Unum Life Insurance Company of America
2211 Congress Street, Portand, ME 04122
Policy Number 851664 011
This is NOT an application for insurance. This is an enrollment form.
Please complete the entire form. Blank fields may delay processing.
NOTE: If you DO NOT wish to make changes, do not complete this form.
Please email Jenn Williams or contact Jenn on Microsoft Teams if you have questions.
Limitations, Exclusions, Reductions and Terminations
Effective Dates: Delayed Effective Date: The plan effective date is provided in your certificate. Your effective date may be later than the plan effective date. Coverage for employees who are not in active employment because of an injury, sickness, temporary layoff, or leave of absence is not effective until they have returned to active employment with the employer.
Spouse and Dependent Coverage: If your spouse or child has a serious injury, sickness, or disorder, or is confined, their coverage may not take effect. Payment of premium does not guarantee coverage. Please refer to your policy contract or see your plan administrator fro an explanation of the delayed effective date provision that applies to your plan.
Benefit Reduction: Coverage amounts reduce as you age in accordance with your plan. Coverage may not be increased after a reduction. This is a sample reduction schedule:
Age: Insurance Amount Reduces to:
70 65% of original amount
75 50% of original amount
If your plan has a different age reduction it will be on your certificate.
Exclusion for Suicide Life: Life insurance benefits will not be paid for deaths caused by suicide in the first 24 months after your effective date of coverage or after any increased coverage. If your plan has a different exclusion period for suicide it will be on your certificate.
AD&D Benefit Exclusions if AD&D coverage is included in your plan:
Accidental death and dismemberment benefits are paid for loss of:
- Both hands or both feet or sight of both eyes
- One hand and one foot
- One hand and the sight of one eye
- Speech and hearing
AD&D Exclusions and Limitations, if AD&D is included in your plan*: Accidental death and dismemberment benefits are not paid for losses caused by, contributed to by, or resulting from:
- disease of the body; diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM);
- suicide, self-destruction while sane, intentionally self-inflicted injury while sane or self-inflicted injury while insane;
- war, declared or undeclared, or any act of war;
- active participation in a riot;
- committing or attempting to commit a crime under state or federal law;
- operating any motorized vehicle while intoxicated: and
- the voluntary use of any prescription or non-prescription drug, poison, fume, or other chemical substance unless used according to the prescription or direction of your physician.
Some exclusions and limitations may not apply. Your certificate has details.
Termination of Coverage:
Your coverage and any spouse and dependent coverage will end of the earliest of:
- the date the policy or plan is cancelled;
- the date you are no longer in an eligible group;
- the date your eligible group is no longer covered;
- the last day of the period for which you have made any required contributions; or
- the last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate.
In addition, coverage for any spouse or dependent will end on the earliest of:
- the date your coverage under a plan ends;
- the date your dependent ceases to be an eligible dependent;
- for a spouse, the date of divorce or annulment;
- the date of your death.
Unum will provide coverage for a payable claim that occurs while you, your spouse, or dependents are coverage under the plan.
*The suicide exclusion does not apply in Washington and is limited to 12 months in Missouri and North Dakota. In New York accidental losses due to drug addiction may be excluded.
Certificate issued under policy form controls: This information is not a complete description of the insurance coverage offered. The policy or its provision may vary or be unavailable in some states. For complete details of coverage please refer to policy form C.FP-1, except in MD please refer to C.FP-1D. Your certificate of coverage controls your benefits and rights.