the archdiocese of new york benefits administration resource guide

THE ARCHDIOCESE OF NEW YORK 

BENEFITS ADMINISTRATION 

RESOURCE GUIDE 

Administration Procedures for Plans Sponsored by the Archdiocese of New York


MISSION STATEMENT 

The beliefs and principles of the Catholic Faith serve as the 

basis for the operation of the Archdiocese of New York and its 

constituent members as expressed in the following mission 

statement. 

We, the Catholic People of God of the Archdiocese of New 

York have a mission, given by the Lord Himself, to live and 

proclaim His gospel message. This mission, entrusted by Jesus, 

calls us to be aware of the local area and the world, the spiritual 

and the material, the present and the future. The same gospel 

that challenges us is also our consolation. The same Lord who 

commanded, “Go therefore and make disciples of all nations,” 

added, “I am with you always, until the end of the world.” 

(Matthew 28:19-20)


BENEFITS ADMINISTRATION RESOURCE GUIDE 

TABLE OF CONTENTS 

I. Important Information: Page 

- Important Notice 1 

- New Employee Checklist 2 

- Benefits Administrator’s Resource Contacts List 3 

- Rules For Member Groups Participating in the Archdiocesan Group Insurance Plan 4 

- Benefits Eligibility Outline 5 

- AONY Division Claim Codes 6 

- Change of Contact 7 

II. 

Administration of Group Health Benefit Plan: 

- HIPAA (Health Insurance Portability & Accountability): Notice of Privacy Practices 8 

- AONY Authorization For Release of Information 9 

- United Healthcare Authorization for Use and Disclosure of Private Health Information 10 

- AONY Group Health Benefits Eligibility 11 

- How to Enroll in the Group Health Benefit Plan and/or Make Changes to a Member’s 

Group AONY Health Benefit Coverage or Change Personal Information 12 

- Certification for Disabled Dependent Children over the age nineteen (19) 13 

- Certification of Disability for the Disabled Children’s Provision Form 14 

III. 

Benefits Summaries: 

- Summary of Benefits: For Clergy, Religious, Seminarians & Lay Employees 15 

- Summary of Benefits: For Bargaining Lay Faculty 16 

- Summary of Benefits: For Medicare Supplement for Retired Lay Employees over 

age 65, Clergy and Religious Who have Medicare Primary Benefits (MSYRX) 17 

IV. 

Filing for Claims: 

- How to File a Medical Claim (Instructions) 18 

- Prescription Benefit Summary 19 

- How to File a Claim for Prescription Drugs (Instructions) 20 

V. When Group Health Benefit Coverage Ends…….. 

- Important Notice (Administration Instructions): for completing Benefit Transfer, 21 

Termination and Reinstatement Transmittal Form 

- Benefit Transfer, Termination and Reinstatement Transmittal Form 22 

- Group Health Benefits For Employees Separating From Service 23 

- (Sample Letter) Notice to Member Losing Coverage 24 

- AONY Notice of Group Benefit Continuance Eligibility 25 

- Group Health Benefits For Employees Retiring from Service Prior to Age 65 26 

- Group Health Benefits For Employees Retiring from Service at Age 65 or Later 27 

- Notice of Benefit Status due to Separation from Employment 28 

Revised July 2009 1

VI. Administration of Life & AD&D Page 

- Basic Life Insurance Outline 29 

- How to File A Claim for Basic Group Life Insurance (Instructions) 30 

- Premium Waiver – Basic Group Life Insurance Coverage (Instructions) 31 

- Group Life Insurance Benefits For Employees Separating From Service 32 

- Portability of Group Life Insurance & Supplemental Term Life Insurance Outline 33 

- Group Life Insurance Benefits For Employees Separating From Service – 

Conversion of Basic Group Life & Supplemental Term Life Insurance 34 

VII. 

Administration of Short Term Disability (New York State Short Term Disability Benefits) 

- AONY Short Term Disability Outline 35 

- How to File a Claim for New York State Disability Benefits (Instructions) 36 

- “Sample Letter” - Notice to Disabled Employee 37 

VIII. 

Administration of Long Term Disability 

- Long Term Disability Outline 38 

- How to File a Claim for Long Term Disability Benefits (Instructions) 39 

IX. 

Administration of Dental Coverage 

- Group Dental Insurance Outline 40 

- CIGNA Dental for Clergy and Religious Plan Description 41 

- AONY CIGNA Dental PPO for Clergy Enrolled in High Option Plan II 42 

- AONY CIGNA Dental PPO for Religious Brothers and Sisters on Stipend and 

Institutions Electing High Option Plan for Religious Plan II 43 

- AONY CIGNA Dental PPO for Religious Brothers and Sisters Plan I 44 

- How to File a Dental Claim (Instructions) 45 

X. Administration of Vision Coverage 

- Davis Vision Care for Clergy and Religious Cover Page 46 

- AONY Davis Vision PPO Plan for Clergy and Religious Brothers and Sisters 47 

- AONY Benefit Plan Highlights - Group Vision Care Outline 48 

- Davis Vision Care for Clergy and Religious Summary 49 

- How To File a Vision Care Claim (Clergy and Religious only) 50 

XI. 

Administration of Voluntary Plans 

- Description of Voluntary Plans 51 

- AONY Supplemental Life Insurance 52 

- Northeast Dental Plan of America 53 

- Important Notice 54 

Revised July 2009 2

Section I 

Important Information

IMPORTANT NOTICE 

The Archdiocese of New York reserves the right to modify or discontinue any of the 

group plans at any time. 

The benefits described in the Resource Guide are subject to the terms, conditions, 

limitations, and exclusions of the plan contracts issued by the individual insurance 

carriers to your group. If a difference exists between the information in the 

Resource Guide and the actual contract, the contract governs. 

Participation in any of the group plans is limited to individuals who otherwise 

satisfy the specific eligibility requirements for such group plans, and are either (i) 

employed by the Archdiocese of New York; or (ii) employed by an institution or 

agency properly listed in the Official Catholic Directory, which has adopted and 

participates in such group plans with the consent of the Archdiocese of New York. 

Nothing contained in this guide should be construed as creating an employment 

relationship of any kind between the Archdiocese of New York and any individual, 

nor should it be interpreted as affecting any employment relationship between an 

employee and his or her actual employer. 

-1-

NEW EMPLOYEE CHECKLIST 

The following New Employee Checklist was developed as a tool to aid local 

administrators when a new employee is hired. The list includes benefit plans 

available to new employees as well as general policies. The checklist also 

includes forms and information that should be collected by the employer at 

the time of hire. 

It is important to note that policies and benefits may vary by institution. This 

checklist should only be used as a guide. 

-2-

New Employee Checklist 

Below is a list of Employee Benefits, Policies and Procedures, which should be discussed with each 

new employee at the time of initial orientation (date of hire or just before). Not all benefits are 

applicable to every institution. Simply list “N/A” next to any benefit that does not apply at your 

institution, or if the new employee is not eligible. (If scheduled to work less than 35 hours per week, 

an employee may not be eligible for all benefits). 

Please refer to the Summary Plan Description Booklets for each benefit plan for additional 

information. 

_______Application for Employment 

_______W-4 Form 

_______I-9 Form + Documentations 

_______Health Benefits* 

_______Dental Insurance* 

_______Basic Life 

_______AD&D Insurance* 

_______Long Term Disability 

_______Pension Form 

_______Regular Work Hours 

_______Overtime 

_______Vacation 

_______Absence Policy 

_______Other 

_______Personal Days 

_______Holy Days/Holidays 

_______Sign-in Sheet 

_______Paycheck – Direct Deposit* 

_______I.D. Cards 

_______403(b) Savings Plan* 

_______ Supplemental Life 

_______Job Posting 

_______Dress Code 

_______Smoking Policy 

_______Telephones 

_______Code of Conduct 

_______Problem Resolution 

_______Sick Pay 

_______Recycling Program 

_______Emergency Contact 

_____________________________________ _____________________________ _____________ 

Employee Name (please print) Employee Signature Date 

*Keep a copy for your files. 

Revised 04/01/06

BENEFITS ADMINISTRATOR 

RESOURCE CONTACT LIST 

-3-


BENEFITS ADMINISTRATOR’S RESOURCE CONTACTS LIST 

VENDOR CONTACT PHONE WEBSITES POLICY 

Number 

AONY Benefits Office Life & Health Division 

212.371.1011 www.archny.org 

212.980.1272 Fax 

Access & view: 

Ella O’Sullivan/Dir. of Life & Health (Ext. 3034) 

Margaret Gonzalez/Deputy Director (Ext. 3026) -The Archdiocese of New 

Gloria Glover/Benefits Administrator (Ext. 3018) York’s Notice of Privacy 

Frances Yee/Benefits Administrator (Ext. 3047) Practice pertaining to 

disclosure of health 

benefit information 

REASON 

-Oversees health & life 

insurance benefits 

management 

-Oversees compliancy of 

HIPAA regulations for 

disclosure of employee PHI 

(Personal Health Info) 

Employee Benefit 

Connections 

United Health Care 

Ellen Means/Manager 

1011 First Avenue – Room 1679 

New York, NY 10022 

Customer Service 

Claims Processing: 

United Healthcare 

P.O. Box 740800 

Atlanta, GA 30374-0800 

212.371.1000 

Ext. 3060 

212.644.0690 Fax 

800.736.1264 www.uhc.com 

-View copy of the Benefits 

Administrator’s Resource 

Guide 

ebc@archny.org Administrators can: 

-Verify member’s benefits 

-Request enrollment packets 

For current provider 

directory) 

Policy: 

#708652 

Have members call for: 

-Claims Issues 

-ID Cards 

-Medical Claim Forms 

-UHC Directories 

-Pre-certification 

-Mental Health Info. 

CVS Caremark Prescription 

Plan 

Prescription Drugs Benefits 

Revised 07/01/09 


Mail Service: 

P.O. Box 2110 

Pittsburgh, PA 15230-2110 

Prescription Reimbursement: 

P.O. Box 52196 

Phoenix, AZ 85072-2196 

800.565.7091 

(Pharmacists 

may also call for 

authorizations 

and assistance.) 

www.myuhc.com 

www.caremark.com 

- updated pharmacy info 

- online order refills 

- Retail info 

- Drug history & info 

Plan Code: 

CRK 

Group Code: 

CMGRX 

Provides member one-step 

access to their personalized 

health care information 

Have members call for: 

-Enrollment verifications 

-ID Cards 

-Prescription Mail Order 

Forms 

-Prescription Claim Form 

-to get reimbursement at 

nonparticipating pharmacy


Number 


888.563.1124 

GL-674263 

Hartford Life Insurance Co. 

Basic Group Life 

Life Claims: 

Hartford Life Insurance 

Companies 

P.O. Box 2999 

Hartford, CT 06104-2999 

877.320.0484 – 

Portability, 

Conversion & 

Claim Status 

REASON 

-Death Claim Forms 

-Assistance with filling out 

death claim forms. 

-Death Claim Status 


Premium Waiver of Group 

Life Benefit for Disabled 

Employees 

Customer Service 888.563.1124 

860-843-4713Fax 

GL-674263 

-Request form to file Life 

Premium Waiver for an 

employee who may be absent 

from work due to injury or 

illness for at least 12 months. 


premium waiver form. 


Supplemental Life 

Enrollment Package 

Employee Benefit Connections 

Ellen Means/Manager 

Johnnell Pankey/Benefits Coordinator 

Wendy Calhoun/Benefits Coordinator 

212.371.1000 

212.644.0690 Fax 

(Ext. 3049) 

(Ext. 3038) 

(Ext. 3048) 

GL-674263 

-Enrollment package 



(Voluntary Plan) 

(Employee payroll 

deduction) 


(Portability & Conversions) 

Basic Group Life 



Short Term Disability 

Customer Service 888.331.7234 GL-674263 -Assistance with filling out 

claim form 



Hartford Life Syracuse Benefit 

Management Services Center 

P.O. Box 4925 

Syracuse, NY 13221 

Have employee call for: 

-Status of enrollment 

877.320.0484 GL-674263 Have employee call for: 

-Status of Portability or 

Conversion Benefits for Basic 

Group Life & Supplemental 

Life 

800.538.0134 LNY-612197 -Short Term Disability Claim 

Form 


claim form 

-Status of Short Term 

Disability Claim 

Revised 07/01/09


Number 



Long Term Disability 

Hartford Life 

Syracuse Benefit Management 

Services Center 

P.O. Box 4871 

Syracuse, NY 13221 

REASON 

800.538.0134 GLT-674263 -Long Term Disability Claim 

Form 


claim form 

-Status of Long Term 

Disability Claim 

CIGNA Dental Plan 

For members of Clergy, 

Religious & Eligible Lay 

Employees 

Customer Service 800.244.6224 www.cigna.com 0435433 Have Members of Clergy 

or Religious call for: 

-Dental claim forms 

-Status of Dental Claim 

Davis Vision 

For members of Clergy, 

Religious & Eligible Lay 

Employees 

Northeast Dental Plan of 

America 

Voluntary Plan 

(Employee direct pay to 

Northeast Dental) 


Vision Care Processing Unit 

P.O. Box 1525 

Latham, NY 12110 


845 Third Avenue, 20th Fl. 


Dentists may also call for 

enrollment status and 

claims issues. 

800.999.5431 www.davisvision.com 7821 Have Members of Clergy 

or Religious call for: 

-Enrollment verification 

-Vision claim form 

-Claim Status 

800.828.2222 

212-688-9708 Fax 

-Provider Directory 

www.dentalsave.com Have employees call for: 

-Enrollment package for 

employees of the Archdiocese 

of New York” (special discount) 

Revised 07/01/09

RULES FOR MEMBER GROUPS PARTICIPATING IN THE 

ARCHDIOCESE OF NEW YORK 

GROUP INSURANCE PLAN 

-4-


RULES FOR MEMBER GROUPS PARTICIPATING IN THE ARCHDIOCESAN GROUP BENEFITS PROGRAM 

Eligibility for group membership in the Archdiocese of New York Group Benefits Program (hereinafter referred to as the 

“Benefit Program”) is restricted to agencies, organizations, and institutions (individually and collectively referred to as 

“Group[s]”) currently listed in The Official Catholic Directory published by Kennedy and Sons that maintain at least one 

location within the geographic boundaries of the Archdiocese of New York. The majority of a Group’s 

employees/members, including an employee’s/member’s spouse and dependent children, (collectively referred to as 

“Enrollees”) enrolled in the Benefit Program must work and/ or reside within the geographic boundaries of the 

Archdiocese in order to participate in the Benefit Program. 

Groups joining the Benefit Program must commit to participating in the Benefit Program for a minimum of two 

years. 

A) COVERAGE 

1. Each Group must include all lines of coverage that the Group provides for their eligible Enrollees covered under 

the Benefit Program unless the Enrollee is not eligible for a particular coverage. Each Group must provide 

coverage for life, accidental death and dismemberment (“AD&D”), and New York statutory disability 

(“NYDBL”) to all eligible Enrollees and offer medical coverage to all eligible Enrollees. The obligatory 

coverages are as follows: 

i) Clergy Life, AD&D, Medical, Dental, and Vision 

ii) Religious Brothers and Sisters 

Medical and Dental *(and Vision for Religious on stipend) 

iii) Lay Employees 

Life, AD&D, NYDBL, and Medical 

*(Dental retired Religious on stipend) 

2. Regarding Section A(1) above, the Archdiocese will allow any Group insurance arrangements in force prior to 

October 1, 2000 for Groups enrolled in the Benefit Program as of July 1, 2000, but will not permit any additional 

deviations. Groups must not offer any other outside benefit programs that would compete with the Benefit 

Program. For example, Groups participating in the Benefit Program should not offer their Enrollees medical 

coverage options that are not sponsored by the Archdiocese. 

3. The Benefit Program determines eligibility requirements for enrollment in the Benefit Program, and the Group 

must not vary or restrict eligibility by occupation or class. Except as designated by the Benefit Program, the 

eligibility classifications for participation in the Benefit Program must be the same for all types of coverage on 

the Group level. (Currently, the only variance is the six-month waiting period for Long Term Disability 

coverage.) 

4. Groups are responsible for offering medical coverage to eligible new hires prior to the date that the employee 

would be eligible for coverage. 

Revised 01/2008

5. All clergy and religious orders whose Groups provide medical coverage through the Health Benefit Program 

must provide coverage for all similarly situated religious and clergy except where like coverage, obtained prior 

to the eligibility for coverage under the Benefit Program, remains in force.* 

6. Medicare. Groups must abide by the Medicare integration rules that apply to the Archdiocese of New York. 

Medicare is secondary to the Archdiocese medical coverage except under the following circumstances: 

I. Medicare is the primary coverage for retired clergy * and retired Enrollees and their spouses who are age 

65 or older. 

II. 

Medicare is primary for the disabled spouses of retired Enrollees. 

III. Medicare is primary for all religious Brothers and Sisters who are age 65 and older. * Religious Brothers 

and Sisters age 65 and over who are entitled to Medicare must change their coverage to a Medicare 

Supplement or a Medicare Risk Plan. The employing Group will reimburse the Religious Order for the 

Medicare Part B premium. 

IV. 

Medicare is primary for disabled Enrollees who qualify for Medicare as a result of a disabling illness or 

injury provided the employee has not been on the employer’s active payroll for at least six months. 

V. If Medicare is the primary medical plan for the primary insured (employee, clergy, religious) the 

insured cannot be covered under a non-Medicare plan except that lay retirees and retired clergy and 

religious with Medicare as primary may enroll in the group Medicare supplemental health plan offered 

by the Archdiocese of New York. 

7. Any Enrollee who has previously waived medical coverage (for himself/herself and/or his/her dependents) has 

the right to elect medical coverage each year during the open enrollment period. Coverage changes elected 

during the open enrollment period will take effect on the Benefit Program anniversary date, currently January 1. 

Normally Enrollees cannot change their health coverage elections except at open enrollment; however, under 

certain circumstances Enrollees can change their coverage election during the Benefit Program year. Enrollees 

may elect to join the Benefit Program or enroll their eligible dependents in the Benefit Program if the Enrollee 

experiences a qualifying event, as defined by the Benefit Program documents. Other than as previously stated in 

this paragraph, mid-year enrollments will not be permitted except for persons newly eligible who enroll within 

30 days following the date they become eligible for coverage. 

8. Long-Term Disability Coverage. Groups providing long-term disability (“LTD”) coverage to their employed 

Enrollees must purchase it through the Benefit Program. Employed Enrollees must work a minimum of 30 hours 

per week (20 hours per week for lay faculty covered by a collective bargaining agreement) and be actively 

employed by the Group with the Archdiocese LTD coverage for the previous six months to be eligible for LTD 

coverage. 

B) GROUP TERMINATION OF COVERAGE 

9. If a Group will be terminating coverage under the Benefits Program, the Group must notify the Archdiocese 

Benefits Office in writing at least 60 days prior to the proposed termination date. All coverage in any part of the 

Benefits Program will terminate on the same date. Group terminations must be effective on the Benefits Program 

anniversary date, January 1. Please direct all questions and correspondence regarding Benefits Program 

termination to Ella O’Sullivan, Director of Life & Health Benefits, Archdiocese of New York, 1011 First 

Avenue, New York, NY 10022. 

10. Groups that terminate their medical coverage will be billed a terminal premium equal to the premium 

due for the last three months the medical coverage was in force with the Benefit Program in order to 

* Priests or Religious who are not entitled to Medicare coverage should contact Margaret Gonzalez, Deputy Director of Life & 

Health Benefits, Archdioces of New York: phone 212.371.1011, Ext. 3026, Fax 212.980.1272, or e-mail: 

Margaret.Gonzalez@archny.org immediately. 

Revised 01/2008

provide funds to pay claims submitted after the termination date on behalf of or by the terminating 

Group’s Enrollees that were incurred prior to the date of termination. 

11. Groups terminating coverage under the Benefit Program will be precluded from rejoining the Benefit Program 

for a minimum of two years from the group termination date. Reenrollment will be at the discretion of 

Archdiocesan management following a review of payment history and claims experience. 

C) PREMIUM PAYMENT 

12. Basic life, AD&D, and LTD coverage must be provided to eligible employed Enrollees at the Group’s expense. 

Enrollees must be enrolled for these coverages within 30 days of the Enrollee’s initial eligibility date. Groups 

can charge employed Enrollees the maximum allowable contribution for NYDBL. For entities directly reporting 

to the Archdiocese (including parish corporations and Archdiocesan schools), you must comply with the 

Archdiocese’s schedule of employed Enrollee contributions for medical coverage as published annually in the 

open enrollment packages. For all other Groups, the Group must fund at least 70% of the employed Enrollee and 

50% of dependent Enrollee medical premiums for full-time employed Enrollees. Groups must submit any 

proposed changes in the Enrollee contribution levels in writing to the Chancellor within 60 days prior to the 

Benefit Program anniversary date, currently January 1. 

13. Any employee meeting the eligibility requirements for medical coverage is required to contribute towards the 

premiums and must be covered under the Benefit Program, unless the employee submits a written waiver of 

coverage (form or letter) within 30 days of the eligibility date. All eligible employees must complete and sign a 

Group Health Benefits Election Form to indicate their payroll deduction election. 

14. Premium Payment is due and expected within 30 days of the premium due date. Groups are responsible for the 

payment of the full premium to the Archdiocese of New York. 

D) RECORDKEEPING AND ADMINISTRATION 

15. Groups providing medical coverage for their eligible Enrollees must obtain (and retain on file) a completed 

Group Enrollment Change form and a Group Health Benefits Election form from each eligible employee. If an 

employee has elected to waive medical coverage for a given Benefit Program year, this should be so indicated 

on both forms. 

16. The Group must comply with all data requests in an accurate and timely manner. 

17. All Groups must notify Employee Benefit Connections within 30 days of the prescribed effective date for a 

change in an Enrollee’s coverage status. Some examples are as follows: an Enrollee becomes eligible for 

coverage (new hire or change in job status), retires, terminates from their position, experiences a life status 

change such as marriage, birth of a child, or change in spouse’s employment status that affects medical 

coverage. The Group must submit a written memo or change form to Employee Benefit Connections to notify 

the Benefit Program of the Enrollee’s status change. The Group administrator must include the specific reason 

for the requested change as part of the request. Certain Enrollee status changes must also include additional 

forms in order for the change to be processed. The following changes require a medical enrollment/ change 

form: adding a spouse or child, change of martial status. 

