Disability Benefit PLAN CCPOA Benefit Trust Fund Disability Coverage, When Sick Leave Isn’t Enough Disability Benefit PLAN Gold or Silver Shield Coverage You have a challenging job – one with more than your fair share of risk. To protect you and your loved ones, the CCPOA Benefit Trust Fund offers the Disability Benefit Program – a plan that helps you meet basic living expenses while you are unable to work. COMMONLY ASKED QUESTIONS Who is eligible to enroll? You are! All active full-time permanent employees and Permanent Intermittent Employees (PIEs) who are members in good standing with CCPOA are eligible to apply. This includes rank-and-file members, supervisors and managers. Please Note: An applicant may be denied coverage in the Disability Benefit Program based on prior medical conditions. There is a 2-year exclusion for pre-existing conditions (certain conditions may be subject to longer exclusion periods). What does the Program cover? The Disability Benefit Program provides benefits if you are unable to work due to a disability that is covered under the Program (not all disabilities are covered under the program). How much are the premiums? The Silver Shield premium is currently $45 per month. The Gold Shield premium is currently $65 per month. Gold Shield provides disability coverage both on-thejob and off-the-job. Will my benefits equal my full paycheck? No. However if you are a Silver Shield member you will receive 100% of your base salary (when combined with other income benefits for qualified non-occupational disabilities) up to the maximum benefit of $3000 per month. Gold Shield members with non-occupational disabilities will receive a benefit equal to 65% of your base salary (when combined with other disability income for qualified non-occupational disabilities) up to the maximum benefit of $5150 per month. For Gold Shield members after 24 months, if you are severely disabled (cannot perform two or more Activities of Daily Living (ADLs) your benefit will increase to 75%. However, if not, the benefit will remain at 65% if, after the second year you are unable to work at any type of employment. How quickly can I start using the program after I complete enrollment? You are able to use the program immediately after you successfully complete enrollment. However, each level of coverage has a different waiting period (called an “elimination period”) before benefits begin. For Gold Shield, benefits begin after 30 consecutive calendar days from the date you are certified as disabled. For Silver Shield, benefits begin after 180 consecutive calendar days from the date you are certified as disabled. (Pre-existing condition limitations apply). Do I have to use my sick leave? Yes. If at the end of your elimination period (i.e. the beginning of your coverage period) you still have sick leave or Catastrophic Time Bank (CTB) credits left, the program works like this: you would receive the minimum Disability Benefit each month in addition to your full pay provided by your sick leave or CTB. When these credits are gone, your full Disability Benefit kicks in - paying 65% of your base pay up to $5150 for Gold Shield and 100% of your base pay, up to $3000 for Silver shield, when combined with other disability income. KEY BENEFITS Pick Your Level of Coverage Gives you the flexibility to select a plan that meets your needs. Gold Shield** provides up to 65%* of your base pay or $5,150 per month ( whichever is lower) for injuries during the coverage period. Silver Shield provides up to 100%* of your base pay or $3000 per month (whichever is lower) during the coverage period. Waiting periods apply – 30 days for Gold and 180 days for Silver. Affordable Gold Shield is $65 per month, which includes on-the-job and off-the-job coverage. The Silver Shield premium is $45 per month. 24 Month Coverage Period This applies to both occupational and nonoccupational disabilities under Silver and Gold Shield. Under Gold Shield, your coverage may extend up to age 65 if your non-occupational disability prevents you from working any job. Premium Waiver You pay no premium for the duration of your disability under both Gold and Silver Shield plans once you have been disabled for 60 days. Benefits are contingent upon satisfying all requirements of the Program document. *These benefits are offset under the Program by certain other income benefits. **Gold Shield provides a 75% benefit if the injury or illness is so severe that after 24 months of benefits, you cannot perform two basic Activities of Daily Living (includes bathing, dressing, toileting, transferring, continence and feeding) – for non-occupational disabilities. Some