Form Adm 4302 - Group Life Insurance - Continuation Laid Off Employees printable pdf download

Form Adm 4302 - Group Life Insurance - Continuation Laid Off Employees

ADM 4302

GROUP LIFE INSURANCE

CONTINUATION LAID OFF EMPLOYEES

Pursuant to Ohio Revised Code Section 124.81(C) and applicable Administrative Rules, you are

entitled to have life insurance coverage while in laid-off status for a period of one year providing

you pay the total year premium prior to leaving state service. You may be eligible for a partial

refund if you are recalled from layoff within 12 months.

Employee Name____________________________ State of Ohio User ID____________

Agency Name______________________________ Bargaining Unit # ____________

Amount of Coverage:_________________ (See the “Group Life” amount on your OAKS paystub).

Date of Layoff:_______________________

Rate: $0.130 per $1,000/month for bargaining unit members

$0.105 per $1,000/month for exempt employees

Examples: $40,000 = 40 units X $.130 X 12 months = $62.40 (bargaining unit employees)

$40,000 = 40 units X $.105 X 12 months = $50.40 (exempt employees)

TOTAL ANNUAL PREMIUM $____________

I elect coverage in the amount listed above and have attached a personal check or money order for the

annual premium amount.

__________________________________________________________________

Employee signature

Date

Payment Instructions:

Employees represented by a bargaining unit should make their check payable to Prudential and mail it

along with this form to: Union Benefits Trust, 390 Worthington Rd, Suite B, Westerville, OH 43082

Exempt employees should make their check payable to: Employee Benefit Fund 8100 and mail it along

with this form to: Benefits Administration Services, c/o Life Insurance Manager, 30 E. Broad St., 27th

Floor, Columbus, OH 43215.

DO NOT WRITE BELOW THIS LINE

Coverage begins (month after layoff):_________________Coverage expires:____________

Date paid:______________ Amount paid:____________ Date of refund:_______________

Adm4302 (rev 01/15)

Form Adm 4302 - Group Life Insurance - Continuation Laid Off Employees