18. Under certain circumstances, an Enrollee may need to be retroactively enrolled or reinstated for medical and/ or 

other coverages. Generally, the Archdiocese will allow for an Enrollee to be retroactively enrolled or terminated 

within two months following the date of the change in coverage. The Archdiocese will credit Groups for no 

more than two months of premium for retroactive coverage terminations. Withholding of back premium on 

these Enrollees will result in the same consequences as not paying current premium. 

Your Group must abide by the coverage and policy rules with respect to eligibility, non-discrimination, 

enrollment dates, procedures and vendor contractual requirements. Liabilities arising out of the Archdiocese’s or 

Group’s failure to adhere to these policies will be the responsibility of the erring party. Failure to abide by the 

policies as outlined above can result in termination of a Group’s coverage under the Benefit Program. 

Revised 01/2008

BENEFIT ELIGIBILITY OUTLINE 

-5-

B E N E F I T E L I G I B I L I T Y O U T L I N E 

BENEFITS ELIGIBILITY EFFECTIVE DATE WAITING 

PERIOD 

United HealthCare Choice Plus Plan 


800.736.1264 

Cancer Research Service Center 

866.936.6002 

(Members must first call to open a dialog 

with UHC and the Cancer Service Center) 

www.myuhc.com 

(Member’s personalized information site. 

Member needs to create password) 

United HealthCare Medicare 

Supplement Plan 


800.736.1272 

Cancer Research Service Center 

866.936.6002 

(Members must first call to open dialog with 

UHC and the Cancer Service Center) 

www.myuhc.com 

(Member’s personalized information site. 

Member needs to create password) 

• Diocesan and Extern Priests as 

approved by the Office of Priest 

Personnel. 

• Religious Brothers & Sisters 

• Seminarians 

• Aegis of Religious Orders for Parish, 

and Private Schools 

• Non-bargaining Lay Employees 

working in Catholic High Schools & 

all Bargaining Lay Faculty Members 

scheduled to work at least 20 hours. 

• Non-bargaining lay employees of the 

Archdiocese of New York, who 

regularly scheduled to work at least 20 

hours. 

• Employees of Child Care Agencies 

• Early retired Bargaining Lay Faculty 

Members (ages 55 to 64), who 

participated in plan prior to 

retirement, have 10 years service, 

receiving a pension from AONY 

and not working for another 

Archdiocesan institution. 

• Retired non-bargaining lay 

employees who have worked for the 

Archdiocese at least 10 years and at 

least 55 years old, receiving a pension 

from AONY and not working for 

another Archdiocesan institution. Must 

have participated in the plan prior to 

retirement. 

•Retired Diocesan & Extern Priests 

who are Medicare eligible. 

• Religious Brothers & Sisters who 

become eligible and elect Medicare 

Parts A & B at age 65. 

• Retired non-bargaining lay employees 

who elected this coverage prior to 

retiring from the Archdiocese of NY 

- Immediate Coverage 





- First of the month after 

30 days of employment 

- Varies by Agency 

- Retirement Date 



or Date of Medicare 

(Parts A & B) 

- Date of Medicare 

(Parts A & B) 

- Retirement date 

- None 

- None 

- None 

- None 

- None 

- 30 Days 

(at least) 

- Varies 

- None 

- None 

- None 

- None 

- None 

EMPLOYER’S 

COST 

- Entire Premium 




- Based on Schedule 

- Based on a Schedule 


- None (Retiree pays) 





BASIC DESCRIPTION 

Choice Plus plan which provides medical and 

hospital benefits. 

Primarily a self-referral health plan. 

Participant is not required to select a 

primary care physician. 

(See Summary Plan Description for 

details) 

Medical and hospital plan that supplements Medical 

Primary coverage. 

Participant is subject to deductibles and coinsurance. 

(See Summary Plan Description for 

details) 

NOTE: This is a summary description of the plan benefits only and is subject to the term, conditions, limitations and exclusions set forth in each plan’s official plan document. If there are conflicting information contained between this summary and the any of the official 

plan documents plan documents will preside. 

The Archdiocese of New York reserves the right to amend or revoke its policies at time without notice. Nothing in this summary constitutes a promise or guarantee of continuing benefits 

Revised May 2008


PERIOD 

Caremark Prescription Plan 

(Must be enrolled in 

group medical plan) 

(800) 565-7091 

www.caremark.com 

Hartford Life Insurance Company 

Group Life Insurance 

Policy #GL-674263 

888.563-1124 

Conversion & Portability Info: 

877.320.0484 

Mutual of Omaha Company 

Accidental Death & 

• Active & Retired Diocesan and 

Extern Priests as approved by the 

Office of Priest Personnel. 

• Active and Retired Religious Brothers 

& Sisters 

• Seminarians 


and Private Schools 





• Non-bargaining lay employees of the 

Archdiocese of New York regularly 


• Employees of Child Care Agencies 

• Early retired Bargaining Lay Faculty 

Members (ages 55 to 64), who 

participated in plan prior to 

retirement, has 10 years service, 

receiving a pension from the 

AONY and not working for another 

Archdiocesan institution. 

• Retired non-bargaining lay 

employees who have worked for the 

Archdiocese at least 10 years and at 

least 55 years old, receiving a pension 

from AONY and not working for 

another Archdiocesan institution. 

Must have participated in the plan 

prior to retirement. 

• Members of the Clergy as approved 

for coverage by the Office of Priest 

Personnel. 


CHSA, & Private Schools. 





• Lay employees who are regularly 

scheduled to work 20 hours each 

week. 

• Lay employees employed by Child 

Care Agencies 

• Members of the Clergy as approved 

for coverage by the Office of Priest 

Personnel. 







30 days of employment 








30 days of employment. 


EMPLOYER’S 

COST 





Revised May 2008 

- None 

- None 

- None 

- None 

- None 

- 30 Days 

(at least) 

- Varies 

- None 

- None 

- None 

- None 

- None 

- 30 days 

(at least) 

- Varies 















Prescription drug benefit plan, which enables 

participants to purchase prescribed drugs at a retail 

pharmacy or through a mail order service. 

(Refer to the Prescription Drug 

Benefit Program booklet for more 

details) 

(Co-pays subject to change) 

Benefits ranges are $10,000 or one times the annual 

salary ($200,000 max) of the participant as outlined 

in the plan booklet. 

This benefit plan also provides for waiver of 

premiums due to the disability of an employee. 

Benefit also includes a “living benefit”, which is also 

known as an accelerated death benefit, premium 

waiver feature, portability and conversion options. 

(Refer to benefits booklets for further details and 

requirements) 

- Immediate Coverage - None - Entire Premium The principal sum will match the group life 

plan.


PERIOD 

Dismemberment Plan 

(800) 524-2324 



Policy #LNY 612197 

(800) 538.0134 



Policy #GLT-674263 

(800) 538.0134 


CHSA, & Private Schools. 





• Lay employees who are regularly 

scheduled to work 20 hours each 

week. 


Care Agencies 

• All lay employees of participating 

institutions or divisions, who have 

worked at least 4 consecutive weeks 

with a covered employer (State 

mandated benefit) 

• Bargaining lay faculty members 

assigned to work 20 hours. 

• Non-bargaining lay employees 

assigned to work 30 hours. 

• Lay employees of Child Care agencies 

– hours varies by group 




30 days of employment. 


- Immediate Coverage if 

employee changed jobs 

from another covered 

employer. 

- First of the month after 6 

months of employment. 

- First of the month after 6 

months of employment 


- None 

- None 

- 30 days 

(at least) 

- Varies 

7 calendar 

days off the 

job due to 

illness/injury 

that is non 

job related. 

- 180 days of 

disability 


disability 


disability 

EMPLOYER’S 

COST 





- Entire Premium* 

*Employee can share 

cost of premium up to 

$0.60 (cents) per 

payroll deduction. 





There is dismemberment benefit based on a 

schedule. 

(Refer to benefits booklet for further 

details and requirements) 

Benefits starts on the 8th day of eligible disability and 

pays 50% of employee’s base pay up to a maximum 

of $170.00. 

Benefits are paid for a maximum of 26 weeks during 

52 consecutive weeks or during any one period of 

disability. 

Benefit provides 60% of monthly earnings to a 

maximum of $5,000 subject to offsets with other 

disability income such as Social Security disability 

and pension. 

(Refer to benefits booklet for further details and 

requirements) 


Voluntary Group Supplemental 

Life Insurance 

(888) 563-1124 

Northeast Dental Plan of America 

Voluntary Dental Plan 

(800) 828-2222 

www.ndpa.com 

www.dentalsave.com 

• Bargaining lay faculty members who 

are regularly scheduled to work at 

least 20 hours and already enrolled in 

the basic group life insurance. 

• Non-bargaining lay employees who 

are regularly scheduled to work at 

least 20 hours and already enrolled in 

the basic group life insurance. 


Care Agencies. Eligibility hours 

varies among this group. Employees 

must already be enrolled in basic 

group life insurance. 

• All lay employees of the Archdiocese 

of New York 

- Same as for group basic 

life insurance 


life insurance. 


life insurance. 

As soon as membership fee 

is received by North-east 

Dental. Employee may 

enroll over the telephone 

using his/her credit card. 

Same as for 

group basic 

life ins. 

Same as for 

group basic 

life ins. 

Same as for 

group basic 

life ins. 

None 

Through payroll deductions, employees have the 

opportunity to purchase additional life insurance, 

which provides cash accumulation or cash value. 

An eligible employee also has the option of 

purchasing supplemental coverage for his/her 

spouse and dependent children. 

None None Plan offers voluntary dental coverage at 

discounted fees for dental services provided by 

member dentists. 

Employees pay discounted membership fees directly 

to Northeast Dental. 




Revised May 2008

DIVISION CLAIM CODES 

-6-


GROUP AND CLAIM DIVISION CODES 

MEDICAL PLANS 

Group 6000 – Clergy & Seminarians 

053 Clergy (Diocesan Clergy and Externs) 

055 Seminarians 

153 Clergy with Medicare Primary 

156 Retired Clergy over age 65 without Medicare Primary 

Group 7000 - Religious 

050 Religious Brothers and Sisters – (Religious working in outside institutions - high dental option) 

051 Religious Brothers and Sisters – (Religious working within their communities with high or low dental option) 

154 Religious with Medicare Primary with Rx 

Group 4000 - Non-Bargaining Lay Employees 

001 Non-Bargaining Lay Faculty – Parish Schools 

002 Non-Bargaining Lay Faculty – Private Schools 

005 Lay Faculty – Special Education & Religious Vocational Institutions 

006 Trustees of St. Patrick Cathedral 

024 Lay Employees of Cemeteries (Non-Bargaining) 

025 Incarnation Children’s Center 

030A Outside Affiliated Agencies of the Archdiocese 

030B 

Employees of Dominican Sisters 

031 Catholic Charities 

032 Lay Employees of Private Schools (Non-Bargaining) 

033 Chancery, Central Services, and Supporting Departments 

034 Parish/Parish School Employees (Non-Bargaining) 

035 Office of Drug Education (Division of the Dept. of Education) 

036 Beacon of Hope 

037 St. Raymond’s Cemetery – Non-Bargaining 

040 Catholic High School Association Non-Bargaining Employees 

043 Missionaries receiving stipends – Parish/CHSA 

044 Missionaries receiving stipends – Private Schools 

106 Trustees of St. Patrick’s Cathedral – Grandfathered Retirees with Group Life Benefits 

131 Non-Bargaining Lay Retirees over age 65 

134 Non-Bargaining Active Lay Employees over age 65 with Medicare Primary – Grandfathered closed group 

135 Retired Non-Bargaining Lay Employees under age 65 

Group 5000 - Lay Faculty Members Covered by Collective Bargaining 

003 Lay Bargaining Faculty – Parish Schools 

004 Lay Bargaining Faculty – CHSA Schools 

007 Union Officers of the Federation of Catholic Teachers 

103 Early Retired Lay Faculty – Parish Schools 

104 Early Retired Lay Faculty - CHSA 

108 Aged 65+ Spouse of Early Retired Lay Faculty Member of CHSA 

109 Aged 65+ Spouse of Early Retired Lay Faculty Member of Parish School 

Group 2000 - Child Care Agencies 

017 Mission of the Immaculate Virgin, Mt. Loretto – Non-Bargaining Employees 

018 St. Cabrini Home 

019 St. Dominic’s Home 

047 Mission of the Immaculate Virgin, Mt. Loretto – Bargaining Employees 

113 Child Care Agencies Retirees over age 65 

114 Child Care Agencies Retirees under age 65 

Division Codes.Arch System Revised 07/01/09

Group 3000 - New York State Continuance Coverage 

813 Eligible Non-Bargaining Lay Employees and their dependents 

814 Eligible Bargaining Lay Employees and their dependents 

Non-Medical Groups 

008 Ferncliff Nursing Home – Dental Only 

026 St. Patrick’s Home (Management) – Life Only @ 1xBAE 

026 St. Patrick’s Home (Non-Management) – Life Only @ $10,000 

027 Rosary Hill Home – LTD Only 

028 St. Rose’s Home – LTD Only 

038 Dominican Fathers (Lay Employees) - Life Only @ $10,000 

045 St. Vincent De Paul Residence – Dental Only 

052 Religious Brothers and Sisters – No Medical. Dental & Vision Only 

Division Codes.Arch System Revised 07/01/09


NOTICE 

CHANGE NAME OF CONTACT LISTED ON 

MONTHLY INSURANCE BILLING STATEMENT 

__________________________________________________________________ _______________ 

INSTITUTION NAME INSTITUTION # 

__________________________________________________________________ 

STREET ADDRESS 

________________________________________________________________________ 

CITY AND STATE 

________________________________________________________________________ 

TELEPHONE NUMBER 

________________________________________________________________________ 

FAX NUMBER 

________________________________________________________________________ 

CURRENT CONTACT 

________________________________________________________________________ 

NEW CONTACT 

_________________ 

TITLE 

_________________ 

TITLE 

__________________________________________________________________ 

EFFECTIVE DATE OF CHANGE 

________________________________________________________________________ 

SIGNATURE OF PASTOR/PRINCIPAL 

________________________________________________________________________ 

PASTOR/PRINCIPAL PRINT NAME 

________________________________________________________________________ 

SIGNATURE OF LOCAL ADMINISTRATOR 

________________________________________________________________________ 

LOCAL ADMINISTRATOR PRINT NAME 

_________________ 

DATE 

_________________ 

DATE 

_________________ 

DATE 

_________________ 

DATE 

SEND FORM TO: 

EMPLOYEE BENEFIT CONNECTIONS 

1011 FIRST AVENUE – ROOM 1679 

NEW YORK, NEW YORK 10022 

FAX 212.644.0690 

11/2008

HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT 

(HIPAA) 

NOTICE OF PRIVACY PRATICES 

-8-

Revised: January 1, 2006 Effective: April 14, 2003 

NOTICE OF PRIVACY PRACTICES 

UNDER FEDERAL PRIVACY REGULATIONS YOUR MEDICAL RECORD IS PROTECTED 

FROM DISCLOSURE AND YOU ARE GRANTED SPECIFIC RIGHTS TO CONTROL HOW 

YOUR HEALTH INFORMATION IS USED. THIS NOTICE OF PRIVACY PRACTICES 

DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED 

AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT 

CAREFULLY. 

We Respect and Protect Your Privacy 

Respect for your privacy, especially with regard to Protected Health Information, has long been 

highly valued by your employer. We are committed to providing you with quality health care and 

services that meet your needs. That commitment includes protecting personal health information we 

obtain about you. Your employer, in accordance with applicable federal and state law, is committed 

to maintaining the privacy of your personal health information. 

New federal health privacy regulations that were issued as a result of the Health Insurance Portability 

& Accountability Act of 1996 (HIPAA) establishes broad individual privacy rights, obligates your 

health provider to keep your medical records confidential, and ensures that your employer cannot 

have access to your health information for employment purposes. In addition, HIPAA requires all 

health care records and other individually identifiable health information used or disclosed by us in 

any form, whether electronically, on paper, or orally, be kept confidential. 

This federal law gives you, the plan participant, significant new rights to understand and control how 

your health information is used. HIPAA imposes penalties if we misuse your personal health 

information. As required by HIPAA, we have prepared this Notice of Privacy Practices (Notice) to 

explain (1) your specific rights to access and control your personal health information, (2) how we are 

required to maintain the privacy of your health information, and (3) the limited circumstances in 

which we may use and disclose your health information. 

Who Will Follow This Notice 

This Notice describes the Protected Health Information practices of (a) your employer, (b) the group 

health plan it participates in, which is sponsored by the Archdiocese of New York (the “Plan”), and 

(c) that of any third party that assists in the administration of Plan claims. 

Our Pledge Regarding Protected Health Information 

We understand that Protected Health Information about you and your health is personal. We are 

This Notice is Also Available in Spanish


committed to protecting Protected Health Information about you. We create a record of the health 

care claims reimbursed under the Plan for Plan administration purposes. This Notice applies to all of 

the medical records we maintain. Your personal doctor or health care provider may have different 

policies or notices regarding the doctor’s use and disclosure of your Protected Health Information 

created in the doctor’s office or clinic. 

Your Rights Regarding Your Protected Health Information 

You and your legal representative, if any, have the following rights with respect to the Protected 

Health Information we have about you in our records. 

Right to Inspect and Copy. You have the right to inspect and copy Protected Health Information 

that may be used to make decisions about your Plan benefits. To inspect and copy Protected Health 

Information that may be used to make decisions about you, you must submit your request in writing. 

If you request a copy of the information, we may charge a fee for the costs of copying, mailing or 

other supplies associated with your request. 

We may deny your request to inspect and copy in certain very limited circumstances. If you are 

denied access to Protected Health Information, you may request that the denial be reviewed. 

Right to Amend. If you feel that Protected Health Information we have about you is incorrect or 

incomplete, you may ask us to amend the information. You have the right to request an amendment 

for as long as the information is kept by or for the Plan. In addition, you must provide a reason that 

supports your request. We may deny your request for an amendment if it is not in writing or does not 

include a reason to support the request. In addition, we may deny your request if you ask us to 

amend information that: 

• is not part of the Protected Health Information kept by or for the Plan: 

• was not created by us, unless the person or entity that created the information is no 

longer available to make the amendment; 

• is not part of the information which you would be permitted to inspect and copy; or 

• is accurate and complete. 

Right to an Accounting of Disclosures. You have the right to request an “accounting of 

disclosures” of your Protected Health Information made to you or our personal representative by the 

Plan in the six years prior to the date on which the accounting is requested, except for disclosures: 

• to carry out treatment, payment, or health care operations; 

• pursuant to a valid authorization; or 

• incident to a permitted or required use or disclosure. 

Your request must state a time period, which may not be longer than six years and may not include 

dates before April, 2003. Your request should indicate in what form you want the list (for example, 

paper or electronic). The first list you request within a 12-month period will be free. For additional 

lists, we may charge you for the costs of providing the list. We will notify you of the cost involved 

and you may choose to withdraw or modify your request at that time before any costs are incurred. 

Right to Request Restrictions. You have the right to request a restriction or limitation on the 

Protected Health Information we use or disclose about you for treatment, payment or health care 

operations. You also have the right to request a limit on the Protected Health Information we 

disclose about you to someone who is involved in your care or the payment for your care, like a 

family member or friend. For example, you could ask that we not use or disclose information about 



a surgery you had. 

We are not required to agree to your request. In your request, you must tell us (1) what information 

you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you 

want the limits to apply. 

Right to Request Confidential Communications. You have the right to request that we 

communicate with you about medical matters in a certain way or at a certain location. For example, 

you can ask that we only contact you at work or by mail. We will not ask you the reason for your 

request. We will accommodate all reasonable requests. Your request must specify how or where you 

wish to be contacted. 

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You 

may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this 

Notice electronically, you are still entitled to a paper copy of this Notice. 

If you wish to make any of the requests listed above under “Your Rights Regarding Your Protected Health 

Information”, you must complete and mail to United Healthcare the appropriate form. To obtain the form please call 

the United Healthcare phone number on the back of your United Healthcare ID card. Forms should be mailed to 

the address printed on the forms. After United Healthcare receives your signed, completed form, United Healthcare 

will respond to your request. 

You may obtain a copy of this Notice from the Plan sponsor’s website, www.archny.org 

To obtain a paper copy of this Notice, call the Plan sponsor at (212) 371-1011, Ext. 3034. 

Our Responsibilities With Respect to Your Protected Health Information 

We are required by law to: 

• make sure that Protected Health Information that identifies you is kept private; 

• give you this Notice of our legal duties and privacy practices with respect to Protected 

Health Information about you; 

• follow the terms of the Notice that is currently in effect; 

• notify you if we cannot accommodate a requested restriction or request; 

• accommodate your reasonable requests regarding methods to communicate health 

information with you; and 

• accommodate your request for an accounting of disclosures. 

Your Authorization to Use and Disclose Your Protected Health Information 

General uses and disclosures of Protected Health Information not covered by this Notice or the laws 

that apply to us will be made only with your written permission. If you provide us permission to use 

or disclose Protected Health Information about you, you may revoke that permission, in writing, at 

any time. If you revoke your permission, we will no longer use or disclose Protected Health 

Information about you for the reasons covered by your written authorization. You understand that 

we are unable to take back any disclosures we have already made with your permission, and that we 

are required to retain our records of the care that we provided to you. 



Limited Circumstances in Which We May Use and Disclose Your Protected Health 

Information 

The following categories describe the limited ways that we use and disclose Protected Health 

Information. For each category of uses or disclosures we will explain what we mean and present 

some examples. Not every use or disclosure in a category will be listed. However, all of the ways we 

are permitted to use and disclose information will fall within one of the categories. 

For Treatment (as described in applicable regulations). We may use or disclose Protected Health 

Information about you to facilitate medical treatment or services by providers. We may disclose 

Protected Health Information about you to providers, including doctors, nurses, technicians, medical 

students, or other hospital personnel who are involved in taking care of you. For example, we might 

disclose information about your prior prescriptions to a pharmacist to determine if a pending 

prescription is contraindicative with prior prescriptions. 