medical conditions can result in an application being denied and there are limitations for pre-existing conditions. Enhances Disability Leave Benefits Allows you to supplement your base pay if you are on Industrial Disability Leave (IDL) or Enhanced Industrial Disability Leave (EIDL), by paying a minimum benefit of $206 per month under Gold Shield, and $400 per month under Silver Shield. Helps while your Workers’ Comp benefits are pending Gold Shield participants are provided with an additional provisional benefit, above the basic minimum monthly benefit, while your Workers’ Comp case is pending. If you win your case, you will receive a back-pay award from the Workers’ Compensation Appeals Board. You use this money to repay the additional provisional benefit, still keeping each month’s minimum benefit. If you lose your case, and you are otherwise eligible for benefits, you keep every dime. No Age-Related Premiums Age is not an issue. Whether you are 21 or 61, you pay the same amount. BENEFITS Gold S Coverage for Non-occupational Disabilities* Up to 65% of base pay or (whichever is lower) ** Coverage for Occupational Disabilities* Only with Gold Shield A minimum benefit of $2 addition to your IDL1 or E the State. Provided only u (complete) Elimination Period 30 consecutive calendar Maximum Benefit Period Up to 24 months for non-o or illness. Up to age 65 for disabilities if disabled from occupation. Gold Shield – Up to 24 mon injury or illness Coordination with CTB, NDI, ENDI, Sick Leave and Other Benefits Coordinates with income receive under NDI3, CTB Sick leave, and any other disability benefits ( for ex insurance by Standard o combined total monthly of your base pay, except t Trust benefits will in no e per month or be less than Premium Waiver*** Your monthly premium w you have been certified d consecutive calendar day Surviving Dependant Benefit Six months of continued Premium $65 per month 1. Industrial Disability Leave 2. Enhanced Industrial Disability Leave 3.Non-Industrial Disability Insura 6. Temporary Disability 7. Permanent Disability * These benefits are offset under the Program by certain other income benefits ** Gold Shield provides a 75% benefit if the injury or illness is so severe that after 24 months of benefit transferring, continence and feeding), for non-occupational disabilities, otherwise benefit remains at *** Premium Waivers are effective only after the “elimination period” of the policy has been met and for Gold Shield benefits; 180 days for Silver Shield benefits. This is a brief summary of the benefits provided through the CCPOA exact explanation of benefits, please see the Summary Program Descr documents, the official Plan documents will govern. Shield $5,150 per month 206 per month in EIDL 2 payments from under Gold Shield days occupational injury non-occupational m working any Silver Shield Up to 100% of base pay or $3,000 per month (whichever is lower)* A minimum benefit of $400 per month in addition to your IDL1 or EIDL 2 payments from the State. 180 consecutive calendar days Up to 24 months for occupational and nonoccupational injury or illness nths for occupational e you are eligible to 4 , ENDI5, TD6, PD7, r individual or group xample: disability or AFLAC) to provide a benefit of up to 65% that the combined event exceed $5,150 n $206 per month will be waived once disabled for 60 ys monthly benefits Coordinates with income you are eligible to receive under NDI3, CTB 4, ENDI5, TD6, PD7, Sick leave, and any other individual or group disability benefits ( for example: disability insurance by Standard or AFLAC) to provide a combined total monthly benefit of up to 100% of your base pay, except that the combined Trust benefits will in no event exceed $3,000 per month or be less than $400 per month Your monthly premium will be waived once you have been certified disabled for 60 consecutive calendar days Three months of continued monthly benefits $45 per month ance 4. Catastrophic Time Bank 5. Enhanced Non-Industrial Disability Insurance ts, you cannot perform two basic Activities of Daily Living (including bathing, dressing, toileting, t 65%. covered disabilities only. After being certified disabled, you must wait 30 consecutive days for Benefit Trust Fund’s Disability Benefit Plan. For a more detailed and ription. If there is a conflict between this brochure and the official Plan Time off work isn’t always a vacation. Apply Today. “I crushed my femur... and was totally bedridden for 3-4 months. If it were not for Disability Benefit Plan I certainly would also be crushed financially. I thank God I joined...” Program Participant For More Information on the Disability Benefit Plan, please call the CCPOA Benefit Trust Fund 800 - IN UNIT - 6 or visit our website: www.ccpoabtf.org “We’ve Got You Covered” Important Note: This brochure is intended to provide highlights of the CCPOA BTF “Disability Benefit Plan.” Full details about the terms, benefits, conditions and limitations are contained in the Program documents. Any conflict between this brochure and the official Plan documents, the official Plan will govern. The Trust reserves the right to amend, modify or terminate the Plan at any time without providing advanced written notice. We’ve Got You Covered. 