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TIAA/CREF COVERAGE FOR GROUP LONG-TERM DISABILITY HIGHLIGHTS To help protect against the financial hardship you and your family would suffer if _ you became disabled and could not work, the University of the Virgin Islands is providing you with group long-term disability coverage. This insurance plan contains the following features: > Replaces a percentage of your monthly income > Continues to contribute to your retirement plan > Provides annual increases to help counter inflation > Gives a lump sum benefit to your survivors > Offers Social Security Assistance and rehabilitation The policy provision, definitions, and limitations are fully detailed in your Certificate of Insurance which is enclosed. Please be sure to check them. HIGHLIGHTS: > ELIGIBILITY All full-time faculty members, administrative staff, and professional staff members on regular appointments. > COST The University of the Virgin Islands is pleased to provide this insurance at no cost to you. Group Insurance Enrollment/Change Form DISABILITY he LANDARD.. ADMINISTRATOR FOR TIAA Please consult with your employer to determine what coverages are available to you under your plan and if the insurance you elect requires proof of good health. You cannot be insured for coverage elected on this form which you are not eligible for under the TIAA group insurance policy issued to your employer. If you elect an insurance option that is greater than that for which you are eligible, you will automatically be insured for the highest option you would otherwise be eligible for. For an initial enroilment, please complete Part 1 of this form, sign, date and return it to your employer as soon as possible. For a change in your insurance coverage, complete only those sections that apply to the change being requested, sign, date, and return the form. Please retain the pink copy for your records. C1 Initial Request 1 Change Request Effective Date | Part 1 EMPLOYEE INFORMATION (To be completed by employee) Please Print Last Name First ML Social Security Number Date of Birth Sex Employment Date Positicn (Title) Annual Salary Om OF $ Coverage Selection (check one): CO | elect only the insurance to which | am or may become entitled at no cost to me. 0 I authorize the proper deductions, if any, from my earnings as my contribution toward the cost of this Insurance. C1 | do not wish to enrol/or participate (applicable only to contributory plans.) Optional Income Benefit (if applicable): © | authorize the proper deductions, if any, from my earnings as my contribution toward the cost of this insurance. If more than one option is available, indicate option selected. Option Selected C1 I do not wish to enrol/or participate (applicable only to contributory plans.) Certification of Disabllity Insurance Coverage Through Previous Employer (if applicable): A. () Professional Examples: 8. Cl Service supervisors of these staff members. Examples: Previous E 2, Prior Insurance Company Date Prior Coverage Terminated ravious Employer pany ath Day Year Employee Signature Date Part 2 © EMPLOYER INFORMATION (To be completed by employer) Employer Group No. Sub Unit (if applicable) Date Employee Entered Mo. Day Year Reinstatement Date Re-Employed Mo. Day Year an Eligible Class Clyes CINo Annuity Premium Benefit if applicable (check one): (1 The employee is participating in our formal retirement plan. CITIAA-CREF [1 Other (1 The employee Is eligible but is not participating in our forma! retirement plan. (1 The employee is not eligible for our formal retirement plan. Occupation Information - Complete all Questions 1. Eligible Class: Employze is a member of eligible class: (11 (12 113 C1 Other (fill in class) 2. Position Type: Employee is a member of the: [] Faculty [1 Administration (1 Technical/Professional [] Secretarial/Clerical OC) Maintenance/Housekeeping C) Other 3. Occupation Class: Choose A or B or circle a title in one of the examples below. Associates who are usually engaged in activities that are considered non-physical in nature (sedentary ~ light). Professor, Nutrition Adviser, Coach, Human Resources Staff Specialist, Librarian, Marketing Coordinator, Risk Manager, Engineer, Telecommunication Specialist, Administrator, Secretary. Associates who are usually engaged in activities that are considered physical in nature. These positions include Baker, Carpenter, Custodian, Cook, Electrician, Locksmith, Security Guard, Mechanic, Supply Room Clerk, Nutrition Aide, Staff Nurse, Welder, Parking Attendant, Grounds Keeper, Extension Agent. Employer — Original Si 11023-TIAA Employee — Pink Copy (Please kaeg for your records} (103;