For Payment (as described in applicable regulations). We may use and disclose Protected Health 

Information about you to determine eligibility for Plan benefits, to facilitate payment for the 

treatment and services you receive from health care providers, to determine benefit responsibility 

under the Plan, or to coordinate Plan coverage. For example, we may tell your health care provider 

about your medical history to determine whether a particular treatment is experimental, 

investigational, or medically necessary or to determine whether the Plan will cover the treatment. We 

may also share Protected Health Information with a utilization review or precertification service 

provider. Likewise, we may share Protected Health Information with another entity to assist with the 

adjudication or subrogation of health claims or to another health plan to coordinate benefit 

payments. 

For Health Care Operations (as described in applicable regulations). We may use and disclose 

Protected Health Information about you for other Plan operations. These uses and disclosures are 

necessary to run the Plan. For example, we may use Protected Health Information in connection 

with: conducting quality assessment and improvement activities; underwriting, premium rating, and 

other activities relating to Plan coverage; submitting claims for stop-loss (or excess loss) coverage; 

conducting or arranging for medical review, legal services, audit services, and fraud and abuse 

detection programs; business planning and development such as cost management; and business 

management and general Plan administrative activities. 

As Required By Law. We will disclose Protected Health Information about you when required to 

do so by federal, state or local law. For example, we may disclose Protected Health Information 

when required by a court order in a litigation proceeding such as a malpractice action. 

To Avert a Serious Threat to Health or Safety. We may use and disclose medical information 

about you when necessary to prevent a serious threat to your health and safety or the health and 

safety of the public or another person. Any disclosure, however, would only be to someone able to 

help prevent the threat. For example, we may disclose Protected Health Information about you in a 

proceeding regarding the licensure of a physician. 



Specific Situations 

We may disclose your Protected Health Information under the following specific situations: 

Disclosure to Health Plan Sponsor. Information maintained by the Archdiocese of New York 

may be disclosed to another health plan for purposes of facilitating claims payments under that plan. 

In addition, Protected Health Information may be disclosed to Archdiocesan personnel solely for 

purposes of administering benefits under the Plan. 

Disclosure to Business Associate. Business Associate may use and disclose Protected Health 

Information for the proper management and administration of the Business Associate or to meet its 

legal responsibilities. Such Protected Health Information may only be disclosed for such purposes if 

the disclosures are Required By Law or the Business Associate obtains certain reasonable assurances 

from the person to who the information is disclosed. 

Organ and Tissue Donation. If you are an organ donor, we may release Protected Health 

Information to organizations that handle organ procurement or organ, eye or tissue transplantation 

or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. 

Military and Veterans. If you are a member of the armed forces, we may release Protected Health 

Information about you as required by military command authorities. We may also release Protected 

Health Information about foreign military personnel to the appropriate foreign military authority. 

Workers’ Compensation. We may release Protected Health Information about you for workers’ 

compensation or similar programs. These programs provide benefits for work-related injuries or 

illness. 

Public Health Risks. We may disclose Protected Health Information about you for public health 

activities. These activities generally include the following: 

• to prevent or control disease, injury or disability; 

• to report births and deaths; 

• to report child abuse or neglect; 

• to report reactions to medications or problems with products; 

• to notify people of recalls of products they may be using; 

• to notify a person who may have been exposed to a disease or may be at risk for 

contracting or spreading a disease or condition; 

• to notify the appropriate government authority if we believe a patient has been the 

victim of abuse, neglect or domestic violence. We will only make this disclosure if you 

agree or when required or authorized by law. 

Health Oversight Activities. We may disclose Protected Health Information to a health oversight 

agency for activities authorized by law. These oversight activities include, for example, audits, 

investigations, inspections, and licensure. These activities are necessary for the government to 

monitor the health care system, government programs, and compliance with civil rights laws. 

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Protected 

Health Information about you in response to a court or administrative order. We may also disclose 

Protected Health Information about you in response to a subpoena discovery request, or other lawful 

process by someone else involved in the dispute, but only if efforts have been made to tell you about 

the request or to obtain an order protecting the information requested. 



Law Enforcement. We may release Protected Health Information if asked to do so by a law 

enforcement official: 

• in response to a court order, subpoena, warrant, summons or similar process; 

• to identify or locate a suspect, fugitive, material witness, or missing person; 

• about the victim of a crime if, under certain limited circumstances, we are unable to obtain 

the person’s agreement; and 

• in emergency circumstances to report a crime; the location of the crime or victims; 

or the identity, description or location of the person who committed the crime. 

Coroners, Medical Examiners and Funeral Directors. We may release Protected Health 

Information to a coroner or medical examiner. We may also release Protected Health Information 

about members of the Plan to funeral directors as necessary to carry out their duties. 

National Security and Intelligence Activities. We may release Protected Health Information 

about you to authorized federal officials for intelligence, counter intelligence, and other national 

security activities authorized by law. 

Inmates. If you are an inmate of a correctional institution or under the custody of a law 

enforcement official, we may release Protected Health Information about you to the correctional 

institution or law enforcement official. This release would be necessary (1) for the institution to 

provide you with health care; (2) to protect your health and safety or the health and safety of others; 

or (3) for the safety and security of the correctional institution. 

Change to This Notice 

We reserve the right to change this notice. We reserve the right to make the revised or changed 

notice effective for Protected Health Information we already have about you as well as any 

information we receive in the future. We will post a copy of the current notice on the Plan website. 

This notice and future notices will contain on the first page, in the top right-hand corner, the 

effective date. 



More Information or Complaints 

If you want more information about your privacy rights, do not understand your privacy 

rights, are concerned that your privacy rights have been violated or disagree with a decision 

that your employer, the Archdiocese of New York and/or United Healthcare made about 

access to your confidential information, you may contact your employer, the Plan sponsor’s 

Privacy Office or United Healthcare’s Privacy Office. If you choose, you may also file a 

complaint with the Secretary of the U.S. Department of Health and Human Services. Any 

such complaint would be addressed to: 

Secretary of the U.S. Department of Health and Human Services, Region II Office for Civil 

Rights U.S. Department of Health and Human Services, Jacob Javits Federal Building 26 

Federal Plaza - Suite 3302 New York, NY 10278 Telephone number 212-264-3313 

Your employer, the Archdiocese of New York and United Healthcare will not take any action 

against you if you file a complaint with the Secretary or United Healthcare. The Privacy Office 

for the Archdiocese of New York may be contacted at: 

Director of Life & Health Benefit Programs, Privacy Officer of the Archdiocese of New 

York, 1011 First Avenue New York, New York 10022, Telephone number (212) 371-1011, 

Ext. 3034 

You may contact United Healthcare’s Privacy Office at: 

Privacy Office at United Healthcare, Customer Service-Privacy Unit, P.O. Box 740815, 

Atlanta, GA, 30374-0815, Telephone number: (800) 736-1264 

All complaints must be submitted in writing. 



AUTHORIZATION FOR RELEASE OF INFORMATION 

_____________________________________________________________________________________________________________________ 

Section A: Must be completed for all authorizations 

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I 

understand that this authorization is voluntary. I understand that if the organization authorized to receive the 

information is not a health plan or health care provider, the released information may no longer be protected by 

federal privacy regulations. 

Patient/Participant Name _____________________________ SSN: _____________________ 

Persons/organizations providing the information: Person/organizations to receive the information: 

__________________________________________ ___________________________________________ 

__________________________________________ ___________________________________________ 

Specific description of information (including date(s)): ______________________________________________ 

_____________________________________________________________________________________________ 

_____________________________________________________________________________________________ 

_____________________________________________________________________________________________ 

IF THE REQUESTED RECORDS CONTAIN INFORMATION PERTAINING TO PSYCHIATRIC OR 

MENTAL HEALTH, DRUG OR ALCOHOL TREATMENT, OR HIV RELATED INFORMATION, YOU MUST 

SPECIFICALLY CONSENT TO THE RELEASE OF SUCH INFORMATION BY INITIALING ONE OR 

MORE OF THE FOLLOWING: 

____ I understand that if my records contain information pertaining to diagnosis and/or treatment for 

alcoholism and/or drug abuse or dependency, such information will be released pursuant to this 

authorization form. 

____ I understand that if my records contain information pertaining to diagnosis and/or treatment regarding 

psychiatric and/or mental health issues, such information will be released pursuant to this authorization form. 

____ I understand that if my records contain information pertaining to HIV antibody test results and/or AIDS 

diagnosis and treatment, such information will be released pursuant to this authorization form. 

Restrictions? Yes___ No___ If yes, please describe: _______________________________ 

_____________________________________________________________________________________________ 

_____________________________________________________________________________________________ 

Section B: Must be completed only if a health plan or a health care provider has requested the authorization 

1. The health plan or health care provider must complete the following: 

a. What is the purpose of the use or disclosure? ___________________________________________________ 

_________________________________________________________________________________________ 

b. Will the health plan or health care provider requesting the authorization receive financial or in-kind 

compensation in exchange for using or disclosing the health information described above? 

Yes ____ No _____ 

2. The patient or the patient's representative must read and initial the following statements: 

a. I understand that my health care treatment and payment, my enrollment in the health plan and my 

eligibility for benefits will not be affected if I do not sign this form. Initials: ________ 

b. I understand that I may see and copy the information described on this form if I ask for it, and that I will 

get a copy of this form after I sign it. Initials: __________ 

Section C: Must be completed for all authorizations 

The patient or the patient's representative must read and initial the following statements: 

- 9 - 

NY01/LASKA/855065.1

1. I understand that this authorization will expire (select a. or b.): 

a. on __ __/__ __/__ __ __ __ (DD/MM/YYYY) Initials: _________ 

b. at the occurrence of the following event: __________________________________Initials: _________ 

2. I understand that I may revoke this authorization at any time by notifying the plan in writing, but if I do it won't have 

any affect on any actions taken before my revocation was received. Initials: ________ 

______________________________________________________ 

Signature of individual or individual’s representative 

(Form MUST be completed before signing) 

____________________________ 

Date 

Printed name of individual's representative(if applicable):____________________________________________ 

Description of representative’s authority to act for the individual: _____________________________________ 

*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION* 

NY01/LASKA/855065.1

AUTHORIZATION FOR THE USE AND DISCLOSURE OF INFORMATION 

This authorization must be dated and signed by the individual or by a person authorized by law to give this authorization. File 

copy and facsimile transmission are considered equivalent to the original (unless applicable state law provides otherwise). If 

UnitedHealthcare seeks the authorization from an individual for a use or disclosure of Protected Health Information (PHI), 

UnitedHealthcare must provide the individual with a copy of the signed authorization. 

I authorize United HealthCare Insurance Company, and its subsidiaries/affiliates (“UnitedHealthcare”), to use or disclose my medical, 

claim, or benefit records, including any individually identifiable health information contained in these records, as described below. I 

understand these records may contain information created by other persons or entities, including physicians and other health care 

providers as well as information regarding the use of drug and alcohol treatment services, HIV/AIDS treatment, mental health services 

[Note: Psychotherapy notes may be used/disclosed only pursuant to a separate authorization pertaining only to psychotherapy notes], 

reproductive health services, and treatment for sexually transmitted diseases. 

1. Persons/entities authorized to receive the information (including address of where information should be sent, if applicable): 

Name: 

Address: 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

2. Type of information UnitedHealthcare is authorized to use or disclose: 

____________________________________________________________________________________________________ 

____________________________________________________________________________________________________ 

3. The information will be used or disclosed for the following purposes: At the request of the Individual 

4. I understand that I may revoke this authorization at any time by notifying UnitedHealthcare in writing at PO Box 740800, Atlanta, 

GA, 30374-0800, except to the extent that: 

(a) UnitedHealthcare has taken action in reliance on this authorization; or 

(b) If authorization was obtained as a condition for obtaining insurance coverage, other law provides the insurer with the right to 

contest a claim under the policy. 

5. This authorization expires [on] [upon] ________________[date] or is valid ______________ [event]. Please note: This 

authorization may be valid for a maximum time period of one year. 

I understand that once health information about me has been disclosed by United HealthCare Insurance Company to a third party, the 

health information may no longer be protected by federal privacy laws. 

___________________________________________________________________________________________________________ 

Printed name of individual or individual's representative 

___________________________________________________________________________________________________________ 

If representative, relationship to individual and authority to act for individual 

_____________________________________________________ _______________________ ______________________ 

Signature of individual Subscriber Id # Date 

Form: AUTH MEM 011504 - 10 -

Eligibility 

Effective Date 

Employee Contribution 

Benefit Summary 


Group Health Benefits Eligibility 

Employees who are regularly scheduled to work a minimum of 20 hours each week. 

Eligible dependent spouse. 

Unmarried, dependent children (natural or adopted) are eligible until the end of 

the calendar year in which the child turns 19 years old. Dependent children 

enrolled as full time college students are eligible unitl the end of the year the 

child turns 25 years old as long as he/she is unmarried and enrolled in an 

accredited school on a full time basis. 

First of the month following 30 days of employment, provided you have 

completed the health enrollment form. **(Refer to footnotes) 

Fixed schedule based on type of coverage elected and regularly scheduled 

work hours. 

Refer to the following section which describes: 

*United Healthcare Choice Plus Plans: (In -network providers can be accessed 

via 800.736.1264 or www.myuhc.com) 

*Medicare Supplement for Retired Lay Employees over age 65, Clergy and Religious 

who have Medicare Primary Benefits. (MSYRX) 

*Notice of Privacy Practice (To be given to all health plan participants) 

*Authorization for Use and Disclosure of Private Health Information. 

(Health plan participants must complete and sign form to authorize local 

benefits administrator to help resolve health claim issues. Additional form is 

required by the health plan participant to authorize other persons to use and 

disclosure of medical claims information such as family member etc.) 

**Effective date is immediate for: 

Divs. 001 thru 005 - Bargaining/Non-Bargaining Lay Faculty 

Div. 040 - Non-Bargaining Lay Employees of CHSA 

Divs. 043 & 044 - Aegis of Religious Orders for Parish/CHSA & Private schools 

Divs. 050 & 051 - Religious Brothers & Sisters 

Div. 053 & 156 - Clergy 

Div. 055 - Seminarians 

Div. 153 - Clergy with Medicare Primary Coverage 

Div. 154 - Active and Retired Religious with Medicare Primary Coverage 

**Effective date is first of the month following 30 days of service: 

Div. 006 - Trustees of St. Patrick's Cathedral 

Div. 024 - Non-Bargaining Lay Employees of Cemeteries 

Div. 030A - Lay Employees of Outside Affiliated Agencies 

Div. 030B - Employees of Dominican Sisters 

Div. 031 - Catholic Charities 

Div. 032 - Non Bargaining Lay Employees of Private Schools 

Div. 033 - Central Services 

Div. 034 - Non Bargaining Lay Employees of Parishes and Parish Schools 

Div. 035 - Office of Drug Education (ADAPP) 

Div. 037 - St. Raymond's Cemetery (Non-Bargaining Employees) 

Div. 038 - Lay Employees of Dominican Fathers 

Div. 045 - St. Vincent de Paul Residence 

Grandfathered closed group Div. 134 - Active Non-Bargaining Lay Employee with Medicare Primary (>age 65 & < 20 ees) 

**Effective date is three months for: 

Div. 017 - Mission of the Immaculate Virgin (Non-bargaining) 

Div. 018 - Cabrini Home 

Div. 019 - St. Dominic's Home 

Div. 025 - Incarnation Children Center 

Div. 036 - Beacon of Hope 

Div. 047 - Mission of the Immaculate Virgin (Bargaining Unit) 

11 07/2009

HOW TO ENROLL IN THE GROUP HEALTH BENEFIT PLAN 

AND/OR 

MAKE CHANGES TO A MEMBERS GROUP HEALTH BENEFIT COVERAGE 

OR CHANGE PERSONAL INFORMATION 

To enroll a new member, or to make changes to an existing member’s benefit 

Information: 

• The member must manually complete a “Health Benefit Plan Enrollment and 

Change Form” 

The new member should return the completed enrollment forms, to their local benefits 

administrator. The local administrator should retain copies of the completed forms for their 

records, and forward the original forms to: 




212.371.1000, Ext. 3060 Fax 212.644.0690 

Employee Benefit Connections must have the completed enrollment information, with all 

required documentation within 30 days of date of eligibility. Incomplete 

applications, or applications received more than 30 days after the effective date will 

NOT be processed. This applies to new enrollments, and as well as changes. Failure 

to comply can result in loss of member’s coverage. 

CHANGES TO HEALTH BENEFITS 

The member must complete a Health Benefit Plan Enrollment & Change Form, 

and attach any required documentation, and submit the form and documents to 

their local administrator. The administrator is responsible to review the forms and 

documents for accuracy and completeness, make copies for their records, and 

mail the original forms to Employee Benefit Connections (Address listed on 

form) for processing. 

TO OBTAIN HEALTH BENEFIT PLAN ENROLLMENT AND CHANGE 

FORMS PLEASE CONTACT EMPLOYEE BENEFIT CONNECTIONS AT: 

212.371.1000, EXT. 3060 

- 12 - 

Revised 07/2009

ADDITIONAL INFORMATION CONCERNING CHANGES PERMITTED 

OUTSIDE OF INITIAL ELIGIBILITY PERIOD AND OPEN ENROLLMENT 

Qualified Life Events: 

The following are qualified life events* which would permit employees and their 

eligible dependents to special enroll in the group medical plan outside the initial 

enrollment or open enrollment period: 

• Loss of other medical coverage due to loss of employment or reduction in hours 

• Marriage 

• Birth or adoption of a child 

• Death of employee spouse through whom member had medical coverage 

Other Changes Permitted: 

• Terminate medical coverage for member, member’s spouse/child who is no longer an 

eligible dependent under the terms of the group medical plan 

• Change of home address, martial status 

• Change of base salary (effects the amount of Life, AD&D and LTD Insurance) 

• Retirement 

• Under certain circumstances, when a member of the Clergy aged 65 & over, is fully 

retired and has enrolled in Medicare (Part A and Part B) Coverage, medical coverage 

may be changed to a Medicare Supplemental Plan. A photocopy of the Medicare card 

must accompany the new health enrollment form. ** 

• Religious Sister who reaches age 65 and eligible for Medicare (Part A and Part B) 

Coverage. Secure a copy of the Medicare I.D. card and attach the copy to the Health 

Benefit Plan Enrollment & Change Form and mail it to Employee Benefit Connections, 

1011 First Avenue, Room 1679, New York, New York 10022. 

* Documentation will be required to validate life event 

** Contact Employee Benefit Connections (212.371.1000, Ext. 3060) for details. 

Revised 07/2009

Annual Salary 

(Benefit 

Administrator Use 

Only) 

$______________ 


HEALTH BENEFIT PLAN ENROLLMENT & CHANGE FORM 

Note: Return your completed form to you Local Benefits Administrator within 30 days of the date of enrollment, a life event, date of any change(s). Failure to do so may 

result in loss of coverage. 

Effective Date of 

Coverage or 

Change 

Month/Day/Year 

/ / 

Please indicate the reason you are completing this form: 

❑ New Hire ❑ Open Enrollment ❑ Waive Coverage ❑ Marital/ Status Change ❑ Dependent Enrollment 

❑ Medicare Enrollment ❑ Retirement ❑ Work Hours Change ❑ Update Salary ❑ Name Change ❑ Address Change 

MEMBER INFORMATION 

Last Name_____________________________________________ First Name__________________________________________ MI____ Social Sec. #:__________-_________-___________ 

Date of Birth_____/_____/_____ Gender: ❑ Male ❑ Female Home Address:_________________________________________________________________________ Apt. No.__________ 

City________________________________________________________ State______ Zip__________ Home Phone__________________________ Work Phone_________________________ 

Status: ❑ Active ❑ Retired Occupation__________________________________________ Covered by Collective Bargaining Agreement: ❑ Yes ❑ No Date of Hire_____/_____/_____ 

❑ Part Time Employee ❑ Full Time Employee Regular Weekly Work Hours______ Marital Status: ❑ Single ❑ Married Marriage Date: ____/____/_____ ❑ Divorced ❑ Widowed 

DEPENDENT INFORMATION 

List below your name and the name(s) of eligible dependent(s) to be covered, your spouse and dependent children. A child will be considered a dependent if: 1) Age 19 to the end of calendar year) or 

2) Age 25 (if full-time college student-to the end of a calendar month in which child reaches age 25 as long as he/she is unmarried and enrolled in an accredited school on a full time basis.) Obtain the 

Statement of Dependent Eligibility Beyond Limiting Age in Plan Due to Mental Retardation or Mental or Physical Handicap Form to apply for extension of coverage for a disabled child before the 

child reaches the limiting age. 

First Name of Dependent 

(Include Last Name if Different from Yours) 

Sex 

M/F 

Date of Birth 

Mo./Day/Yr. 

Relationship to Employee Social Security Number Full Time 

Student? 

Yes/No 

Disabled? 

Yes/No 

EMPLOYER INFORMATION 

Employer (Institution)_____________________________________________________________________ Institution No.___________ Division Code__________ 

Employer Street Address ______________________________________________________________________________ City____________________________________________________ 

State________ Zip Code___________ Phone__________________________ 

IMPORTANT 

FORM CONTINUES ON THE REVERSE SIDE 

Page 1 of 2 

Contact us: ebc@archny.org Web Page: www.archny.org/benefits Revised 05/01/08

Select from the following coverage options for the Plan Year: 

MEDICAL PLAN ELECTION 

• Type of Medical Coverage: ❑ Single ❑ Two Person ❑ Family ❑ Medicare Supplement ❑ Waive Medical Coverage 

Payroll contribution Election: 

I elect that the employee contributions for the coverage I have selected be subtracted from my paycheck on the following basis: 

❑ Pre-Tax ❑ Post-Tax ❑ N/A 

OTHER MEDICAL COVERAGE 

Are you a dependent/or spouse covered by another health plan? ❑ Yes ❑ No. 