1-800-In-Unit-6 1-800-468-6486 CCPOA Benefit Trust Fund 2515 Venture Oaks Way, Suite 200 Sacramento, CA 95833-4235 www.ccpoabtf.org The Disability Benefit Program is governed by the Employee Retirement Income Security Act of 1974, as amended ("ERISA"). Please read the Disability Benefit Summary Program Description for more information about the Program and your rights under ERISA. 1-03-3000-01 2013_DBPBroch.v4 Q212R08 ❏ ❏ ❏ ❏ ❏ ❏ D.The gastrointestinal tract, liver, gall bladder, stomach, including ulcer or hernia? E. The genito-urinary system, kidneys, reproductive organs including prostatitis or uterine fibroids, albumin, blood or sugar in the urine? J. Any injury, disease, condition, or abnormality not mentioned above, including, for example, bone injuries? I. Any physical defect or deformity including impaired vision, speech or hearing? H.Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), HIV or any other immune deficiency disorder? G.Cancer, tumor, arthritis, gout or disorder of joints, muscles or bones? F. The endocrine system including diabetes, thyroid or adrenal disorder? ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ Yes NO Date of Application: AC T I V E K. Are you actively working within the duties of your occupation? ❏ ❏ C.The heart, blood or blood vessels including heart attack, heart murmur, anemia, high blood pressure, chest pains, rheumatic fever, or hepatitis? ❏ ❏ Yes NO B. The respiratory system including tuberculosis, asthma, emphysema or shortness of breath? A. The brain or nervous system including epilepsy, dizziness, stroke, mental or nervous disorder? IMPORTANT NOTE: All participants in the Disability Benefit Plan need to complete a Survivor Benefit Beneficiary Designation Form for this program. This form is available at www.ccpoabtf.org or the Trust office. Authorization: I understand that I will be required to sign a release of medical information provided to me by the Trust Office to determine eligibility for participation in and/or benefits under the Disability Benefit Plan. If my application for participation in the Disability Benefit Program is approved my signature serves as my express written authorization of payroll deductions for the coverage I have elected at the rate in force until I notify the Trust in writing to discontinue deductions, or otherwise cease to be eligible to participate. Signature of Applicant: X Active Sex: ❏ Male ❏ Female ZIP: In the past 5 years has there existed, or have you been treated for or told by a physician or practitioner that you have conditions implicating any of the following: State: SSN: “I hereby authorize the State Controller to deduct from my salaries and wages the amount specified now or in the future for membership dues and any benefit program for which I have applied, which is sponsored by the California Correctional Peace Officers Association (CCPOA). This authorization will remain in effect until canceled by me or by CCPOA Benefit Trust Fund. I certify that I am a member of CCPOA and understand that termination of CCPOA membership will cancel all deductions made under this authorization.” Please explain all of the “YES” answers checked, except “K” (including dates) If necessary, use additional paper. The falsity or lack of completeness of any statement made on this application shall be sufficient reason for the denial, suspension or termination of benefits under this program. ❏ GOLD SHIELD – $65/month ❏ SILVER SHIELD STD – $45/month ■ Plan Selection (Check One) Height: E-mail: Weight: City: Address: Phone: Birthdate: Application CCPOA Disability Benefit Plan Full Name (print): We’ve Got You Covered. 1-800-In-Unit-6 1-800-468-6486 CCPOA Benefit Trust Fund 2515 Venture Oaks Way, Suite 200 Sacramento, CA 95833-4235 www.ccpoabtf.org The Disability Benefit Program is governed by the Employee Retirement Income Security Act of 1974, as amended ("ERISA"). Please read the Disability Benefit Summary Program Description for more information about the Program and your rights under ERISA. 1-03-3000-01 2013_DBPBroch.v4 Q212R08