SUMMARY OF BENEFITS Class 1
Sponsored By: City of Haltom City Effective Date: October 1, 2023 Policy Number: 01-020673-00
The information in this summary may be replaced by any subsequently issued summary or policy amendment.
Eligibility
All Eligible Employees working a minimum of 32 hours per week and their eligible dependents. Employee
Increments of $10,000
of $500,000 or 5 x
Spouse Life Benefit
Spouse Amount
Minimum Amount
Increments of $5,000
$5,000 Maximum Amount
$250,000 not to exceed 100% of Supplemental Employee Coverage
Child Amount Live Birth to 26 year(s): Increments of $5,000 to a maximum of $10,000 Employee
Amount
Increments of $10,000 Minimum Amount
Lesser of $500,000 or 5 x Earnings
Spouse AD&D Benefit
Spouse Amount Increments of $5,000
Minimum Amount
Maximum Amount
$5,000
$250,000 not to exceed 100% of Supplemental Employee Coverage
Child AD&D Benefit
Child Amount Live Birth to 26 year(s): Increments of $5,000 to a maximum of $10,000
Benefit Reduction Employee
Original Benefit Amount Reduced To 65% at age 65*
50% at age 70*
*Round to the next higher $100
Benefit Reduction Spouse
Original Benefit Amount Reduced To 65% at age 65* 50% at age 70*
*Round to the next higher $100
Evidence of Insurability
Evidence of Insurability is required for all amounts of insurance selected after the initial 31-day eligibility period and for any amount in excess of the Guarantee Issue amount.
Additional Benefit
Details
Accelerated Death Benefit
Conversion
Portability
Waiver of Premium
If an employee has been diagnosed as terminally ill, Symetra Life Insurance Company may pay a portion of the death benefit in advance to the employee. Please refer to your employee certificate for additional information.
A conversion benefit is available that allows you to convert your group coverage to an individual policy if certain conditions apply. Please refer to your employee certificate for additional information.
This coverage may be continued at group rates upon termination o f employment. Certain restrictions apply. Please refer to your employee certificate for additional information.
With proof of disability, Symetra Life Insurance Company will waive Life Insurance premiums for a period of time for an employee that becomes disabled prior to a certain qualifying age. Certain restrictions, such as an elimination period, apply. Please refer to your employee certificate for additional information.
AD&D Riders Includes Seat Belt, Airbag, Repatriation, Child Education, Day Care, Rehabilitation, Spouse Education and Adaptive Home and Vehicle benefits. Please refer to your employee certificate for additional information.
Contact Information for Claims
Phone: 1-877-377-6773
Fax: 1-877-737-3650
Symetra Life Insurance Company Life and Absence Management Center
P.O. Box 1230
Enfield, CT 06083-1230
Symetra® is a registered service mark of Symetra Life Insurance Company.
Rates for Supplemental Life coverage Monthly Supplemental Employee Life Rates per $1,000 of coverage
Monthly Supplemental Spouse Life Rates per $1,000 of coverage
Calculating Your Cost
Supplemental Employee Life: /1,000 = $ (volume) x (rate)
Supplemental Spouse Life: /1,000 = $ (volume) x (rate) Monthly Cost
Supplemental Child Life:
Supplemental Employee AD&D:
Supplemental Spouse AD&D:
Supplemental Child AD&D:
/1,000 = $ (volume) x (rate)
/1,000 = $ (volume) x (rate)
/1,000 = $ (volume) x (rate)
/1,000 = $ (volume) x (rate)
This summary provides only a brief description of the Life Insurance coverage insured by Symetra Life Insurance Company under the LGC-13000 8/06 series Group Life Insurance policy. For a complete description, including all definitions, exclusions, limitations, and reductions in coverage, as well as information on termination of benefits, please contact your benefit administrator or refer to the Group Insurance Certificate you will receive when you become insured. Coverage will be offered under Group Policy number 01-020673-00. All benefits are subject to the terms and conditions of the Group Policy. If there is a difference between the information in this summary and the information contained in the Group Insurance Certificate, the terms of the Group Insurance Certificate will prevail. The terms of coverage may change over time; always refer to your current Group Insurance Certificate for information regarding your insurance benefits.
Symetra® is a registered service mark of Symetra Life Insurance Company.