If “Yes”, please complete this section: Name and address of other insurance carrier: ______________________________________________________ Policy Number_______________________ 

Other Insurance Carrier Phone #:________________________ Primary Named Insured_____________________________________________ Person(s) Covered: ❑ Self ❑ Spouse ❑ Child(ren) 

Policyholder___________________________________________________ Address____________________________________________________________________________________________ 

Employer___________________________________________________ Address_____________________________________________________________ Phone_____________________________ 

Association (if applicable)______________________________________ Address____________________________________________________________ Phone_____________________________ 

Effective Date_______/________/_________ Plan Type: ❑ Hospital ❑ Medical ❑ Major Medical ❑ Extended Medical 

MEDICARE INFORMATION 

If this election form includes a person with Medicare coverage, complete the following (Attach a copy of your red, white and blue Medicare card): 

Name of Medicare Eligible Person Hospital (Part A) 


Medical (Part B) Effective 

Date 

Medicare Identification # 

HIB Suffix 

VISION CARE - CLERGY AND RELIGIOUS ONLY 

Clergy: ❑ Yes ❑ No Coverage Religious: ❑ Yes ❑ No Coverage (Coverage is mandatory for Religious on stipend) 

My signature below affirms eligibility for coverage, and authorization to deduct any contribution from my paycheck. All information provided is complete and true to the best of my knowledge. 

Any person who knowingly and with intent to defraud an application of health benefits or statement of claim containing any materially false information or conceals for the purpose of misleading 

information concerning any fact material thereto commits a fraudulent act, which subjects such person to civil penalties. 

If retired or otherwise not actively at work, I agree to pay the applicable premium required or portion thereof within 30 days of the premium due date. 

Employee/Participant Signature (Required):_________________________________________________________________________________ Date:_________________________________ 

Employer’s Signature (Required):_________________________________________________________________________________________ Date:_________________________________ 

Employer Print Name (Required):_________________________________________________________________________________________ 

Administrators: Mail completed form to – Employee Benefit Connections, 1011 First Avenue, Suite 1679, New York, New York 10022 or Fax form to 212.644.0690 

Contact us: ebc@archny.org Web Page: www.archny.org/benefits Revised 05/01/08 

Page 2 of 2


Group Health Benefit Election Form 

Non-Bargaining Full-Time Employees 

Effective January 1, _____ to December 31, _____ 

Name_______________________________________________ 

Soc. Security Number_________________________ 

Address_______________________________________ City________________________ State______ Zip________ 

Institution___________________________________________ Inst. No._______________ Division No.___________ 

Effective Date____________________ No. of Work Hrs./Week______ Payroll File# (If applicable)_____________ 

Select the appropriate member annual contribution option for the current benefit plan year: 

United Healthcare Plan (PPO) 

Single Coverage Two Person Coverage Family Coverage 

[ ] $______ [ ] $______ [ ] $_______ 

Dependent Coverage 

Name___________________________________________ Relationship______________ Date of Birth____________ 





Waiver of Medical Coverage 

Complete this section if you are waiving employee and/or dependent coverage. 

[ ] I elect to waive the employee health coverage under this plan. 

[ ] I elect to waive the dependent health coverage under this plan. (Check this box only if you have eligible dependents that you will not be 

covering under this plan). 

If you waive medical coverage, you (and/or your eligible dependents) will not be eligible to participate in the plan until the next benefit plan year, 

unless you experience a life status change. Life status changes include marriage, birth or adoption of a child, death, or a change in your or your 

spouse’s employment status, which affects you or your dependents’ eligibility for medical coverage. 

I elect that the employee contributions for the coverage I have selected be deducted from my paycheck on the following basis: 

[ ] Pre-tax [ ] After-tax 

If you select to have your contributions deducted from your pay on a pre-tax basis, your earnings for the purposes of computing Social Security 

benefits could be reduced. If you have concerns regarding this issue, contact your accountant or tax advisor before selecting this option. 

I understand that this election is effective during the current benefit plan year, unless there is a life status change. Life status change include 

marriage, divorce, birth, or adoption of a child, death, or change in employment status for my spouse or me, which would affect my dependents’ or 

my eligibility for coverage. 

I certify that all of the information contained on this coverage election form and my application is true. I understand the elections that I have 

indicated above and agree to have any employee contribution(s) deducted from my paycheck. 

Signed______________________________________________________________________ 

Date______________________________________ 

Member: Return this form to your local administrator 

Local Administrator: PLEASE RETAIN THIS FORM IN YOUR FILES FOR PAYROLL DEDUCTIONS 

Revised 01/2008



Non-Bargaining Part Time Employees 


Name_______________________________________________ 








[ ] $__________ [ ] $___________ [ ] $__________ 
























Signed______________________________________________________________________ Date______________________________________ 



Revised 01/2008



Bargaining Lay Faculty Members 


Name_______________________________________________ 








[ ] $_______ [ ] $_______ [ ] $________ 
























Signed______________________________________________________________________ Date______________________________________ 



Revised 01/2008

CERTIFICATION FOR DISABLED DEPENDENT CHILDREN OVER THE AGE 

OF NINETEEN (19) 

Members who are covered under the Group Health Benefit and have a covered Dependent 

Child(ren) over the age of 19, who is disabled, must submit a completed Statement of 

Dependent Eligibility Beyond Limiting Age In Plan Due To Mental Retardation or 

Mental or Physical Handicap form (refer to sample form on the following page). 

The Local Administrator should complete and sign the Employer’s Statement, before 

giving the form to the employee. Instruct the employee to complete the Employee Section 

of the form and have the dependent child’s physician complete the Physician’s Statement. 

Upon completion of the form the employee can make a copy for their confidential file and 

mail the original form to United Healthcare (address is listed on the form). 

United Healthcare will review the Certification and notify the member and the Employee 

Benefit Connections Department at the Archdiocese, if the dependent child is approved to 

remain as an eligible dependent on the group health benefit, and when re-certification is 

required. 

For additional information, call United Healthcare at 800.736.1264. 

- 13 -

STATEMENT OF DEPENDENT ELIGIBILITY BEYOND LIMITING AGE IN PLAN DUE TO 

MENTAL RETARDATION OR MENTAL OR PHYSICAL HANDICAP 

EMPLOYEE’S STATEMENT 

ANSWER ALL QUESTIONS BELOW. 

OMITTED INFORMATION WILL CAUSE DELAYS. 

Name (Print) First Middle Last Social Security Number 

Date of birth Male 

/ / 

Female 

Present Street City State Zip Code Marital Single Widowed Phone (with area code) 

Address: 

Status: Married Divorced ( ) 

Dependent Information 

Name (Print) First Middle Last Social Security Number 

/ / 

Present Street City State Zip Code Marital Single 

Address: 

Status: Married 

Date of birth Male 

Female 

Relationship to Employee 

Name and address of 

dependent’s current employer 

If not now employed, give 

date last employed 

Estimated income of 

dependent from all sources 

$_____________ monthly 

Percentage of support of 

dependent supplied by 

employee 

_______________% 

Is dependent permanently 

residing in employer’s 

household? 

Yes No If No, Explain 

Is dependent listed as a dependent in your last Federal Personal Income Tax Return? Yes No If No, Explain 

Explanations 

I KNOW IT IS A CRIME TO FILL OUT THIS FORM WITH FACTS I KNOW ARE FALSE OR TO 

LEAVE OUT FACTS I KNOW ARE IMPORTANT. 

Signed (Employee) 

Date 

PHYSICIAN’S/SURGEON’S STATEMENT 

ANY FEE FOR THE COMPLETION OF THIS STATEMENT TO BE PAID BY THE EMPLOYEE. 

ANSWER ALL QUESTIONS BELOW. OMITTED INFORMATION WILL CAUSE DELAYS. 

Patient’s Name First Middle Last Patient’s Date of Birth 

Is this dependent presently incapable of self-sustaining employment by reason of: 

Mental Retardation? Physical Handicap? Mental Handicap? Other (explain) 

Yes No Yes No Yes No Yes No 

Date dependent became 

incapable of self-sustaining 

employment 

Diagnosis of condition causing incapacity. If mental retardation is present, give degree of retardation. Give as much detail as 

possible. Please give date and report of surgery, X-rays, electrocardiograms, or other special tests. Use a separate sheet of 

paper if necessary. 

Does the patient have a job? Yes No 

Do you know what the patient’s job is? Yes No Do you know what the duties the patient’s job requires? Yes No 

Has this patient been able to do full or part-time work of any Will the patient be capable of self support? 

kind? No Yes, From _____________ Date 

No Yes, From _____________ Date 

The patient is presently (check one) Ambulatory Bed confined House confined Hospital confined 

Physician’s/Surgeon’s Name (Print) Address Phone (with area code) 

( ) 

I KNOW IT IS A CRIME TO FILL OUT THIS FORM WITH FACTS I KNOW ARE FALSE OR TO Date 

LEAVE OUT FACTS I KNOW ARE IMPORTANT. 

Signed 

EMPLOYER’S STATEMENT 

ANSWER ALL QUESTIONS BELOW. 

OMITTED INFORMATION WILL CAUSE DELAYS. 

Employee’s Name First Middle Last Certificate No. 

Date dependent’s coverage was originally effective 

If previously canceled, give date. 

Employer Group Branch Sub Division 

Title 

Date 

Signed by 

FOR USE BY United Healthcare 

Dependent eligibility will continue to Month Day Year 

Dependent eligibility declined. Give reason. 

Signature 

Date

Section III 

Benefits Summaries


SUMMARY OF MEDICAL BENEFITS 

For Clergy, Religious, Seminarians & Non-Bargaining Lay 

Employees 

UNITED HEALTHCARE CHOICE PLUS PLAN 

-15-

Summary of Benefits 

UnitedHealthcare Choice Plus 

Archdiocese of New York 

Active Plan for Clergy, Religious, Seminarians, and Lay Employees 

Effective January 1, 2006, if you have any questions please call UnitedHealthcare Member 

Services at 1-800-736-1264 or register on myuhc.com to get detailed information on your 

coverage. 

Choice Plus plan gives you the freedom to see any Physician or other health care professional 

from the Network, including specialists, without a referral. With this plan, you will receive the 

highest level of benefits when you seek care from a network physician, facility or other health 

care professional. In addition, you do not have to worry about any claim forms or bills. 

You also may choose to seek care outside the Network, without a referral. However, you should 

know that care received from a non-network physician, facility or other health care professional 

means a higher deductible and coinsurance. We recommend that you ask the non-network 

physician or health care professional about their billed charges before you receive care. 

Some of the Important Benefits of Your Plan: 

• You have access to a Network of 

physicians, facilities and other health 

care professionals, including specialists, 

without designating a Primary Physician 

or obtaining a referral. 

• Benefits are available for office visits 

and hospital care, as well as inpatient 

and outpatient surgery. 

• United Healthcare’s Nurseline connects 

you to registered nurses and a library of 

recorded programs on important health 

topics 24 hours a day, 7 days a week, 

from anywhere in U.S. 

• We offer the Language Line Services so 

that you can talk with us in 140 different 

languages. Just call customer service 

and ask for an interpreter. 

• Emergencies are covered anywhere in the 

world. 

• Care Coordination SM services are available 

to help identify and prevent delays in care 

for those who might need specialized help. 

• The tools and information at myuhc.com 

are practical and personalized so you can 

get the most out of your benefits. Register 

at myuhc.com and connect to current 

information about your benefits and health 

care interests. 

• Cancer Resource Services provides 

information on comprehensive cancer 

treatment services. Benefit from using 

one of our Centers of Excellence by 

calling 1-866-936-6002.

Choice Plus Benefits Summary 

Types of Coverage Network Benefits / Copayment Amounts Non-Network Benefits / Copayment Amounts 

This Benefit Summary is intended only to highlight 

your Benefits and should not be relied upon to fully 

determine coverage. This benefit plan may not cover all 

of your health care expenses. More complete 

descriptions of Benefits and the terms under which 

they are provided are contained in the Summary 

Plan Description that you will receive upon enrolling 

in the Plan. 

If this Benefit Summary conflicts in any way with the 

Summary Plan Description issued to your employer, the 

Summary Plan Description shall prevail. 

Terms that are capitalized in the Benefit Summary are 

defined in the Summary Plan Description. 

Network Benefits are payable for Covered Health 

Services provided by or under the direction of your 

Network physician. 

*Prior Notification is required for certain services. 

Annual Deductible: $150 per Covered Person per 

calendar year, not to exceed $300 for all Covered Persons 

in a family. Cross applies with out of network deductible. 

Out-of-Pocket Maximum: $1,200 per Covered Person 

per calendar year, not to exceed $2,400 per family. The 

Out-of-Pocket Maximum does not include the Annual 

Deductible. Cross applies with out of network out of 

pocket maximum. 

Maximum Plan Benefit: No Maximum Plan Benefit. 

MEMBER PAYS 

1. Ambulance Services - Emergency only Ground Transportation: 10% of Eligible Expenses after 

satisfying deductible 

Air Transportation: 10% of Eligible Expenses after 


2. Dental Services - Accident only (must begin 

within 6 months of injury) 



in a family. Cross applies with in network deductible. 




Deductible. Cross applies with in network out of pocket 

maximum. 

Maximum Plan Benefit: $1,000,000 per Covered 

Person. 

MEMBER PAYS 

Same as Network Benefit 

10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 

3. Durable Medical Equipment (the purchase or 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 

rental of prescribed equipment is covered, including 

needed replacement and repairs) 

4. Emergency Health Services $50 per visit (copay waived if admitted) True Emergencies - Same as Network Benefit 

Non-Emergency Visits - 30% of Eligible Expenses after 


*Notification is required if results in an Inpatient Stay. 

5. Refractive Eye Examinations No Coverage No Coverage 

6. Home Health Care 

Network and Non-Network Benefits are limited to 

200 per calendar year combined in and out of 

network. 

7. Hospice Care 

No annual maximum. 



8. Hospital - Inpatient Stay 10% of Eligible Expenses after satisfying deductible *30% of Eligible Expenses after satisfying deductible 

9. Injections Received in a Physician’s Office $25 per visit 30% of Eligible Expenses after satisfying deductible 

10. Maternity Services Delivery - 10% of Eligible Expenses after satisfying 

deductible 

Prenatal visit – 100% after $25 copay (copay applies to 

first prenatal visit only) 

Outpatient Diagnostic Services - 10% of Eligible 

Expenses after satisfying deductible 

Mother’s Hospital Charge - 10% of Eligible Expenses 

after satisfying deductible 

Newborn Nursery Charge - 10% of Eligible Expenses 

waive deductible 

11. Outpatient Surgery, Diagnostic and Therapeutic 

Services 

Delivery - 30% of Eligible Expenses after satisfying 

deductible 

Prenatal visit – 30% of Eligible Expenses after satisfying 

deductible 







*Notification is required out of network if Inpatient Stay 

exceeds 48 hours following a normal vaginal delivery or 

96 hours following a cesarean section delivery. 

Outpatient Surgery 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 

Outpatient Diagnostic Services 

For lab and radiology/Xray: 10% of Eligible Expenses 


For mammography testing: 10% of Eligible Expenses 


30% of Eligible Expenses after satisfying deductible 


Outpatient Diagnostic/Therapeutic Services - CT 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 

Scans, Pet Scans, MRI and Nuclear Medicine 

Outpatient Therapeutic Treatments 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible

UnitedHealthcare 


12. Physician’s Office Services 

(In network copay does not apply to Preventive 

Care visits for children to age 19) 

$25 per visit. 30% of Eligible Expenses after satisfying deductible 

13. Professional Fees for Surgical and Medical 

Services 

14. Prosthetic Devices 

(The purchase or rental of prescribed equipment is 

covered, including needed replacement and repairs) 



15. Reconstructive Procedures Hospital Inpatient Stay – 10% of Eligible Expenses after 

satisfying deductible. 

Outpatient Surgery - 10% of Eligible Expenses after 


Outpatient Diagnostic Therapeutic Services – 10% of 

Eligible Expenses after satisfying deductible. 

Outpatient Therapeutic Treatments - 10% of Eligible 

Expenses after satisfying deductible. 

Physician’s Office Services - $25 per visit 

16. Rehabilitation Services -Outpatient Therapy 

Network and Non-Network Benefits are limited as 

follows: 90 visits per year for all types of therapy 

combined (physical therapy, occupational therapy, 

cardiac rehabilitation, and restorative speech 

therapy). The visit maximum is combined in and 

out of network. 

17. Skilled Nursing Facility/Inpatient Rehabilitation 

Facility Services 


120 days per calendar year. 

*Hospital Inpatient Stay – 30% of Eligible Expenses 

after satisfying deductible. 







Physician’s Office Services - 30% of Eligible Expenses 


$25 per visit 30% of Eligible Expenses after satisfying deductible 

10% of Eligible Expenses after satisfying deductible *30% of Eligible Expenses after satisfying deductible 

18. Transplantation Services *Services rendered via United Resource Network - 100% *30% of Eligible Expenses after satisfying deductible 

for all professional and facility related expenses. Includes 

travel and lodging benefit up to maximum of $10,000. 

Services rendered at UHC Hospital which is not part of 

the United Resource Network – 10% of Eligible Expenses 


19. Urgent Care Center Services $50 per visit True Emergency – Same as network benefit 

Non-emergency - 30% of Eligible Expenses after 

satisfying deductible


Additional Benefits 

Mental Health Services – Outpatient (Network and 

Non-Network Benefits are limited to 40 visits per 

calendar year combined in and out of network. Two 

group visits reduce 40 visit maximum by one day). 

Substance Abuse Services - Outpatient (Network 

and Non-Network Benefits are limited to 60 visits per 



Mental Health Services – Inpatient and 

Intermediate (Network and Non-Network Benefits are 

limited to 45 days per calendar year combined in and 

out of network. Two days of residential treatment 

coverage reduces visit maximum by one day). Inpatient 

Mental Health visits do not apply to out of pocket. 

Substance Abuse Services – Inpatient and 





Substance Abuse visits do not apply to out of pocket. 

Spinal Treatment (Limited to 60 visits per calendar 

year combined in and out of network) 

Prescription Drugs – Rx vendor is Caremark 

(1-800-565-7091 

Pharmacy fills: On the third fill of a maintenance drug 

at the retail pharmacy, the copay changes to $10/40/70 

per 30 day supply. 

$25 per individual visit; $25 per group visit. 





(does not apply to out of pocket) 


(does not apply to out of pocket) 

*30% of Eligible Expenses after satisfying deductible 



Retail Drug Program – 

$5 per 30-day supply for generic drugs 

$20 per 30-day supply for preferred drugs 

$35 per 30-day supply for non-preferred drugs 

Coverage In Network only 

Generic Incentive: When you fill a Rx for a brand name 

drug that has a generic equivalent you pay the brand 

name copay plus the difference in the cost between the 

brand name and its generic equivalent. 

Mail Order Program – 




Coverage In Network only

Exclusions 

Except as may be specifically provided in Section 1 of the Summary Plan Description (SPD) or 

through a Rider to the Plan, the following are not covered: 

Covered Expenses will not include, and no payment will be made for the following expenses incurred, 

unless those expenses are considered Medically Necessary. 

• Expenses for charges that are not Medically Necessary, except as specified in any notification 

requirements shown in this plan. 

• To the extent that you or any one of your Dependents is in any way paid or entitled to payment 

for those expenses by or through a public program, other than Medicaid. 

• To the extent that payment is unlawful where the person resides when the expenses are incurred. 

• Charges made by a Hospital owned or operated by or which provides care or performs services 

for the United States Government: (a) unless there is a legal obligation to pay such charges 

whether or not there is insurance; or (b) if such charges are directly related to a military-service 

connected Injury or Sickness. 

• For or in connection with an Injury or Sickness which is due to war, declared or undeclared. 

• Charges which you are not obligated to pay or for which you are not billed or for which you 

would not have been billed except that they were covered under this plan. 

• Assistance in the activities of daily living, including but not limited to eating, bathing, dressing, 

toileting or other non-Medically Necessary self-care activities, homemaker services and services 

primarily for rest domiciliary or convalescent care. 

• Cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy 

performed to improve or alter appearance or self-esteem or to treat psychological 

symptomatoloty or psychosocial complaints related to one’s appearance and determined not to 

be Medically Necessary. However, reconstructive surgery is covered as provided under Covered 

Expenses and for the purposes of this exclusion the term cosmetic surgery or therapy shall not 

include reconstructive surgery when such service is incidental to or follows surgery resulting 

from trauma, infection or other disease of the involved part. 

• Macromastia or gynecomastia surgeries; abdominoplasty/panniculectomy; rhinoplasty; 

blepharoplasty; orthognathic surgeries; redundant skin surgery; removal of skin tags; 

acupressure; craniosacral/cranial therapy; dance therapy; movement therapy; applied 

kinesiology; rolfing; prolotherapy; extracorporeal shock wave lithotripsy for musculoskeletal 

and orthopedic conditions. 

• For or in connection with treatment of the teeth or peridontium unless such expenses are 

incurred for: (a) charges made for services or supplies provided for or in connection with an 

accidental injury to sound natural teeth, provided a continuous course of dental treatment started 

within 6 months of the accident; (b) charges made by a Hospital for Bed and Board or Necessary 

Services and Supplies; (c) charges made by a Free-Standing Surgical Facility or the outpatient 

department of a Hospital in connection with surgery, or (d) charges made by a Physician for any 

of the following Surgical Procedures: excision of epulis; removal of residual root (when 

performed by a Dentist other than the one who extracted the tooth); intraoral drainage of acute 

alveolar abscess with cellulitis; alveolectomy; gingvectomy, for gingivitis or periodontitis. 

• For medical and surgical services intended for the treatment or control of obesity, unless 

Medically Necessary. However, treatment of clinically severe obesity, as defined by the body 

mass index (BMI) classifications of the National Heart, Lung and Blood Institute (NHLBI) 

guidelines to be covered only at approved centers if the services are demonstrated, through 

existing peer-reviewed, evidence based, scientific literature and scientifically based guidelines, 

to be safe and effective for treatment of this condition. Clinically severe obesity is defined by 

the NHLBI as a BMMI of 40 or greater without comorbidities, or 35-39 with comorbidities. The 

following are specifically excluded: (a) medical and surgical services to alter appearance or 

physical changes that are the result of any surgery performed for the management of obesity or 

clinically severe (morbid) obesity; and (b) weight loss programs or treatments, whether 

prescribed or recommended by a Physician or under medical supervision. 

• Unless otherwise covered in this plan, for reports, evaluations, physical examinations, or 

hospitalizations not required for health reasons including, but not limited to, employment, 

insurance or government licenses, and court-ordered, forensic or custodial evaluations. 

