This is a group accident policy between Zurich American Insurance Company and the University of Wisconsin Board of Regents for University of Wisconsin System employees. The plan is self-administered by the University.

Eligibility

• University employees eligible for the State of Wisconsin Group Health Insurance Plan are eligible for AD&D.

Enrollment

• You may enroll, change or cancel your coverage at anytime by filing an Enrollment and Change Form with your campus benefits office.

• Coverage is effective on the first of the month following the date you submit your application to your campus benefits office. If you file on the first day of the month, coverage is effective that day.

• Employee Only or Family Plan coverage is available. By electing the Family Plan, you are covering your spouse or domestic partner and dependent children.

• To cover a domestic partner and your domestic partner's eligible children, you must create a domestic partnership for benefits purposes. Please see Domestic Partner Benefits for UW System Employees for detailed information about how to establish a domestic partnership.

• Rehired annuitants who are receiving a Wisconsin Retirement System annuity are excluded from enrollment.

Coverage

• You may select coverage (Principal Sum) of $25,000, $50,000, $100,000, $150,000, $200,000 or $250,000.
  
  
• Under the Family Plan, dependent family members are covered at a percentage of your Principal Sum amount.
  
  
• At age 70, your coverage reduces to a percentage of the Principal Sum.
  
  
• This insurance does not cover any loss resulting from intoxication or while under the influence of alcohol or controlled substance unless administered on the advice of a physician and taken in the prescribed dosage.
  
  
• For limitations and exclusions, please refer to the certificate.
  
  
• All employees and covered family members who have coverage under the AD&D plan are also covered by Zurich Travel Assistance.
  
  
  • Offers comprehensive, world travel service, when you travel 100 miles or more from home.
    
    
  • Provides a familiar standard of care in an unfamiliar place, putting you in contact with resources to get the medical, personal, informational and legal help needed for vacation or business travel.
    
    
  • View the benefit summary or the complete Zurich Travel Assist brochure for more information.

Premium

• Premium cost is based on the type of plan and Principal Sum you select.
  
  
• The University does not contribute toward the premium.
  
  
• Premiums are paid one month in advance.

Program Features

• This insurance will pay benefits according to the Schedule of Coverage.
  
  
• Education and training benefits for your spouse or domestic partner and dependent children if you are enrolled in the Family Plan at the time of your death.
  
  
• If you and your spouse or domestic partner suffer loss of life as result of a common accident while enrolled in the Family Plan, your spouse's or domestic partner's coverage is equal to yours, to a combined maximum of $250,000.
  
  
• A monthly payment for your spouse or domestic partner, in addition to the Principal Sum for the year following your death, if you select the Family Plan.
  
  
• If you become permanently and totally disabled within 180 days of an injury and conditions are met, you may be eligible for a Principal Sum payment.
  
  
• Special Air Ambulance coverage extension is available at additional cost for employees who ride on or operate the university air ambulance.
  
  
• A person covered in the plan may apply for pilot coverage.
  
  
• Continuation of insurance in the group plan is available at a reduced level of coverage for those retiring from the University.
  
  
• Conversion of coverage to an individual plan with the insurance company is available for those under age 70 who terminate employment or end an eligible position.

FAMILY PLAN

If the Family Plan is elected, dependent family members will be covered by the following amounts:

Spouse or Domestic Partner:
The spouse's or domestic partner's coverage is 50% of the Principal Sum, provided there are no covered children at the time. If there are covered children, the spouse's or domestic partner's coverage is 45% of the Principal Sum.

Children:
Each dependent child is covered for 10% of the Principal Sum if there is a covered spouse or domestic partner, subject to a maximum of $25,000. If there is no covered spouse or domestic partner, each child's coverage is 20% of the Principal Sum, subject to a maximum of $37,500.

COVERAGE FOR AGE 70 or OLDER

At age 70 the Principal Sum reduces to a percentage of the Principal Sum available prior to age 70. For example:

SCHEDULE OF COVERAGE

The covered loss must occur within 365 days of the accident.

In the event the covered employee, their spouse, domestic partner or child is not found within a year of the accident, provided the occurrence was under circumstances that would otherwise be covered, it will be assumed the lost individual has sustained loss of life.

For more information, see the insurance fact sheet and the certificate.

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This document was last revised on February 2, 2010