVPD\EHVXEMHFWWRWD[HV7KLVGHWHUPLQDWLRQVKRXOGEHPDGHXQGHUWKHDGYLFHRIDWD[ FRQVXOWDQW OPTION 1 CHOICE PLAN Emergency care Ambulance Air ambulance Initial physician office visit Emergency room Major diagnostic care Treatment care Hospital admission Hospital confinement daily benefit Intensive care unit daily benefit Alternate care and rehabilitative facility daily benefit Follow-up doctor/patient care up to 6 sessions Transportation for care (up to 3 times per accident) Companion lodging (up to 30 days per accident) Family care per child up to 30 days Fractures (per fracture) Ankle, arm, collarbone, elbow, foot, hand, jaw, kneecap, shoulder blade, sternum, wrist Hip Skull depressed Leg, pelvis, skull nondepressed, vertebral column Bones of face, vertebrae, coccyx, rib, nose Finger, toe Chip fractures $150 $600 $50 $150 $100 $1,000 $200 $400 $100 $50 $175 $100 $20 Non-Surg/Surg $300/$600 $1,400/$2,800 $2,500/$5,000 $500/$1,000 $150/$300 $50/$100 25% benefit Dislocations (per injury) Ankle, collarbone sternoclavicular, foot Collarbone acromio and separation, elbow, hand, lower jaw, shoulder, wrist Finger, toe Hip Knee, except kneecap $400/$800 $250/$500 $50/$100 $1,200/$2,400 $500/$1,000 Specific injuries or treatments Transfusions Burns Skin grafts Joint replacement Coma Concussion Dental crown once per accident Dental extraction once per accident $150 $100-$6,400 Additional 25% $1,500-$2,000 $2,000 $100 $150 $50 Eye (removal of foreign body) once per eye/accident Eye (surgical repair) once per eye/accident Laceration Surgery Arthroscopic Abdominal or Thoracic Treatment, per repair Ligaments/tendons, knee cartilage Rotator cuff Ruptured disc Transitional care benefits Crutches Wheelchair for temporary use Wheelchair for permanent use Walker for temporary use Walker for permanent use Prosthesis per limb/device Reasonable modifications to home or vehicle in the case of catastrophic loss Accidental Death & Dismemberment (AD&D) Accidental Death Employee Spouse Child Common carrier enhanced death benefit Transportation of remains Seat belt/helmet AD&D benefit Common disaster enhanced death benefit Loss of or loss of use of one: hand, foot, arm, leg, eye Loss of or loss of use of any one finger, thumb, or toe Catastrophic loss Additional benefits Accident EAP services TravelConnectSM OPTION 1 CHOICE PLAN $100 $300 $50-$400 $250 $1,000 $300 $300 $400 $25 $50 $350 $25 $50 $500 $2,500 $30,000 $10,000 $5,000 2x benefit amt $5,000 10% of AD&D 2x benefit amt $7,000 $300 $50,000 Included Included EMPLOYEE LEVEL BENEFIT OPTIONS Health Assessment Benefit: If an insured undergoes a defined health assessment, a benefit will be paid. Optional $50 Exclusions This accident policy will not cover losses caused by or as a result of: ■ Injury occurring prior to the effective date of coverage or after termination of the coverage ■ Duty as a member of any military, including Reserves or National Guard ■ Travel or flight in or on any Aircraft, except as a fare paying passenger on a regularly scheduled commercial flight ■ Participating in high risk or extreme sports ■ Having cosmetic or elective surgery ■ Participating in or attempting to commit a felony ■ Being incarcerated in any type of penal or detention facility ■ Having a blood alcohol level of .08 grams of alcohol or more per 100 milliliters of blood ■ Deliberately using poison, gas, fumes, or drugs (except when prescribed by a Physician and administered appropriately) ■ Committing or attempting to commit suicide or any other self-inflicted injury ■ Any sickness, disease (physical or mental), or medical or surgical treatment of these ■ Participating in, practicing for, or officiating a semi-professional or professional sport ■ Riding in or driving any motor-driven vehicle for race, stunt show, or speed test ■ War, act of war, or participation in a riot, insurrection or rebellion ■ An injury sustained while residing outside the U.S., U.S. territories, Canada or Mexico for more than 12 months THIS IS NOT A CONTRACT: This illustration was prepared based on the information provided in the Request for Proposal. It is a description of accident coverage available from Lincoln Financial Group and not an offer to contract. More detailed information is available upon request concerning the terms, conditions, and limitations contained in the master policy, if issued. If there are discrepancies between the information contained in this proposal and the master policy, the terms of the master policy will control. State-specific restrictions and requirements may not be addressed in this proposal. An Application for Group Insurance must be completed by the Employer and approved by Lincoln Financial Group before coverage can become effective. This proposal is subject to revision if not accepted on or before the Proposed Effective Date shown on the Benefits and Cost Summary page of this proposal. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates, including insurance company affiliates The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so; and Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group® companies. Product availability and/or features may vary by state. Limitations and exclusions may apply. Affiliates are separately responsible for their own financial and contractual obligations.
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