• Court-ordered treatment or hospitalization, unless such treatment is prescribed by a Physician 

and listed as covered in this plan. 

• Transsexual surgery including medical or psychological counseling and hormonal therapy in 

preparation for, or subsequent to, any such surgery. 

• Any medications, drugs, services or supplies for the treatment of female sexual dysfunction and 

male impotence, such as, but not limited to, anorgasmy, and premature ejaculation. 

• For Infertility Services, including infertility drugs; surgical or medical treatment programs for 

infertility (such as in vitro fertilization, gamete intrafallopian transfer [GIFT], zygote 

intrafallopian transfer [ZIFT], or any variations of this procedures); and artificial insemination 

(including donor fees and any costs associated with the collection, washing, preparation, or 

storage of sperm). Cryopreservation of donor sperm or eggs is also excluded form coverage. 

• For amniocentesis, ultrasound, or any other procedures requested solely for gender 

determination of a fetus, unless Medically Necessary to determine the existence of a genderlinked 

genetic disorder. 

• Medical and Hospital care and costs for the infant child of a Dependent, unless this infant child 

is otherwise eligible under this plan. 


• Non-medical counseling or ancillary services, including but not limited to Custodial Services, 

education, training, vocational rehabilitation, behavior training, biofeedback, neurofeedback, 

hypnosis, sleep therapy, employment counseling, back school, return to work services, work 

hardening programs, driving safety, and services, training, educational therapy or other nonmedical 

ancillary services for learning disabilities, developmental delays, autism or mental 

retardation. 

• Therapy or treatment intended primarily to improve or maintain general physical condition or 

for the purpose of enhancing job, school, athletic or recreational performance, including but not 

limited to routine, long term or maintenance care which is provided after the resolution of the 

acute medical problem and when significant therapeutic improvement is not expected. 

• Consumable medical supplies other than ostomy supplies and urinary catheters. Excluded 

supplies include, but are not limited to bandages and other disposable medical supplies, skin 

preparations and test strips, except as specified in the “Home Health Services” or “Breast 

Reconstruction and Breast Prostheses” sections of this plan. 

• Private Hospital rooms and/or private duty nursing unless determined by the utilization review 

Physician to be Medically Necessary. 

• Personal or comfort items such as personal care kits provided on admission to a Hospital, 

television, telephone, newborn infant photographs, complimentary meals, birth announcements, 

and other articles which are not for the specific treatment or an Injury or Sickness. 

• Artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic 

stockings, garter belts, corsets, dentures and wigs. 

• Hearing aids, including but not limited to semi-implantable hearing devices, audient bone 

conductors and Bone Anchored Hearing Aids (BAHAs). A hearing aid is any device that 

amplifies sound. 

• Aids or devices that assist with nonverbal communications, including but not limited to 

communication boards, prerecorded speech devices, laptop computers, desktop computers, 

Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and 

memory books. 

• Medical benefits for eyeglasses, contact lenses, or examinations for prescription or fitting 

thereof, except that Covered Expenses will include the purchase of the first pair of eyeglasses, 

lenses, frames, or contact lenses that follows keratoconus or cataract surgery. 

• Charges made for or in connection with routine refractions, eye exercises and for surgical 

treatment for the correction of a refractive error, including radial keratotomy, when eyeglasses 

or contact lenses may be worn. 

• All non injectable prescription drugs, nonprescription drugs, and investigational and 

experimental drugs, except as provided in this plan. 

• Routine foot care including the paring and removing of corns and calluses or trimming of nails. 

However, services associated with foot care for diabetes and peripheral vascular disease are 

covered when Medically Necessary. 

• Membership cost or fees associated with health clubs, weight loss programs and smoking 

cessations programs. 

• Genetic screening or pre-implantations genetic screening. General population-based genetic 

screening is a testing method performed in the absence of any symptoms or any significant, 

proven risk factors for genetically linked inheritable disease. 

• Dental implants for any condition. 

• Fees associated with the collection or donation of blood or blood products, except for 

autologous donation in anticipation of scheduled services where in the utilization review 

Physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected 

adjunct to surgery. 

• Blood administration for the purpose of general improvement in physical condition. 

• Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect 

against occupational hazards and risks. 

• Cosmetics, dietary supplements and health and beauty aids and nutritional formulae (except as 

described in Covered Expenses). 

• For or in connection with an Injury or Sickness arising out of, or in the course of, any 

employment for wage or profit. 

• Telephone, e-mail, and Internet consultations and telemedicine. 

• Massage therapy. 

• For charges which would not have been made if the person had no health benefits. 

• To the extent that they are more than Reasonable and Customary charges. 

• Expenses incurred outside the United States or Canada, unless you or your Dependent is a U.S. 

or Canadian resident and the charges are incurred while traveling on business or for pleasure. 

• To the extent of the exclusions imposed by any notification requirement shown in this plan. 

• Elective and non-elective abortions. 

• Health services received after the date your coverage under the Plan ends, including health 

services for medical conditions arising prior to the date your coverage under the Plan ends. 

This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care 

expenses. Please refer to the Summary Plan Description for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this 

description conflicts in any way with the Summary Plan Description, the Summary Plan Description prevails. Terms that are capitalized in the Benefit Summary are defined in the 

Summary Plan Description. 

12/15/05 WARNY003 100-3513



For Bargaining Lay Faculty Members 

UNITED HEALTHCARE CHOICE PLUS II PLAN 

-16 -


UnitedHealthcare Choice Plus 


Active Plan for Bargaining Lay Faculty 

Effective January 1, 2006, if you have any questions please call UnitedHealthcare Member 

Services at 1-800-736-1264 or register on myuhc.com to get detailed information on your 

coverage. 

Choice Plus plan gives you the freedom to see any Physician or other health care professional 

from the Network, including specialists, without a referral. With this plan, you will receive the 

highest level of benefits when you seek care from a network physician, facility or other health 

care professional. In addition, you do not have to worry about any claim forms or bills. 

You also may choose to seek care outside the Network, without a referral. However, you should 

know that care received from a non-network physician, facility or other health care professional 

means a higher deductible and coinsurance. We recommend that you ask the non-network 

physician or health care professional about their billed charges before you receive care. 

Some of the Important Benefits of Your Plan: 

• You have access to a Network of 

physicians, facilities and other health 

care professionals, including specialists, 

without designating a Primary Physician 

or obtaining a referral. 

• Benefits are available for office visits 

and hospital care, as well as inpatient 

and outpatient surgery. 

• United Healthcare’s Nurseline connects 

you to registered nurses and a library of 

recorded programs on important health 

topics 24 hours a day, 7 days a week, 

from anywhere in U.S. 



languages. Just call customer service 

and ask for an interpreter. 

• Emergencies are covered anywhere in 

the world. 

• Care Coordination SM services are 

available to help identify and prevent 

delays in care for those who might need 

specialized help. 


are practical and personalized so you 

can get the most out of your benefits. 

Register at myuhc.com and connect to 

current information about your benefits 

and health care interests. 





calling 1-866-936-6002.

Choice Plus Benefits Summary 




in a family. Cross applies with out of network deductible. 



in a family. Cross applies with in network deductible. 

This Benefit Summary is intended only to highlight 


determine coverage. This benefit plan may not cover all 


descriptions of Benefits and the terms under which 









Network Benefits are payable for Covered Health 

Services provided by or under the direction of your 

Network physician. 

*Prior Notification is required for certain services. 




Deductible. Cross applies with out of network out of 


Maximum Plan Benefit: No Maximum Plan Benefit. 

MEMBER PAYS 

1. Ambulance Services - Emergency only Ground Transportation: 10% of Eligible Expenses after 


Air Transportation: 10% of Eligible Expenses after 





Deductible. Cross applies with in network out of pocket 

maximum. 

Maximum Plan Benefit: $1,000,000 per Covered Person. 

MEMBER PAYS 

Same as Network Benefit 

2. Dental Services - Accident only (must begin 

within 6 months of injury) 


3. Durable Medical Equipment 


(The purchase or rental of prescribed equipment is 

covered, including needed replacement and repairs) 

4. Emergency Health Services $50 per visit (copay waived if admitted) True Emergencies - Same as Network Benefit 

Non-Emergency Visits - 30% of Eligible Expenses after 


*Notification is required if results in an Inpatient Stay. 

5. Refractive Eye Examinations No Coverage No Coverage 



200 per calendar year combined in and out of 

network. 


No annual maximum. 



8. Hospital - Inpatient Stay 10% of Eligible Expenses after satisfying deductible *30% of Eligible Expenses after satisfying deductible 

9. Injections Received in a Physician’s Office $25 per visit 30% of Eligible Expenses after satisfying deductible 

10. Maternity Services Delivery - 10% of Eligible Expenses after satisfying 

deductible 

Prenatal visit – 100% after $25 copay (copay applies to 

first prenatal visit only) 






waive deductible 

Delivery - 30% of Eligible Expenses after satisfying 

deductible 

Prenatal visit – 30% of Eligible Expenses after satisfying 

deductible 

Outpatient Diagnostic Services - 30% of Eligible Expenses 




Newborn Nursery Charge - 30% of Eligible Expenses after 


*Notification is required if Inpatient Stay exceeds 48 hours 

following a normal vaginal delivery or 96 hours following 

a cesarean section delivery.




Services 

Outpatient Surgery 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 


For lab and radiology/Xray: 10% of Eligible Expenses 


For mammography testing: 10% of Eligible Expenses 




Outpatient Diagnostic/Therapeutic Services - CT 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 


Outpatient Therapeutic Treatments 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 

12. Physician’s Office Services (In network copay 

does not apply to Preventive Care visits for children 

to age 19) 


Services 

14. Prosthetic Devices (the purchase or rental of 

prescribed equipment is covered, including needed 

replacement and repairs) 

$25 per visit. 30% of Eligible Expenses after satisfying deductible 



15. Reconstructive Procedures Hospital Inpatient Stay – 10% of Eligible Expenses after 








Physician’s Office Services - $25 per visit 

*Hospital Inpatient Stay – 30% of Eligible Expenses after 








Physician’s Office Services - 30% of Eligible Expenses 



Network and Non-Network Benefits are limited as 

follows: 90 visits per year for all types of therapy 

combined (physical therapy, occupational therapy, 

cardiac rehabilitation, and restorative speech 

therapy). The visit maximum is combined in and 

out of network. 




120 days per calendar year. 


10% of Eligible Expenses after satisfying deductible *30% of Eligible Expenses after satisfying deductible 

18. Transplantation Services *Services rendered via United Resource Network - 100% 

for all professional and facility related expenses. Includes 

travel and lodging benefit up to maximum of $10,000. 


Services rendered at UHC Hospital which is not part of 

the United Resource Network – 10% of Eligible Expenses 


19. Urgent Care Center Services $50 per visit True Emergency – Same as network benefit 

Non-emergency - 30% of Eligible Expenses after 

satisfying deductible



Mental Health Services – Outpatient (Network and 

Non-Network Benefits are limited to 40 visits per 



Substance Abuse Services - Outpatient (Network 

and Non-Network Benefits are limited to 60 visits per 



Mental Health Services – Inpatient and 





Mental Health visits do not apply to out of pocket 

maximum. 

Substance Abuse Services – Inpatient and 





Substance Abuse visits do not apply to out of pocket 

maximum. 





50% of Eligible Expenses after satisfying deductible (does 

not apply to out of pocket maximum) 

50% of Eligible Expenses after satisfying deductible (does 

not apply to out of pocket maximum) 



Spinal Treatment (Limited to 60 visits per calendar 

year combined in and out of network) 


Prescription Drugs – Rx vendor is Caremark 

(1-800-565-7091 
















Coverage In Network only 

Coverage In Network only

Exclusions 































kinesiology; rolfing; prolotherapy; and extracorporeal shock wave lithotripsy for 

musculoskeletal and orthopedic conditions. 




within 6 months of the accident; (b) charges made by a Hospital for Bed and Board or Necessary 

Services and Supplies; (c) charges made by a Free-Standing Surgical Facility or the outpatient 

department of a Hospital in connection with surgery, or (d) charges made by a Physician for any 

of the following Surgical Procedures: excision of epulis; removal of residual root (when 

performed by a Dentist other than the one who extracted the tooth); intraoral drainage of acute 

alveolar abscess with cellulitis; alveolectomy; gingvectomy, for gingivitis or periodontitis. 































• Nonmedical counseling or ancillary services, including but not limited to Custodial Services, 



hardening programs, driving safety, and services, training, educational therapy or other 

nonmedical ancillary services for learning disabilities, developmental delays, autism or mental 

retardation. 






















memory books. 











































12/15/05 WARNY004 100-3513



Medicare Supplement For Clergy, Religious and Lay 

Employees (over 65), Who Have Medicare Primary 

Benefits (MSYRX) 

UNITED HEALTHCARE MEDICARE SUPPLEMENT WITH RX 

-17 -


UnitedHealthcare Medicare plan 


Medicare Supplemental Plan for Clergy, Religious, and Lay Employees (MSYRX) 

Effective January 1, 2006, if you have any questions please call UnitedHealthcare 

Member Services at 1-800-736-1264 or register on myuhc.com to get detailed 

information on your coverage. 

Your Medicare Supplemental plan provides a maximum freedom for dealing with any health care 

situation. This incredibly flexible program lets you make your own health care decisions, 

including which doctors and specialists to visit. Benefits are provided for covered health services 

received from any physician or other licensed medical provider. This plan coordinates with 

Medicare. 

Some Important Benefits of your plan: 

• Receive care from any licensed medical 

physician or other provider you want. 

• Choose to see any licensed specialist you 

want without having to get a referral. 

• Go to any hospital you want-anywhere, 

anytime. 

• Emergencies are covered anywhere in the 

world. 

• Benefits are available for office visits and 

hospital care, as well as inpatient and 

outpatient surgery, when covered health 

services are provided. 



languages. Just call customer service and 

ask for an interpreter. 

• United Healthcare’s Nurseline 

connects you to registered nurses and a 

library of recorded programs on 

important health topics 24 hours a day, 

7 days a week, from anywhere in U.S. 

• Care Coordination SM services are available 

to help identify and prevent delays in care 

for those who might need specialized help. 


are practical and personalized so you can 

get the most out of your benefits. Register 

at myuhc.com and connect to current 

information about your benefits and health 

care interests. 





calling 1-866-936-6002.

Medicare Supplemental Plan Benefits Summary 

Types of Coverage 

Benefits /Copayment Amounts 

This Benefit Summary is intended only to highlight Annual Deductible: $150 per Covered Person per calendar year. 


determine coverage. This benefit plan may not cover all Out-of-Pocket Maximum: $750 per Covered Person per calendar year. 


descriptions of Benefits and the terms under which Maximum Plan Benefit: No Maximum Plan Benefit. 









MEMBER PAYS 

1. Ambulance Services - Emergency only Ground Transportation: 0% of Eligible Expenses 

Air Transportation: 0% of Eligible Expenses 

2. Dental Services - Accident only – Treatment must 

begin within six months of injury. 

3. Durable Medical Equipment 

The purchase or rental of prescribed equipment is 

covered including needed replacement and repair. 



4. Emergency Health Services 0% of Eligible Expenses 

5. Refractive Eye Examinations No Coverage 


Benefits are limited to 200 visits for skilled care 

services per calendar year. 


No annual maximum 

0% of Eligible Expenses 


8. Hospital - Inpatient Stay 0% of Eligible Expenses 

9. Injections Received in a Physician’s Office 20% of Eligible Expenses after satisfying deductible 

10. Maternity Services No coverage 


Services 

Outpatient Surgery 


Outpatient Diagnostic/Therapeutic Services - CT 


Outpatient Therapeutic Treatments 


For lab and radiology/Xray: 20% of Eligible Expenses after satisfying deductible 

For mammography testing: 20% of Eligible Expenses after satisfying deductible 



12. Physician’s Office Services 20% of Eligible Expenses after satisfying deductible 


Services 

14. Prosthetic Devices 

The purchase or rental of prescribed equipment is 

covered including needed replacement and repair. 



15. Reconstructive Procedures Hospital Inpatient Stay – 20% of Eligible Expenses after satisfying deductible. 

Outpatient Surgery - 20% of Eligible Expenses after satisfying deductible. 

Outpatient Diagnostic Therapeutic Services – 20% of Eligible Expenses after satisfying deductible. 

Outpatient Therapeutic Treatments - 20% of Eligible Expenses after satisfying deductible. 

Physician’s Office Services - 20% of Eligible Expenses after satisfying deductible.


Types of Coverage 


90 visits per year for all types of therapy combined 

(physical therapy, occupational therapy, cardiac 

rehabilitation, restorative speech therapy, and 

chiropractic care). 



Benefits are limited to 120 days per calendar year. 

Benefits /Copayment Amounts 



18. Transplantation Services 20% of Eligible Expenses after satisfying deductible 

19. Urgent Care Center Services 0% of Eligible expenses 


Mental Health Services – Outpatient 

Benefits are limited to 45 visits per calendar year. Two 

group visits reduce the 45 visit maximum by one day. 

Outpatient Mental Health visits do not apply to out of 


Mental Health Services - Inpatient and Intermediate 


days of residential treatment reduces the 45 visit 

maximum by one day. 

Substance Abuse Services – Outpatient 


group visits reduce the 60 visit maximum by one day. 

Outpatient Substance Abuse visits do not apply to out 

of pocket maximum. 

Substance Services - Inpatient and Intermediate 


days of residential treatment reduces the 45 visit 

maximum by one day. 

Prescription Drugs - Rx vendor is Caremark 

(1-800-565-7091 



















$70 per 90-day supply for non-preferred drugs

Exclusions 































kinesiology; rolfing; prolotherapy; and extracorporeal shock wave lithotripsy for 

musculoskeletal and orthopedic conditions. 




within 6 months of the accident; (b) charges made by a Hospital for Bed and Board or 

Necessary Services and Supplies; (c) charges made by a Free-Standing Surgical Facility or the 

outpatient department of a Hospital in connection with surgery, or (d) charges made by a 

Physician for any of the following Surgical Procedures: excision of epulis; removal of residual 

root (when performed by a Dentist other than the one who extracted the tooth); intraoral 

drainage of acute alveolar abscess with cellulitis; alveolectomy; gingvectomy, for gingivitis or 

periodontitis. 































• Non-medical counseling or ancillary services, including but not limited to Custodial Services, 



hardening programs, driving safety, and services, training, educational therapy or other nonmedical 

ancillary services for learning disabilities, developmental delays, autism or mental 

retardation. 






















memory books. 











































01/16/07 OARNY005 100-3507

Section IV 

Filing for Claims

HOW TO FILE A MEDICAL CLAIM 

There are several ways to file a claim for medical benefits: 

• Direct Claim - Your healthcare provider’s office can file the claim electronically 

on your behalf with the insurance carrier. 

• Paper Claim - You must complete and sign the Health Claim Transmittal form, 

and mail it to: 

United Healthcare 

P.O. Box 740800 

Atlanta, GA 30374-0800 

United Healthcare’s Customer Service Telephone Number 1.800.736.1264 

• Invoice - If you receive an invoice from a healthcare provider or healthcare 

facility, (laboratory/anesthesiologist, etc.) that lists an insurance information 

section (most times this will be on the reverse side of the invoice), you can 

complete the insurance information section, and either return to the service 

provider, or send it directly to the insurance carrier (follow the directions on 

invoice). Remember to include the group policy number listed on your ID card. 

• If the invoice is itemized, and lists the date(s) of service, a diagnosis or diagnostic 

code, and a total dollar amount of charges you can paper clip (do not staple) the 

invoice to a Health Claim Transmittal form. Complete, sign and mail it to United 

Healthcare at the address listed above. 

Important Note: Keep a copy of any claims that you submit to the insurance 

carrier. 

- 18 - 

Revised 07/2009

Caremark is our current prescription carrier. 

Eligibility 

PRESCRIPTION BENEFIT SUMMARY 

• Participants and their dependents must also be enrolled in the United Healthcare plan 

• Dependent Children covered to age 19, to age 25 full time student or disabled child. 

Co-payments 

• Generic Drug - Lowest Co-payment 

• Preferred Brand Drugs included on Caremark’s Primary Drug list - Moderate Co-payment 

• Brand Drugs not included on Caremark’s Primary Drug list - Highest Co-pay 

Retail Pharmacy 

Participants may purchase a 30-day supply of medications from participating retail pharmacies. 

(For a list of participating pharmacies, please call Customer Service at 800.565.7091 or visit the 

website at www.caremark.com). 

Restrictions – After two maintenance fills at a retail pharmacy during a calendar year, the third 

maintenance fill at a retail pharmacy will be subject to higher Mail Order copayment for a 30 day 

supply. (Refer to Health Benefit Summary for details). 

Mail order 

Participants also have the option of purchasing up to a 90-day supply of medications through 

Caremark’s Mail Order Service Pharmacy. Mail order is one of the most cost effective options. 

(Please refer to booklet for further details or call Customer Service at 800.565.7091). 

NOTES: 

• Vacation Supplies 

Participants and dependents should contact Customer Service at 800.565.7091 or visit the website 

at www.caremark.com before going on vacation for the nearest out of town participating 

pharmacy, or to request a vacation supply of medications. 

Prescriptions purchased through non-participating (out-of-network) pharmacies are not covered. 

• Prescription Exceptions 

Participants requesting coverage for medications not listed in the benefit booklet should fax a 

letter of medical necessity from the physician to the attention of the Fatima Faria, Caremark at 

401.335.7488. 

Refer to Booklet for detailed information regarding covered services. 

- 19 - 

07/2009

HOW TO FILE A CLAIM FOR PRESCRIPTION DRUGS 

In-Network Retail Pharmacy: When a prescription is filled at an in-network pharmacy, 

the insured must present his/her Caremark ID Card and pay the applicable co-pay. 

Prescriptions filled at a non-participating pharmacy are not covered. There is no out-ofnetwork 

coverage for this benefit. 

Mail Order: When using the Mail Order Option, the insured must complete the Mail 

Service Order Form, attach the prescription from the physician, and enclose a check, 

money order, or Credit Card number for the co-payment. (An incomplete Mail Service 

Order form will be returned and processing will be delayed). 

