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Plan Description
Fortis Benefits > Long Term Disability Plan
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Note: This page contains a brief summary of coverage. It does not
state all provisions and limitations of the plan. The terms and provisions of
each plan, as outlined in the plan document, will determine coverage and
eligibility.
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Broker Name:
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Fortis Benefits
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Policy Number:
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34512435
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Original Plan Effective Date:
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12/11/2002
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Rate Guarantee Expiration Date:
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12/11/2002
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Plan Anniversary Date:
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12/11/2202
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Billing Cut-off Day of the Month:
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1
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Retroactive Termination Limit:
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30
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Divisions:
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All Divisions
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Locations:
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California
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Employee Classes:
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Full Time
Manager
Officer
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Validation Method:
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Automatic
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General Plan Information
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Benefit Amount
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60%
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Maximum Monthly Benefit
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$5,000
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Buy-Up Options
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40% - up to a maximum of $3,000
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Elimination Period
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30 days
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Maximum Period of Payment
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To age 65 if disabled prior to age 60
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Definition of Disability
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Base Salary
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Residual
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Covered
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Minimum Monthly Benefit
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$50
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Recurrent Disabilities
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6 months
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Definition of Earnings
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Primary and family social security
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Self Reported Symptoms - Limitations
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12 months
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Mental Illness - Limitations
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12 months
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Pre-Existing Condition Limitations
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12 months
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Survivor Benefit
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3 months
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Rehabilitation Benefit
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Included
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COLA (Rider)
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Covered
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Conversion (Rider)
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Covered
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Return to Work Incentive Benefit
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12 months
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Other examples
Waiting Period Information
Eligible employees are eligible as of the 1st of the month following the employee's hire date.
Termination of Coverage Information
When a plan participant is terminated from the company, the plan coverage ends on the last day of the month following the employee's termination date.
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(per month)
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Base Plan Rate:
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See rates below.
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Age Band Structure
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Coverage Rates
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0-14
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$2
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15-19
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$2
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20-24
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$2
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21-29
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$2
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30-34
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$2
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35-39
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$2
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40-44
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$2
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45-49
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$2
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50-54
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$2
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55-59
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$2
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60-64
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$2
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65 and over
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$2
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Base Plan Rate Type:
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Per $100 of monthly covered payroll
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Base Plan Contribution:
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Employee contributes 0% per month.
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Other examples
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Blue Cross Blue Shield of Michigan
http://www.bluesss.com
Member Services
John Carpet
600 Lafayette East
Detroit, MI 48226
(313) 225-5890
Fax (313) 225-3453
Claims Services
Jennifer Pattern
600 Lafayette East
Detroit, MI 48226
(313) 225-3445
Fax (313) 225-3435
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Enrollment Related Form)