Paper Claim: When a prescription is filled at a non-participating pharmacy and the 

insured has to pay for the full cost of a covered prescription drug; he/she should file a 

paper claim with Caremark. To file a paper claim the insured must complete and sign a 

Prescription Drug Claim Form, attach the original receipt from the pharmacy, and send it 

directly to: 

CVS Caremark, Inc. 

Attn: Claims Department 

P.O. Box 52196 

Phoenix, AZ 85072-2196 

Important Note: Keep a copy of any claims that you submit to the insurance carrier 

- 20 - 

07/2009

MAIL SERVICE 

ORDER FORM 

Mail order form to: 

Please fold here 

Enter ID# if not shown or different from above 

CVS CAREMARK 

PGH WB STD 

PO BOX 2110 

PITTSBURGH, PA 15230-2110 



Prescription Plan Sponsor or Company Name 

DIRECTIONS: Print in BLUE or BLACK ink, using CAPITAL letters. Fill in ovals completely ( ). Complete 

both sides of form. 

To order new prescriptions: Mail your prescription(s) with this form. # of new prescriptions: 

To order refills: Order by Web, phone, or write in Rx number(s) below. # of refill prescriptions: 

FOR FASTEST SERVICE, order refills at www.caremark.com or call the number on your prescription 

benefit identification card. 

SHIPPING ADDRESS IF NOT SHOWN OR DIFFERENT FROM ABOVE: 

Last Name First Name MI Suffix (JR, SR) 

Street Address 

Apt./Suite# 

Use this address 

for this order only. 

City State ZIP Code 


Daytime Phone #: 

- - 

Evening Phone #: - - 

* WEB * 

REFILL INFORMATION: 

To order mail service refills, enter your prescription number(s) here: 

1) 2) 3) 4) 

5) 6) 7) 8) 

* WEB * 

Prescriptions sent in one envelope may be shipped together unless you request otherwise. 

©2008 Caremark. All rights reserved. P12-N

FILL IN FOR UP TO TWO PEOPLE WHO WILL RECEIVE PRESCRIPTIONS WITH THIS ORDER 

1st PERSON ORDERING A PRESCRIPTION 

N I C K N A M E 

Your E-mail: 

Gender: M F 

Easy open caps Print in Spanish 

Suffix 

(JR,SR) 

Date of Birth: 

MM-DD-YYYY 

Date new prescription written: 

Last Name First Name MI 


Doctor’s Last Name 

Doctor’s First Name 

Doctor’s Phone # 

ALLERGY/HEALTH INFORMATION: COMPLETE ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED 

Allergies: None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin 

Sulfa 

Other: 

Conditions: Arthritis Asthma Diabetes Acid Reflux Glaucoma Heart Problem 

High Blood Pressure High Cholesterol Migraine Osteoporosis Prostate Issues Thyroid 


2nd PERSON ORDERING A PRESCRIPTION 

N I C K N A M E 

Your E-mail: 

Gender: M F 

Easy open caps Print in Spanish 

Suffix 

(JR,SR) 


MM-DD-YYYY 

Date new prescription written: 

Last Name First Name MI 



* WEB * 

Doctor’s Last Name 

Doctor’s First Name 

Doctor’s Phone # 

ALLERGY/HEALTH INFORMATION: COMPLETE ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED 

Allergies: None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin 

Sulfa 


Conditions: Arthritis Asthma Diabetes Acid Reflux Glaucoma Heart Problem 

High Blood Pressure High Cholesterol Migraine Osteoporosis Prostate Issues Thyroid 


Special Instructions: 

PAYMENT INFORMATION: Select one payment method below. 

Electronic Check Processing (Please pre-register at Caremark.com or call Customer Care) 

Bill Me Later ® (Subject to credit approval. Please pre-register at Caremark.com or call Customer Care) 

Credit/Debit Card (VISA, MasterCard, Discover or American Express) 

Charge most recently used credit card 

Charge new/updated credit/debit card (provide info below) 

Exp. Date 

MMDD 

Check/Money Order: Amount $ 

. 

Make check or money order payable to CVS Caremark and 

write your ID# on the check/money order. Returned checks 

will be subject to a fee of up to $40, depending on state 

law. 

The selected payment method (unless paying by check) will 

be charged for future orders, unless a different form of 

payment is provided. It will also be charged for any 

outstanding balance due. 

Fill in oval if you DO NOT want the selected payment 

method to be automatically charged for future orders. 

PGH-WB-MOF-1208 

Credit Card Holder Signature/Date 

REGULAR DELIVERY IS FREE 

(Allow up to 10 days for delivery) 

Fill in oval for faster delivery: 

2nd Business Day $17 per order 

Next Business Day $23 per order 

(Charges subject to change) 

Faster delivery options only affect shipping time, 

not processing time and can only be sent to a 

street address, not a P.O. box. 

Please fold here

14423-0808 

STANDARD 

Important! 

STEP 1 

Prescription Reimbursement Claim Form 

* Always allow up to 30 days from the time you send this form until the time you receive the response to 

allow for mail time plus claims processing. 

* Keep a copy of all documents submitted for your records. 

* Do not staple or tape receipts or attachments to this form. 

Card Holder/Patient Information 

Card Holder Information 

Identification Number (refer to your prescription card) 

This section must be fully completed to ensure proper reimbursement of your claim. 

Group No./Group Name 

Name (Last Name) (First Name) (MI) 

Address 

City State Zip 

Patient Information–Use a separate claim form for each patient. 

Name (Last Name) (First Name) (MI) 

Date of Birth Male Female 

Phone Number 

Relationship to Primary member 

Member Spouse Child Other ____________ 

Other Insurance Information 

COB (Coordination of Benefits) 

Are any of these medicines being taken for an on-the-job injury? ❍ Yes ❍ No 

Is the medicine covered under any other group insurance? ❍ Yes ❍ No 

If yes, is other coverage: ❍ Primary ❍ Secondary 

If other coverage is Primary, include the explanation of benefits (EOB) with this form. 

Name of Insurance Company___________________________ ID #__________________ 

Important! A signature is REQUIRED 

NOTICE 

Any person who knowingly and with intent to defraud any insurance company or other person files an application for 

insurance or statement of claim containing any materially false information or conceals for the purpose of misleading 

information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects 

such person to criminal and civil penalties. 

I certify that I (or my eligible dependent) have received the medicine described herein and that the plan participant 

named is eligible for prescription benefits. I also certify that the medicine received is not for treatment of an on-thejob 

injury or covered under another benefit plan. I certify that I have read and understood this form, and that all the 

information entered on this form is true and correct. 

x 

Signature of Plan Participant 

Date 

(Over)

STEP 2 

Submission Requirements: 

You MUST include all orginal receipts in order for your claim to process. Cash register receipts will only be accepted for 

diabetic supplies. The minimum information required is: 

• Patient Name • Prescription Number • Medicine NDC number 

• Date of Fill • Metric Quantity • Days Supply 

• Total Charge • Pharmacy Name and Address or Pharmacy NABP Number 

If Foreign Claim: Country:_______________ Currency:_______________ 

Amount:_______________ 

STEP 3 

Mailing Instructions: 

RXBIN: 

XXXXX 

RXPCN: CRK 

RXGRP: XXXXX 

ISSUER: (80840) 

The RXBIN # is located on front of your 

CVS Caremark Prescription ID card. Please see 

highlighted area to the left for reference. Match 

your RXBIN # to the addresses below. 

ID 

Name 

RXBIN # 610415 mail to: 

CVS Caremark 

P.O. Box 52116 

Phoenix, Arizona 85072-2116 



CVS Caremark 

P.O. Box 52136 


CVS Caremark 

P.O. Box 52196 


RXBIN # 610474 , 610468 , 004245 or 610449 mail to: 

CVS Caremark 

P.O. Box 52010 


IMPORTANT REMINDER 

To avoid having to submit a paper claim form: 

• Always have your card available at time of purchase 

• Always use pharmacies within your network 

• Use medication from your formulary list. 

• If problems are encountered at the pharmacy, call the number on the back of your card .

Section V 

When Group Health 

Benefits End


BENEFITS TRANSFER, TERMINATION AND REINSTATEMENT TRANSMITTAL 

This form is designed to provide a simple and fast method of reporting terminations, transfers & reinstatements. It should be 

submitted within 10 days of an employee’s/dependent’s status change date in order to ensure that the benefit records reflect the 

most current membership status adjustment on the next premium billing. Employers should not wait until paying the premiums to 

report these status adjustments. Employers must keep copies of transmittals for their records. 

Date Last Worked: _________ 

Benefit End Date: _________ 

Benefit Start Date: _________ 

Employee Name:________________________________________ SSN________________________ Division Code________ 

Dependent Name:_______________________________________ SSN________________________ Division Code________ 

Dependent Name:_______________________________________ SSN________________________ Division Code________ 

New Institution Name/Institution Number (If transfer)_______________________________________________________ 

Transaction Type: _______ Reason: ________ Coverage(s) being transferred, terminated or reinstated: _________ 

(See codes below) (See codes below) (See codes below) 

Reason for Termination: Voluntary Termination Involuntary Termination (IMPORTANT – This Section Must Be Completed) 

Priest & Religious transfers only: New Home Address__________________________________________________________ 

__________________________________________________________ 

Telephone __________________________________________________________ 

Preparer’s Signature______________________________________________________________________ Date__________________ 

Preparer Print Name______________________________________________________________________ 

Institution Name/ Inst. Number __________________________________ Address__________________________________________ 

__________________________________________________________ Telephone_____________________________________ 

Refer all questions concerning this form to Employee Benefit Connections, 212.371.1000, Ext. 3060, Fax 212.644.0690. 

TR 

TE 

TD 

TI 

RE 

RD 

RI 

Transaction Type 

(Code descriptions) 

Transfer employee’s & dep. coverage 

Terminate employee’s & dependents’ 

coverage 

Terminate all dependents coverage 

Terminate single dependent coverage 

Reinstate employee’s coverage 

Reinstate all dependents coverage 

Reinstate single dependent coverage 

ET 

RW 

SE 

DV 

IC 

MD 

DE 

TOC 

LOC 

NYS 

IT 

Reason 


Termination of Employment 

Reduction in Work Hours 

Separation 

Divorce 

Ineligible Child 

Medicare 

Death 

Transferred to Other 

Coverage 

Loss of other coverage 

NYS Continuation 

Institution Transfer 

Coverage(s) being transferred, termed or 

reinstated 


HPC Health Plan Coverage 

MSP 

LB 

ADD 

DVI 

DPPO1 

DPPO2 

DEN 

ALL 

LOCAL ADMINISTRATOR, return this form to: 


1011 First Ave, Suite 1679 


Telephone: 212.371.1000, Ext. 3060, Fax: 212.644.0690 

Medicare Supplemental Plan 

Life Benefit 

AD&D 

Davis Vision 

CIGNA Dental/Opt 1 

CIGNA Dental/Opt 2 

CIGNA Dental Indemnity 

Transfer, Terminate, Reinstate 

all benefits 

Contact us: ebc@archny.org 

- 22 - Web Page: www.archny.org/benefits 

Revised April 2009

INFORMATION GUIDELINES FOR 

GROUP HEALTHBENEFITS FOR 

EMPLOYEES SEPARATING FROM SERVICE 

NEW YORK STATE CONTINUATION 

OF GROUP HEALTH BENEFITS COVERAGE 

• Eligible employees, who are separating from the Archdiocese and not eligible for early retirement, may continue 

their group health insurance under the New York State Continuation Law. The continuation period for an 

employee with his/her qualified dependents is 18 months. 

• Under the Uniformed Services Employment and Reemployment Rights Act (USERRA), if an employee is called 

to active duty beyond 30 days, he/she and/or their covered dependents can elect to continue the health benefits for 

up to 24 months during the employee’s military service. This is effective for elections made on or after December 

10, 2004. 

• All employers must provide employees with notice of their rights, benefits and obligations under the Uniformed 

Services Employment and Reemployment Rights Act (USERRA). The notice requirement can be satisfied by 

posting a notice in the same location where other required notices are customarily posted. Please refer to the 

following page for a copy. 

• Qualified dependents include the spouse, dependent children under age 19 or dependent children who are full time 

students under the age of 25. Children born to or placed for adoption with a covered employee during the New 

York Continuance period are also considered qualified dependents. 

• Covered dependents are eligible for continuation of their group health coverage for 36 months if one of the 

following events occurs: the employee’s death; change in dependent’s status when child reaches age 19 or no 

longer a college student; divorce or legal separation from spouse; when employee becomes entitled to Medicare. 

• The spouse of the employee eligible for Medicare may continue health coverage until he/she becomes eligible for 

Medicare. 

• Disabled employees are eligible for continuation coverage up to 29 months provided the Social Security 

Administration determines that such individual was disabled at termination of the group health insurance or at any 

time during the first sixty days of the continuation coverage. Documentation of such disability must be provided 

to the Archdiocese within 60 days of Social Security’s determination. 

• Continuation coverage is not available to individuals entitled to Medicare or become covered under another group 

health plan that has no limitations or exclusions with respect to any pre-existing conditions that the employee or 

his/her dependents may have. 

• The employer is to notify Employee Benefit Connections, in writing, within 30 days from the date of 

termination by completing a “Benefits Transfer, Termination, and Reinstatement Transmittal”, and submit 

the completed Form to Employee Benefit Connections. The form must list the health insurance termination 

date. 

• Beginning December 1, 2007, Employee Benefit Connections will, upon notice, administer the Group Health 

Continuation Benefit, and on behalf of the employer, will complete and sign Part I of the Group Health Benefit 

Continuation Election Form, and forward to the individual losing coverage 

• If an employee or a qualified dependent elect the continuation coverage, the application must be submitted to 

Employee Benefit Connections within the later of 60 days of the group health coverage termination or 60 days of 

the receipt of the Notice of Group Insurance Continuance Eligibility letter. THE FIRST MONTH’S 

PREMIUM PAYMENT MUST ACCOMPANY THE GROUP HEALTH CONTINUATION ELECTION 

FORM. 

- 23 -

★ 

★ 

REEMPLOYMENT RIGHTS 

YOUR RIGHTS UNDER USERRA 

THE UNIFORMED SERVICES EMPLOYMENT 

AND REEMPLOYMENT RIGHTS ACT 

USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake 

military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers 

from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. 

HEALTH INSURANCE PROTECTION 

You have the right to be reemployed in your civilian job if you leave that 

job to perform service in the uniformed service and: 

✩ 

✩ 

✩ 

✩ 

you ensure that your employer receives advance written or verbal 

notice of your service; 

you have five years or less of cumulative service in the uniformed 

services while with that particular employer; 

you return to work or apply for reemployment in a timely manner 

after conclusion of service; and 

you have not been separated from service with a disqualifying 

discharge or under other than honorable conditions. 

If you are eligible to be reemployed, you must be restored to the job and 

benefits you would have attained if you had not been absent due to 

military service or, in some cases, a comparable job. 

RIGHT TO BE FREE FROM DISCRIMINATION AND RETALIATION 

If you: 

✩ are a past or present member of the uniformed service; 

✩ have applied for membership in the uniformed service; or 

✩ are obligated to serve in the uniformed service; 

then an employer may not deny you: 

✩ initial employment; 

✩ reemployment; 

✩ retention in employment; 

✩ promotion; or 

✩ any benefit of employment 

because of this status. 

✩ 

✩ 

If you leave your job to perform military service, you have the right 

to elect to continue your existing employer-based health plan 

coverage for you and your dependents for up to 24 months while in 

the military. 

Even if you don't elect to continue coverage during your military 

service, you have the right to be reinstated in your employer's 

health plan when you are reemployed, generally without any waiting 

periods or exclusions (e.g., pre-existing condition exclusions) except 

for service-connected illnesses or injuries. 

ENFORCEMENT 

✩ 

✩ 

✩ 

✩ 

The U.S. Department of Labor, Veterans Employment and Training 

Service (VETS) is authorized to investigate and resolve complaints 

of USERRA violations. 

For assistance in filing a complaint, or for any other information on 

USERRA, contact VETS at 1-866-4-USA-DOL or visit its website at 

http://www.dol.gov/vets. An interactive online USERRA Advisor can 

be viewed at http://www.dol.gov/elaws/userra.htm. 

If you file a complaint with VETS and VETS is unable to resolve it, 

you may request that your case be referred to the Department 

of Justice or the Office of Special Counsel, as applicable, for 

representation. 

You may also bypass the VETS process and bring a civil action 

against an employer for violations of USERRA. 

In addition, an employer may not retaliate against anyone assisting in 

the enforcement of USERRA rights, including testifying or making a 

statement in connection with a proceeding under USERRA, even if that 

person has no service connection. 

The rights listed here may vary depending on the circumstances. The text of this notice was prepared by VETS, and may be viewed on the internet at 

this address: http://www.dol.gov/vets/programs/userra/poster.htm. Federal law requires employers to notify employees of their rights under USERRA, 

and employers may meet this requirement by displaying the text of this notice where they customarily place notices for employees. 

U.S. Department of Labor 

1-866-487-2365 

U.S. Department of Justice 

Office of Special Counsel 1-800-336-4590 

Publication Date—July 2008

(Sample Letter) 

NOTICE TO MEMBER LOSING COVERAGE 

TO: 

FROM : 

RE: 

DATE: 

____________________________________________________________________ 

(Member’s Name) 

____________________________________________________________________ 

(Employer’s Name) 

Continuation of Health Coverage 

____________________________________________________________________ 

Enclosed is the information you requested regarding the continuation of your or your qualified 

dependent’s group coverage. As your employer, we have included the termination date on the 

enclosed Notice of Group Health Benefit Continuance Eligibility letter. We have also 

completed and signed Part I of the enclosed Group Health Benefit Continuation Election 

Form. 

As mentioned in the enclosed material, if you or your qualified dependent want to apply for 

continuation of the group health coverage, the first month’s premium must be mailed along with 

the enclosed Group Health Continuation Election Form to: 

Employee Benefits Connections 



The checks must be made payable to the Archdiocese of New York. Employee Benefits 

Connections will administer the record keeping of the continuation of health coverage. If you or 

your dependents have any questions regarding enrollment or premium billing issues, please 

contact Employee Benefit Connections at (212) 371-1000, Ext. 3060 for assistance. 

Enclosure 

-24-


NOTICE OF GROUP INSURANCE CONTINUANCE ELIGIBILITY 

This is to inform you that effective ________________________ your health insurance coverage under the 

Archdiocese of New York Group Insurance Plan will be discontinued. 

Under the New York State Continuation Law, you and your covered dependents are eligible for Continuation of 

Health coverage provided your employment terminated or because you are transferred to an ineligible class of 

employee. You and/or your covered dependents can elect to continue coverage under the plan for up to 18 

months from the date your coverage terminated, provided you pay the required premiums within the balance due 

period. 

Under the Uniformed Services Employment and Reemployment Rights Act, if you are called to active duty 

beyond 30 days, you and/or your covered dependents can elect to continue health coverage under the plan for up 

to 24 months during your military service. 

Covered dependents include a child born to or placed for adoption with a covered employee during the period of 

New York Continuance. Qualified beneficiaries may elect to change their coverage upon the birth or adoption 

of a child while under continuance. 

Covered dependents are eligible for coverage for up to 36 months if one of the following events occurs: 

‣ the Employee’s death, 

‣ change in dependent status (for example, child reaches limiting age or is no longer a full-time student), 

‣ divorce or legal separation, or 

‣ the dependent would otherwise lose coverage when the employee becomes entitled to Medicare. 

When the employee becomes eligible for Medicare, the spouse may continue coverage until such time he/she 

becomes eligible for Medicare or until the allowed 36 months of coverage lapses, whichever comes first. 

Documentation that the spouse is not eligible for Medicare is to be sent to Employee Benefit Connections within 

31 days of the date the employee becomes Medicare eligible. 

Disabled individuals are eligible for up to 29 months of continuation coverage provided the Social Security 

Administration determines that the individual was disabled at termination or at any time during the first sixty 

days of continuation coverage. Disabled individuals must provide documentation of the determination of 

disability to Employee Benefit Connections within 60 days of Social Security’s determination. 

- 25 - 

Revised 01/2008

Continuation coverage is not available to you if you are entitled to Medicare or become covered under another 

group health plan that has no limitations or exclusions with respect to any pre-existing conditions that you or 

your dependents may have. 

If you decide to elect this coverage, you must submit your applications within the later of 60 days of your 

coverage termination or 60 days of your receipt of this letter. You must also at that time submit your first 

premium payment. Note: Subsequent premiums are due on the first of each month. If you are submitting 

your application later than 45 days from the effective date of your Continuation of Coverage, you must 

submit payment for all months due with your application. 

Your continuation coverage will terminate when one of the following occurs: 

‣ the period of continuation coverage has elapsed, 

‣ coverage under the policy would have otherwise ended, 

‣ you do not pay the monthly premium within the 31-day grace period, 

‣ the Archdiocese of New York terminates and does not replace the plan, 

‣ (If you lose your disability status) either at the end of the original 29-month period or 31 days after Social 

Security determines that you are no longer disabled. 

The current rates and the coverage options are indicated on the enclosed enrollment form. The rates are subject 

to change at any time and may also change on the first of a given month if warranted by a plan change. When 

benefits end, there is no conversion option. 

If you elect continuation coverage, please complete the attached election form and return it to Employee Benefit 

Connections within 60 days. Please keep in mind that if you decline continuation coverage, or if you do not 

elect coverage within the 60-day notification period, you will no longer be entitled to this benefit. Your checks 

must be made payable to the Archdiocese of New York. You must submit your enrollment form along with 

your initial payment to: 




All subsequent monthly premiums must be submitted to: 




Please call (212) 371-1000, Ext. 3060 to speak to a representative if you have questions concerning your 

premium billing. 

Revised 01/2008


Group Health Continuation Election Form 

January 1, _____ to December 31, _____ 

Employee Name: 

PART 1: To be completed by Employer 

Gender: 

Male 

Female 

Social Security Number: 

Hire Date: 

Name and Address of Employer: Institution #: 

Qualified Event: Date of Event: Date Coverage Ends: 

Applicant (If Other Than Employee) Name: 

Relationship to Employee: 

Gender: 

__ Male 

__ Female 


12:00 a.m. 

____ Surviving Spouse ____ Former Spouse ____ Dependent Child 

UNITED HEALTHCARE PPO PLAN 

CONTINUATION MEDICAL COVERAGE TYPE 

Coverage Type: [ ] $______ [ ] $_______ [ ] $_______ 

Single Two Person Family 

It is hereby certified that the above employee/applicant is eligible for the continuation of the type of coverage indicated 

above. 

Authorized Employer Representative’s Signature:___________________________________________________ 

Employer’s Name______________________________________________ Date___________________________ 

PART 2: To be completed by Person making the election. Please check the appropriate boxes below. 

I have read the NOTICE FOR CONTINUATION OF COVERAGE and understand that I have the option of changing my 

current coverage. 

__ I elect to continue my current medical coverage. (If you checked this section, please continue on the reverse side) 

__ I do not wish to continue any medical coverage. ________________________________________ Date__________ 

(Please sign and date here and return to your employer if you checked 

this section) 

Revised 09/2007


Group Health Continuation Election Form 

(Continued) 

PART 3: To be completed by Employee’s Spouse if Employee made election. Please check one of the 

boxes below. 

I have read the NOTICE FOR CONTINUATION OF COVERAGE and have reviewed the election my 

spouse made above. 

____ I agree with the election made by my spouse. 

____ I do not wish to participate with the continuation of health coverage as elected by my spouse. 

Signature of Spouse: 

Date: 

PART 4: To be completed by Person making the election to continuation of health benefits coverage. 

Names of Persons to be 

covered (including 

Employee) 

Social Security 

Number 

Gender Date of 

Birth 

Relationship to 

Employee (Self, 

Spouse or 

Dependent child) 

If covered by another plan, 

give insurance company 

name and address and policy 

number. 

Name: 

PART 5: To be completed by Person making the election. 

Number and Street Address: 

City: State: Zip Code Country: 

Telephone Number: 

Note: Subsequent premiums are due on the first of each month. If you are submitting your application 

later than 45 days from the effective date of your Continuation of Coverage (shown on Page 1), you must 

submit payment for all months due with your application. 

Signature of Person making the election 

Date: 

Revised 09/2007

GROUP HEALTH BENEFITS FOR EMPLOYEES 

RETIRING FROM SERVICE PRIOR TO AGE 65 

RETIREE HEALTH BENEFITS PRIOR TO AGE 65 

• Eligible employees, who are retiring from the Archdiocese prior to age 65 and entitled to receive 

pension income, may elect to keep their group health coverage at full cost up to age 65. At such 

time the employees may elect the United Healthcare Medicare Supplemental Plan. 

• The early retirees must have completed 10 years of full time employment and be at least 55 years 

old (55/10 rule). 

• Early retirees will be responsible for paying the monthly premiums to their former employers. 

• The retirees should complete Group Health Benefits Election for Retirees form and the Health 

Benefit Plan Enrollment & Change Form. These forms will be sent to Employee Benefit 

Connections to process the status code change to the appropriate retiree division code: 

103 - Bargaining Lay Faculty Members of the Association of Catholic School (Terminate at 65) 

104 – Bargaining Lay Faculty Members of the Catholic High School Association (Terminate at 65) 

114 – Non-bargaining lay employees under the Child Care Agencies (Prior to age 65) 

135 – Non-bargaining lay employee (Prior to age 65) 

- 26 -


Group Health Benefit Election for 

Early Retired Lay Bargaining Faculty Members 

Effective January 1, _____ through December 31, _____ 

Name__________________________________________________________ Soc. Security No.______________________ 

Address_____________________________________________ City______________________ State______ Zip_________ 

Institution_________________________________________________________ Institution/Division Number __________ 

Month and Year of Retirement____________________________ Home Telephone Number_________________________ 

Select one of the following coverage options for the remainder of the current benefit plan year. Only those employees and 

dependents, who are presently covered under the Archdiocese medical plan on your retirement date, are eligible. Retired Lay 

Bargaining Faculty members age 65 and older are not eligible to continue coverage. Please refer to your contract or 

consult with your local personnel administrator. 

United Healthcare Plan 

Monthly Rates: Retiree Only Retiree (Pre-65) + Retiree (Pre-65) Retiree (Pre-65) 

(Select One) (Pre-65) One Dependent + One Dependent + Two or More 

(Pre-65) (Post-65) Dependents 

[ ] $_____ [ ] $_______ [ ] $_______ [ ] $______ 

Waiver of Coverage 

[ ] I elect to waive the retiree health coverage under this plan. 

I understand that I can only change my election when a qualifying life event applies during the current benefit plan year. 

I understand that this election is effective during the current benefit plan year. 

I certify that all of the information contained on this coverage election form and my application is true. I agree to pay the 

monthly premium for the plan selected for the remainder of the policy year. 

Signed: ____________________________________________________________________ 

Date: 

____________________________________________________________________ 

Retiree: Return this form to you former local administrato 

Local Administrator: RETAIN THIS FORM IN YOUR FILES FOR FUTURE REFERENCE 

Revised 09/2007


Group Health Benefits Election for Retired Lay Employees 







dependents, who are presently covered under the Archdiocese medical plan on your retirement date, are eligible. 


Monthly Rates: Single Two Person Single Two Person Two Person Family Coverage 

(Select One) 65 & Over 65 & Over Under 65 Under 65 1 under 65 & 

1 over 65 

[ ] $_____ [ ] $______ [ ] $______ [ ] $______ [ ] $______ [ ] $______ 



I understand that I can only change my election when a qualifying life event applies during the current benefit plan year. 

I understand that the rates are subject to change on the first of any given month if warranted by the plan. 


monthly premium for the plan option selected for the remainder of the current benefit plan year. 

Signed: ____________________________________________________________________ 

Date:_______________________________________ 

Retiree: Return this form to your former local administrator 


Revised September 11, 2007

GROUP HEALTH BENEFITS FOR EMPLOYEES 

RETIRING FROM SERVICE AT AGE 65 OR LATER 

RETIREE HEALTH BENEFITS AT AGE 65 OR LATER 

• Eligible employees, who are retiring from the Archdiocese at age 65 or later, may elect to 

apply United Healthcare Medicare Supplemental Plan at full cost of the premium. 

• The retirees should complete the Group Health Benefit Election for Retirees form and the 

Health Benefit Plan Enrollment & Change Form. These forms must be sent to Employee 

Benefit Connections to process the status change to the appropriate retiree division code: 

108 – Aged 65+ spouses of early retired lay bargaining faculty members of parish schools 

109 – Aged 65+ spouses of early retired lay bargaining faculty members of CHSA 

113 – Non-bargaining lay employees under the Child Care Agencies 

131 – Non-bargaining lay employees 

• In addition, a copy of the red, white & blue Medicare card must accompany these forms. 

• The retirees will be responsible for the monthly premium payments to their former employers. 

• Medical benefits will be coordinated between Medicare as the primary coverage and the 

United Healthcare Medicare Supplemental Plan as secondary coverage. 

Note: Bargaining Lay Faculty Members and their dependents are not eligible to the retiree group health 

when the Early Retired Bargaining Lay Faculty Members turns age 65. 

- 27 -


Group Health Benefits Election for Retired Lay Employees 







dependents, who are presently covered under the Archdiocese medical plan on your retirement date, are eligible. 


Monthly Rates: Single Two Person Single Two Person Two Person Family Coverage 

(Select One) 65 & Over 65 & Over Under 65 Under 65 1 under 65 & 

1 over 65 

[ ] $_____ [ ] $______ [ ] $______ [ ] $______ [ ] $______ [ ] $______ 




monthly premium for the plan option selected for the remainder of the current benefit plan year. 

Signed: ____________________________________________________________________ 

Date:_______________________________________ 

Retiree: Return this form to your former local administrator 


Revised September 11, 2007

GUIDELINES FOR COMPLETING NOTICE OF BENEFIT STATUS 

DUE TO SEPARATION FROM EMPLOYMENT FORM 

The following form was developed to aid local administrators when reviewing various benefits at 

the time an employee is terminating employment. 

Ideally, we suggest that whenever possible, that the local administrator review this list in 

advance and prepare any necessary papers and forms, so that at the time of the Exit Interview, 

they are prepared and the process should proceed with relative ease. 

Instructions For Completing Form: 

• Complete the top of the form by listing the terminating employee’s full legal name, the name 

of the institution (employer) and the institution-division number. 

• Insert the employee’s separation date on the next line. 

• Insert the termination date in the Group Medical Coverage section. The group medical 

benefit will terminate on the last date of the month in which the employee terminates 

employment. 

• Ask the terminating employee if they wish to continue the group medical coverage for 

themselves or their eligible dependents. 

• Employee Benefit Connections will mail the Group Health Continuation Election form to the 

employee or eligible dependents, when they receive from the institution (employer) the 

BenefitsTransfer, Termination and Reinstatement Transmittal form to terminate group 

health benefits for an employee or a dependent. Employee Benefit Connections will also 

administer the continuance of the medical coverage. The employee will be instructed to 

return the completed and signed form to Employee Benefit Connections along with the first 

month’s premium. 

• Insert the termination date in the Group Life Insurance section. The group life insurance will 

terminate on the employee’s last day of employment at 12:00 (midnight). 

• In the Group Long Term Disability Insurance section, if your institution offers this benefit, 

insert the termination date for this benefit. The group long term disability insurance will 

terminate on the employee’s last day of employment. 

• An authorized employer representative and the terminating employee must sign and date the 

Notice of Benefits Status Due to Separation From Employment form on pages 1 and 2. 

The original copy of the form should be given to the employee and a copy should be retained 

in the employer’s office. 

- 28 - Revised 07/2009

____________________________________ _____________________________________ ____________ 

Employee Name (Print) Employer (Institution) Institution-Div. # 

NOTICE OF BENEFIT STATUS DUE TO SEPARATION FROM EMPLOYMENT 

The following is a summary of your benefit coverage status as of your separation date:__________________ 

(insert date) 

GROUP MEDICAL COVERAGE 

If you and/or your spouse and/or dependent child(ren) are not entitled to Medicare or covered as an employee or continue 

under another group health plan you have the option to continue your group medical coverage(s) for up to eighteen (18) 

months. Additionally, the eighteen (18) month continuation period may be extended for an additional eleven (11) months (to 

the maximum of twenty-nine (29) months of continuation of coverage), if it is determined that the qualified beneficiary was 

disabled at any time during the first sixty (60) days of continuation of coverage. To qualify for the extension, the 

determination of disability must be an official determination made by the Social Security Administration and the plan 

administrator must be notified with the determination within sixty (60) days of the date of such determination. 

Covered dependents are eligible to continuation of group medical coverage for up to 36 months in the event of the employee’s death; 

change in dependent status (i.e. no longer a full time student; divorce or legal separation); dependent would otherwise lose coverage when 

employee becomes eligible for Medicare. If you or your spouse, and/or dependent children wish to elect continuation of coverage, you 

must notify your local administrator in writing within 60 days from the date you would lose coverage as a result of a qualifying event or 

60 days from the date you receive this notice, whichever is later. In addition, you must pay the premiums within 45 days from the date of 

election of continuation of coverage. Subsequent premiums are due on the first of each month. All premium payment checks should be 

made payable to the Archdiocese of New York and should be sent to: 


1011 First Ave, Suite 1679 


Your current single, family, or employee plus one medical coverage(s) will terminate on __________________________, 

unless you elect one of the following options: 

Do you elect continuation of your group medical coverage: 

Employee: Yes_______ No_________ 

Spouse: Yes_______ No_________ 

Dependent Child(ren) Yes_______ No_________ 

If you have elected yes, you must complete and sign the Group Health Continuation Election Form, which will be mailed 

under separate cover. 

__________________________________________________________________________ 

Authorized Employer Representative’s Signature 

______________________ 

Date 

____________________________________________________________________________ 

Employee/Member Signature 

____________________________________________________________________________ 

Spouse’s/Dependent’s Signature 

____________________ 

Date 

____________________ 

Date 

NOTE: ORIGINAL OF THIS FORM SHOULD BE GIVEN TO EMPLOYEE, MAKE A COPY FOR EMPLOYEE’S FILE. 

Separation From Employment 07/2009

____________________________________ _____________________________________ ____________ 

Employee Name (Print) Employer (Institution) Institution-Div. # 

GROUP LIFE INSURANCE 

Your current group life insurance with Hartford Life will terminate on your last day of employment ____________________. 

(insert date) 

You may continue your life insurance by electing one of the following options within 31 days following the date your coverage 

terminates. 

Portability Option: 

Terminating employees who have not reached the Defined Retirement Age (in accordance with the 1983 amendments of the 

United States Social Security Act) would be eligible to apply for continuation of life insurance under the Portability Option at 

group rates. If you are age 65 or older when electing portability, coverage would immediately be reduced by 25% of 

the amount eligible for portability. Additional coverage terminates at age 75. 

Conversion Option: 

Conversion is available upon termination of coverage subject to plan limitations. Please contact your local administrator for 

additional information. 

To secure Applications for Portability or Conversion, you may call Hartford Life at (877) 320-0484. 

GROUP LONG TERM DISABILITY INSURANCE (if applicable) 

Your current LTD insurance will terminate on your last day of employment ______________________. There is no 

conversion privilege for this benefit. 

(insert date) 

FLEXIBLE SPENDING ACCOUNT (if applicable) 

If you have an accrued amount in your Flexible Spending Account as of your date of separation, you can be reimbursed for 

medical/dependent expenses incurred prior to your separation date. You must submit an FSA claim form and copies of 

supporting documentation directly to Ceridian. 

RETIREMENT PLAN 

For information concerning pension benefits, please send written request to the Archdiocese of New York, Pension 

Department, 1011 First Avenue, New York, NY 10022. All inquiries must include your name, social security number, the 

name and address of the local employer institution where you were employed (list all institutions if more than one), and 

signature of the employee. 

___________________________________________________ ____________________________________________ 

Authorized Employer Representative Signature Date Employee Signature Date 

NOTE: ORIGINAL OF THIS FORM SHOULD BE GIVEN TO EMPLOYEE, MAKE A COPY FOR EMPLOYEE’S FILE. 

Separation From Employment 07/2009

Section VI 

Administration of Life, 

Supplemental & AD&D


Basic Life 

Eligibility 


Employee 

Contribution 

Basic Benefit 

Employees who are regularly scheduled to work a minimum of 20 hours each 

week and after you have satisfied the waiting period. (Refer to summary plan 

description booklet for further details). 

First of the month after waiting period (see summary benefit booklet for 

additional details). 

None 

See benefit booklet for life amount 

Minimum Benefit $10,000 

Maximum Benefit $375,000 

Age Reduction 

Accidental Death 

& 

Dismemberment 

Benefit (AD&D) 

Beneficiary 

Portability Option 

Conversion 

Privilege 

Reduced by 35% at age 65 and to 50% of the basic benefit at age 70. (Refer to 

summary plan description booklet for minimum benefit.) 

Same amount as basic life benefit for accidental death. Benefits also payable if 

you suffer an accidental injury resulting in the loss of a hand, foot or eye. (Refer 

to summary plan booklet for details). 

The person or persons you choose to receive any benefit payable upon the insured's 

death. 

This option permits an individual prior to retirement, who has not reached the 

normal retirement age under the 1983 United States Social Security Act , to 

continue the same amount of basic life in place on the date of his/her employment 

termination at a group premium rate. (Refer to the summary plan description 

booklet for details). 

This option provides for the conversion of the group life benefits to an individual 

life policy, if for example, your coverage ends due to termination of employment. 

The individual can apply for life insurance coverage up to the amount in place on 

the date of his/her employment termination. The insurance carrier will determine 

the premium. (Refer to the summary plan booklet for details) . 

- 29 - Revised 07/01/09


Life and Accidental Death & Dismemberment 

Enrollment/Beneficiary Designation Form 

For Priests & Final Year Seminarians 

PLEASE PRINT CLEARLY OR TYPE 

Name of Insured: _________________________________________________________________ 

(Last) (First) (MI) 

Date of Birth: __________________________ 

(Month) (Day) (Year) 

Social Security No.: ______________________ 

Institution Number: _________________ Plan Code (Division Number): ( ) 053 ( )153 ( )156 

Insurance Benefit: $15,000.00 

Effective Date: _________________________________ 

(Month) (Day) (Year) 

Beneficiary: Archbishop of New York Beneficiary Tax ID Number: 133089351 

Beneficiary Address: 


1011 First Avenue - Room 1940 

New York, New York 10022 

I Certify That The Above Information Is Correct 

_______________________________________________________________ 

(Insured’s Signature) 

______________ 

(Date Signed) 

Administrator, please return original copy of this form to: 


Attn: Benefits Office 

Life & Health Department 

1011 First Avenue – 16 th Floor 

New York, New York 10022 

Revised 06//2008


GROUP NON-CONTRIBUTORY BASIC LIFE 

ENROLLMENT AND CHANGE FORM 

Please print clearly and be sure to sign and date this form. Return your completed form to your employer’s office. 

( ) I want to be covered under the group plan benefits for which I am eligible. (Initial enrollment) 

( ) Update: Change of beneficiary 

Your Name:_______________________________________________________________________________________ 

Home Address:_____________________________________________________________________________________ 

Social Security Number:______________________________________________________________________________ 

Date of Birth:___________________________ Sex: ( ) Male ( ) Female 

Marital Status: ( ) Single ( ) Married ( ) Divorced ( ) Widowed 

Home Phone:_____________________________________ Work Phone:_____________________________________ 

Name of Employer:___________________________________________________________________________________ 

Employer’s Address:__________________________________________________________________________________ 

Occupation:_________________________________________________________________________________________ 

Institution #:__________ Division #::___________ If this is a transfer, give old institution/Division #:______________ 

Salary:$______________________ Date of Hire:____________________ Effective Date:_____________________ 

( ) I do not want to be covered for the group plan benefits for which I am eligible. I understand that I will have to submit 

evidence of good health satisfactory to the insurance carrier if I want this coverage at a later date. 

Designation of Beneficiary 

( ) I designate as my beneficiary(ies): 

Name:______________________________________________________________________________________________ 

Address:____________________________________________________________________________________________ 

Date of Birth:______________________________ Relationship to Employee:____________________________________ 

Name:______________________________________________________________________________________________ 

Address:____________________________________________________________________________________________ 


If the beneficiary dies before me, I designate as contingent beneficiary: 

Name:______________________________________________________________________________________________ 

Address:____________________________________________________________________________________________ 


♦ If there is more than one beneficiary or more than one contingent beneficiary, they will share the death benefits equally, 

or all will be paid to the survivor. 

♦ I RESERVE the right to change this designation at any time. 

Employee’s Signature:______________________________________________ Date:____________________________ 

ADMINISTRATORS, mail original form to: Employee Benefit Connections, 1011 First Ave., Room 1679, New York, NY 10022 

For additional beneficiaries, please attach a separate list and include the names, addresses, dates of births and relationship to the employee 

Contact us: ebc@archny.org Web Page: www.archny.org/benefits Revised 09/04/07

HOW TO FILE A CLAIM FOR BASIC GROUP LIFE INSURANCE 

(Hartford Life Insurance Company – Group Policy Number – GL 674263) 

Upon notification of death: 

• Verify that the deceased employee was covered under the Basic Group Life 

Insurance and the amount of Basic Life Insurance Benefit in effect at the time of 

the employee/insured) death. 

• Contact Hartford Life Insurance Company at 1-888-563-1124 and request a Proof 

of Death Claim Form. 

• Secure a copy of the initial Group Life Enrollment Form, signed by the employee, 

and if applicable, the latest Change of Beneficiary Designation Form. (Copies of 

these forms are usually retained in an employee’s file and the original is retained 

at the Employee Benefit Connections Office). 

• Secure a Certified Copy of the Certificate of Death (this is usually obtained from 

the beneficiary or and immediate family member of the deceased). 

• When the current primary beneficiary(s) is established, send the Proof of Death 

Claim Form to the beneficiary(s) (if more than one primary beneficiary; send a 

claim form to each primary beneficiary listed) to complete, sign and return to the 

local administrator with one Certified Copy of the Certificate of Death. The 

completed form(s) can be mailed to: 

Hartford Life Insurance Companies 

Attn: Life Claims 

P.O. Box 2999 


Suggest that the Local Administrator include a cover letter to Hartford Life, 

requesting that the local administrator is copied on all communications 

concerning the particular group life insurance claim. If claim is not paid within 

15 working days contact Hartford Life to find out the status of the claim. 

Follow same procedure for Accidental Death and Dismemberment, except the 

claim* would be filed with: 

Mutual Of Omaha 

Mutual of Omaha Plaza 

Omaha, NE 68175 

Tel: 1-800-524-2324 

* Claim Amount for AD&D is the same as Basic Life – refer to AD&D Summary 

Booklet for Group policy number for your institution) 

Note: Keep a copy of all claims filed with the insurance carrier. 

- 30 -

PREMIUM WAIVER 

Basic Group Life Insurance Coverage 

Employees under age 65 who are covered under the basic group life insurance plan, who 

are absent from work due to injury or illness for an extended period of time (at least 12 

months) would be eligible to apply for a premium waiver for their basic group life. 

A premium waiver is a provision, which allows for the continuation of life insurance 

coverage for the employee, without payment of premium, while the employee is disabled. 

To apply for a waiver of premium, the employer, or the employee may contact Hartford 

Life Insurance Company at 1.888.563.1124 to request an Application for Premium 

Waiver. The Application for Premium Waiver is composed of three sections, the 

Employer Section, the Employee Section, and the Physician’s Statement. 

If the employee is covered under the Hartford Life Group Long Term Disability Plan (LTD) and a 

claim for LTD Benefits has been filed with the Hartford Life, Hartford Life will automatically 

start the premiums waiver process. We encourage the local benefits administrator to contact 

Hartford Life directly (1.888.563.1124) to confirm that the premium waiver application has been 

filled. 

For questions about how to complete the Premium Waiver Application form, call 

Hartford life toll-free number at 1.888.563.1124. 

Completed Applications for Premium Waiver should be mailed to: 

Hartford Life 

Group Life Claims 

P.O. Box 2999 


If approved by Hartford Life, the life insurance coverage will continue until the employee/member 

is no longer disabled or the employee is deceased. Hartford will contact the disabled employee for 

periodic updates. If the employee fails to reply, the life insurance coverage may be terminated. 

(Refer to the Hartford Life Group Life Booklet for details). 

IMPORTANT: 

This benefit is time sensitive. Please be aware that the policy requires that the Notice and 

Proof of Loss be submitted to Hartford Life within one year of the last day of work as an 

Active Full Time Employee. 

- 31 -

GROUP LIFE INSURANCE BENEFITS FOR 


PORTABILITY OF BASIC GROUP LIFE & 

GROUP SUPPLEMENTAL TERM LIFE INSURANCE 

• Employees may elect portability of their group life insurance to a group portability policy 

when employment terminates for any reason prior to retirement. (Retirement means the date 

you attain normal retirement age under the 1983 United States Social Security Act, and any 

amendments thereto). Eligible employees may apply for a group portability policy within 31 

days from the termination date of the group life insurance. Also, the application can be filed 

within 45 days from the date the portability notice is given, if that date is later than 15 days 

from the date the benefits terminated. (Refer to booklet for eligibility requirements). 

• The enrollment period for the portability of the group life insurance policy ends 90 days from 

the date the employee’s employment is terminated, regardless of when the portability 

application was given to the employee. 

• Portability insurance for $5,000 or less is not allowed unless the insurance applies to 

Dependent Child coverage. (Refer to booklet for further details). 

• The employer must complete and sign part A of the Application for Group Life Insurance 

Under the Hartford Group Insurance Trust Form. The employee should get the original 

copy to be mailed to the insurance company. (A photocopy should also be included in the 

employee’s file). 

• It is the employee’s responsibility to mail the form to Hartford Life Insurance Company, 

Attention: Portability Administration, P.O. Box 248108, Cleveland, OH 44124-8108. The 

employee must submit the required premium along with the application. The local employer 

will advise the applicant of the premium cost. The employee should call (800) 548-5157 for 

any assistance. Employer should call (800) 228-6108, extension 2201 for additional 

assistance. 

February 2008 - 32 -

PORTABILITY OF GROUP LIFE INSURANCE & SUPPLEMENTAL TERM LIFE INSURANCE 

Notice of Portability 

If an individual is not given notice of the existence of the Portability privilege within 15 days of the terminating 

event, which results in the Portability option he/she will have an additional period in which to exercise Portability 

rights. This additional period will end 45 days following the date he/she is given notice of the right to exercise 

Portability rights or 90 days following the date on which the terminating event which results in the Portability 

option occurs, whichever occurs first. 

What if death occurs during the Portability election period? 

If the individual should die within the 31-day portability election period, the current carrier will, upon receipt of 

acceptable proof of death, pay the Amount of Life Insurance the individual was entitled to continue under the 

Portability provision. However, in no event will a benefit be payable under both of the 31-day conversion privilege 

election period and this portability election period. 

INSTRUCTIONS: 

Employer: Complete Part A of the application, make a copy to be included in the institution’s records and then 

give the application to the employee (or the employee’s spouse under the Supplemental Term Life Insurance) 

whose coverage is terminating. The employer must attach to the application the most current copy of the 

employee’s enrollment form. The amount of insurance that the employer identified in Part A must match the 

amount of insurance elected on the enrollment form. If the amounts are not the same, an explanation must be 

attached. 

Applicant: If an employee wishes to continue the group life insurance they had with the employer, he/she must 

complete Part B of the application, make a copy for his/her records and return the completed application along with 

the premium within 31 days of termination of group coverage to: 

Hartford Life 

Attention: Portability Administration 

P.O. Box 248108 

Cleveland, OH 44124-8108 

IMPORTANT NOTE: The employee should be advised to take the following information into consideration when 

deciding whether to apply for portability of coverage. Coverage under the group portability policy reduces and 

terminates upon reaching certain ages. 

Under the Supplemental Term Life Insurance, a dependent child or student coverage terminates when such 

dependents reach the limiting ages of 19 (child) or 25 (student). Portability coverage for the employee and spouse 

will be reduced by 25%. If Portability is elected at age 65 or older the Supplemental coverage will immediately be 

reduced by 25%. Supplemental Insurance coverage terminates at age 75. 

Under the Basic Group Life Insurance benefit, only the eligible employee has the right to exercise the portability 

and conversion options. See booklets for further details 

If an employer or applicant has questions about completing the application, they should call Hartford Life at 

1.877.320.0484. 

- 33 - 07/2009



CONVERSION OF BASIC GROUP LIFE & SUPPLEMENTAL TERM LIFE INSURANCE 

• Employees are eligible to convert their basic group life insurance & their group supplemental 

term life insurance to individual policies. Eligible employees should apply for conversion 

policies within 31 days from the termination date of their basic group life insurance and their 

supplemental term life insurance. Also, the application can be filed within 45 days from the 

date the conversion notice is given, if that date is later than 15 days from the date the benefits 

terminated. 

• Eligibility for application for conversion to individual life insurance coverage ends 91 days 

from the date the basic group life insurance and the supplemental term life insurance 

terminated, regardless of when the conversion application was given to the employee. 

• The employer must complete and sign parts A. Notice of Conversion Privilege – Life 

Insurance Only Form. The employee should be given the original copy of the form to be 

mailed to the insurance company. (A photocopy should also be included in the employee’s 

file). 

• The conversion option under the Group Supplemental Term Life Insurance is also 

available to an eligible employee’s spouse and dependent child. 

• It is the employee’s responsibility to mail the form to The Hartford Life Companies, Attn: 

Group Conversion Unit, P.O. 248108, Cleveland, OH 44124-8108. The employee will receive 

a cost and benefit quotation for the converted coverage from Hartford once the form is 

received. The employee should call 877.320.0484 for any assistance. 

- 34 -

SAMPLE NOTICE 

(This information should be sent to the employee who is losing group life coverage.) 


EMPLOYEES SEPARATION FROM SERVICE 

NOTICE OF CONVERSION PRIVILEGE FOR BASIC GROUP LIFE 

& SUPPLEMENTAL TERM LIFE INSURANCE 

Insurance coverage for you is being terminated as of the DATE OF GROUP COVERAGE TERMINATION 

shown on the NOTICE OF BENEFITS STATUS DUE TO SEPARATION FROM EMPLOYMENT 

summary. You have the right to CONVERT your Group Life coverage without having to submit evidence of good 

health. Your group insurance booklet contains the specific conversion privilege. 

BASIC GROUP LIFE INSURANCE may be converted to an individual life insurance plan. Conversion to term 

insurance is not available in all states. You may convert any amount up to the benefit level you had under the 

group plan. Special restrictions and limits apply when coverage on an entire class of employees or members 

terminates. 

The conversion option for the GROUP SUPPLEMENTAL TERM LIFE INSURANCE is also extended to an 

eligible employee’s spouse and dependent children. 

To receive a cost and benefit quotation for CONVERTED coverage: 

• Complete all information requested in Part B of the enclosed form. Your local employer or local administrator 

must complete Part A. Both Parts A & B must be completed and signed before a quote may be given by the 

insurance carrier. Retain a copy of the Notice of Conversion Privilege-Life Only form for your records. 

• Mail the original copy of the Notice of Conversion Privilege-Life Insurance Only form directly to: 

The Hartford Life Companies 

Attn: Group Conversion Unit 

P.O. Box 248108 

Cleveland, OH 44124-8108 

Conversions will expire unless the completed form is mailed to Hartford within: 

a. 31 days from the Date of Group Coverage Termination, or 

b. 15 days from the date the NO TICE OF CONVERSION PROVILEGE is given to you, whichever is 

later. (This will not extend your rights to apply for conversion beyond 91 days after the Date of Group 

Coverage Termination). 

If you have any questions on how to complete the enclosed form, you may call the Conversion Unit at 

1.877.320.0484.

Section VII 

Administration of 


(New York State Short 

Term Disability Benefits)



Eligibility 

Effective 

Date. 

Employee 

Contribution 

Basic Benefit 

Waiting 

Period 

Definition of 

Disability 

Benefit 

Duration 

Employees who have worked at least four 

consecutive weeks. 

First of the month following 30 days of employment 

None 

50% of employee's average weekly wage up to a 

maximum of $170.00. 

Seven calendar days of disability due to off the job 

illness or injury for which no benefits are payable. 

Benefits are payable on the eighth consecutive day of 

disability. 

Employee is prevented from performing work because 

of off the job illness or injury. Disability connected 

with pregnancy is included. 

Benefits are paid for a maximum of 26 weeks during 

52 consecutive weeks or during any one period of 

disability. 

Time Limit 20 days after the first day of disability (to avoid any 

for a Filing penalties ). 

Claim 

- 35 -

HOW TO FILE A CLAIM FOR NEW YORK STATE DISABILITY BENEFITS 

(Hartford Life Insurance Company -Policy Number LNY 612197) 

• Upon notification that an employee is unable to work for eight consecutive days due to a non 

job-related illness or injury, the local administrator should send a, Notice And Proof Of Claim 

For Disability Benefits Form (DB-450) to the disabled employee, with a cover letter requesting 

that the employee to complete: 

- Part A - the Claimants Statement, and have their doctor complete 

- Part B - Health Care Provider’s Section 

The form should be returned to the employer, to complete the Employer’s Statement. 

• The employer should make a copy for their files, and mail the original disability form to: 

The Hartford 

Syracuse Benefit Management Services Office 

P.O. Box 4925 

Syracuse, NY 13221-4925 

• Should the employee express any concerns about the confidentiality relating to their disability, 

the employer should complete and sign the Employer’s Statement section, make a copy for the 

institution’s or agency’s records and give the form to the employee to have his or her physician 

complete and sign Part B–HealthCare Provider’s Statement section. The employee must 

complete and sign Part A-Claimant’s Statement, before submitting the claim form directly to 

the Hartford 

• If the employee is eligible for salary continuance, (sick pay), from the employer, for part or all 

the time that they are absent from work, the employer would be reimbursed for salary 

continuance at the state disability rate. If the employee is not eligible for sick pay, disability 

benefits will be paid directly to the employee, during the disability period. 

• The employer will receive statement(s) from the Hartford confirming the time period, and the 

amount of benefits the employee was paid during a disability period. 

• Contact the Hartford DBL Customer Service Center at 1 800-538-0134 if you have any 

claims inquiries. 

• Review Part B, 7d. date claimant will be able to return to work. 

Note: See NYS DBL Claim Form (DB 450), and Sample Cover Memo to employee. 

- 36 -

(Sample Letter) 

NOTICE TO DISABLED EMPLOYEE 

To: 

Address: 

Re: 

Date: 

_______________________________________________________________ 

_______________________________________________________________ 

Short Term Disability Benefits Claim Forms 

________________________________________________________________ 

Enclosed is a Notice and Proof of Claim for Disability form as you requested. In order to have this 

claim properly processed, the following is required: 

1. You must complete Part A – Claimant’s Statement. 

2. Your employer must complete and sign the Employer’s Statement section of this form. 

3. Your attending physician must complete and sign Part B- Health Care Provider’s section. 

The general time limit for filing a claim is twenty (20) days after the first day of disability. Therefore, 

the completed form should be filed as soon as possible with: 

The Hartford 

Syracuse Benefit Management Services Office 

P.O. Box 4925 


Our policy number under the current carrier is LNY 612197. 

Just to summarize this coverage, New York State Short Term Disability pays 50% of the average 

weekly wage up to a maximum of $170.00. Benefits are payable on the eighth day of disability after 

the waiting period of seven calendar days. 

Should you have any claim inquiries concerning your claim, please call the Hartford’s claims 

department at (800) 538-0134 

Sincerely, 

Enclosure 

[Employer/Benefits Administrator Name] 

- 37 -

NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS 

CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY 

1. USE THIS FORM IF YOU BECOME SICK OR DISABLED WHILE EMPLOYED OR IF YOU BECOME SICK OR DISABLED WITHIN FOUR (4) WEEKS AFTER 

TERMINATION OF EMPLOYMENT. USE GREEN CLAIM FORM DB-300 IF YOU BECOME SICK OR DISABLED AFTER HAVING BEEN UNEMPLOYED 

MORE THAN FOUR (4) WEEKS. 

2. YOU MUST COMPLETE ALL ITEMS OF PART A - THE "CLAIMANT'S STATEMENT". BE ACCURATE. CHECK ALL DATES. 

3. BE SURE TO DATE AND SIGN YOUR CLAIM (SEE ITEM 12). IF YOU CANNOT SIGN THIS CLAIM FORM, YOUR REPRESENTATIVE MAY SIGN IT IN YOUR 

BEHALF. IN THAT EVENT, THE NAME, ADDRESS AND REPRESENTATIVE'S RELATIONSHIP TO YOU SHOULD BE NOTED UNDER THE SIGNATURE. 

4. DO NOT MAIL THIS CLAIM UNLESS YOUR HEALTH CARE PROVIDER COMPLETES AND SIGNS PART B - THE "HEALTH CARE PROVIDER'S 

STATEMENT. 

5. YOUR COMPLETED CLAIM SHOULD BE MAILED WITHIN THIRTY (30) DAYS AFTER YOU BECOME SICK OR DISABLED TO YOUR LAST EMPLOYER 

OR YOUR LAST EMPLOYER'S INSURANCE COMPANY. 

6. MAKE A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS BEFORE YOU SUBMIT IT. 

PART A - CLAIMANT'S STATEMENT (Please Print or Type) ANSWER ALL QUESTIONS 

1. My name is: (First, Middle & Last) 2. Social Security Number: 3. Date of Birth: 

4. My Address: ( Number, Street, City or Town, State & Zip Code) 

5. My Telephone Number 

( ) 

6. Martial Status: (Check one) 7. My disability is: (if injury, also state how, when and where it occurred) 

Married Single 

8. I became disabled on: 

Month/ Day/ Year 

a. I worked on that day: Yes No 

b. I have since worked for wages or profit: Yes No 

If "Yes", give dates: 

9. Give name of last employer. If more than one employer during the last eight (8) weeks, name all employers. 

Employer's Dates of Employment Average Weekly Wages 

Business Name Business Address Phone Number From Through (Include Bonuses, Tips, 

Month/Day/Year Month/ Day/Year 

( ) 

Commissions, Reasonable 

Value of Board, Rent, etc.) 

( ) 

( ) 

10. My job is or was: (Occupation) Name of Union and Local Number, if member: 

11. For the period of disability covered by this claim: 

a. Are you receiving wages, salary or separation pay: 

Yes No 

b. Are you receiving or claiming: 

(1) Workers' compensation for work-connected disability 

Yes No 

(2) Unemployment Insurance Benefits 

Yes No 

(3) Damages for personal injury 

Yes No 

(4) Benefits under the Federal Social Security Act for long-term disability Yes No 

IF "YES" IS CHECKED IN ANY OF THE ITEMS IN 10a OR 10b, COMPLETE THE FOLLOWING 

I have received claimed From For the period 

To 

12. I have received disability benefits for another period or periods of disability within the 52 weeks immediately before my present 

disability began: Yes No 

If "Yes" fill in the following: I have been paid by: 

From 

To 

13. I have read the instructions above. I hereby claim Disability Benefits and certify that for the period covered by this claim I was 

disabled and that the foregoing statements, including any accompanying statements, are to the best of my knowledge true and 

complete. 

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR 

BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT 

OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO FINES AND IMPRISONMENT. 

Claim signed on: 

Claimant's Signature: 

If signed by other than claimant, print below: name, address, and relationship of representative: 

IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS, 

CONTACT THE NEAREST OFFICE OF THE NYS WORKERS' COMPENSATION 

BOARD, OR WRITE TO: WORKERS' COMPENSATION BOARD, DISABILITY 

BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005 

SI TIENE DUDAS RELACIONADAS CON LA RECLAMACIÓN DE BENEFICIOS 

POR INCAPACIDAD, COMUNIQUESE CON LA OFICINA MAS CERCANA DE 

LA JUNTA DE COMPENSACIÓN OBRERA DE NUEVA YORK, O ESCRIBA A: 

WORKER'S COMPENSATION BOARD, DISABILITY BENEFITS BUREAU, 100 

BROADWAY- MENANDS, ALBANY, NY 12241-0005 

HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE 

LC-5012-14 DB-450 02/04 Page 1 of 3 02/2009


IMPORTANT: USE THIS FORM ONLY WHEN THE CLAIMANT BECOMES SICK OR DISABLED WHILE EMPLOYED OR BECOMES SICK 

OR DISABLED WITHIN FOUR (4) WEEKS AFTER TERMINATION OF EMPLOYMENT. OTHERWISE USE GREEN CLAIM FORM DB-300. 

PART B - HEALTH CARE PROVIDER'S STATEMENT (Please Print or Type) 

THE HEALTH CARE PROVIDER'S STATEMENT MUST BE FILLED IN COMPLETELY AND THE FORM MAILED TO THE INSURANCE 

CARRIER OR SELF-INSURED EMPLOYER, OR RETURNED TO THE CLAIMANT WITHIN SEVEN DAYS OF THE RECEIPT OF THE FORM. 

For item 7d, give approximate date. Make some estimate. If disability is caused by or arising in connection with pregnancy, 

enter estimated delivery date under "Remarks". (Even if considerable question exists, estimate date. Avoid using terms 

such as unknown or undetermined). 

1. Claimant's Name: 2. Date of Birth: 3. Sex: 

Male 

Female 

4. Diagnosis/Analysis: Diagnosis Code: 

a. Claimant's Symptoms: 

b. Objective Findings: 

5. Claimant Hospitalized? Yes No 

From 

To 

6. Operation Indicated? Yes No 

a. Type b. Date 

7. Enter Dates for the Following: 

a. Date of your first treatment for this disability: 

b. Date of your most recent treatment for this disability: 

c. Date claimant was unable to work because of this disability: 

d. Date claimant will be able to perform usual work: 

e. If disability is pregnancy related, please estimate delivery date: 

8. In your opinion, is this disability the result of injury arising out of and in the course of employment or occupational disease? 

Yes No If "Yes", has form C-4 been filed with the Workers' Compensation Board? Yes No 

Remarks: (attach additional sheet, if necessary) 

I affirm that I am a: Chiropractor Physician Psychologist 

Dentist Podiatrist Nurse-Midwife 

License Number: 

Licensed in the State of: 

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR 

BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL 

STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO FINES AND IMPRISONMENT. 

Health Care Provider's Signature: 

Date: 

Health Care Provider's Name: (Please Print) 

Telephone Number: 

( ) 

Office Address: 

(Number, Street , City or Town, State & Zip) 

HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a (4) (a) and 12 NYCRR 325-1.3 require health care 

providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these 

legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information. 

LC-5012-14 DB-450 02/04 Page 2 of 3 02/2009


PART C - EMPLOYER'S STATEMENT 

Employee's full name: (As shown on Social Security Card) 

Social Security Number: 

Employee's Address: (Street, City, State & Zip Code) 


Date of employment: 

If Part Time, give particulars: 

Full Time 

Part Time 

Check days normally worked: 

Sun. Mon. Tues. Wed. Thurs. Fri. Sat. 

Is employee a Union member? If "Yes," is employee entitled to Union Benefits Occupation: 

Yes No Yes No 

Date employee last worked: Date employee returned to work: Were wages continued during disability? 

Yes No 

Were wages Sick pay? 

Yes No From: To: 

Were wages Vacation pay? 

Yes No From 

To 

Is reimbursement requested? 

Yes No 

Is disability due to job? 

Yes No 

EARNINGS 8 WEEKS PRIOR TO DISABILITY 

(Including the week in which the disability began) 

No. Days 

Month Day Year Worked Amount 

If "Yes," has a compensation claim been filed? 

Yes No 

Indicate Weekly Value of Board, Lodging and Tips: 

Is this employee currently covered by Social Security? 

Yes No 

If "No," state grounds for exemption: 

Total 

Is employee enrolled in a Hartford Long Term Disability Plan? 

Yes No If "Yes," effective date 

Based on the employer/employee premium contributions made over the last 3 years, what percentage of the Weekly 

Disability % LTD % benefit is considered taxable? (See section 7 of IRS Publication 15-A for 

information on determining the taxable percentage.) If blank, we will assume the benefit is 100% taxable. 

Employer's Name: 

Employer's Identification Number: 

Address: (Street, City, State & Zip Code) Telephone Number: 

( ) 

Signed by: Date: Title: 

THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION 

LC-5012-14 DB-450 (02/04) Page 3 of 3 02/2009

Section VIII 


Long Term Disability


Benefit Plan Highlights 


Eligibility 


Employee 

Contribution 

Employees who are regularly scheduled to work a minimum of 30 hours each 

week for a participating Employer. (20 hours for bargaining lay faculty members. 

Eligibility varies for employees working for Cemeteries and Child Care Agencies). 

Refer to benefits booklet for details. 

First of the month following six months of employment. 

None. Employer pays full cost of premium 

Basic Monthly 60% of your regular monthly salary not to exceed a maximum of $5,000. 

Benefit 

Minimum 

Monthly Benefit 

Benefit Offsets 

Elimination 

Period 

Definition of 

Disability 

Pre-existing 

Condition 

Limitation 

Benefit Duration 

Accidental 

Dismemberment 

and Loss of Sight 

Survivor Benefit 

The greater of $100 or 10% of the gross monthly benefit. 

Benefits can be reduced by any other income as stated in the booklet such as 

Social Security Disability, Workers' Compensation and Retirement Benefits as 

offsets. 

180 days of continuous disability. 

During the elimination period and for the next 24 months an employee is 

prevented from performing one or more of the essential duties of his/her own 

occupation and as a result their current monthly earnings are no more than 80% of 

the indexed pre-disability earnings. After that, the employee must be so prevented 

from performing one or more of the essential duties of any occupation. (Failure to 

pass a physical examination required to maintain a license to perform the duties 

of the employee's occupation does not alone mean that the employee is disabled.) 

Benefits will not be payable for disabilities caused or contributed to by preexisting 

conditions until the employee has been continuously covered under 

he plan for 12 months. A pre-existing condition is an illness or injury for which 

you received medical treatment, consultation, care or services, or had taken 

prescribed drugs or medicines in the three months prior to your coverage 

effective date. 

For employees disabled prior to age 60, benefits are payable to age 65 but not for 

less than 60 months. Reduced benefit duration for employees disabled after age 

60. (Refer to booklet) 

Benefits payable for accidental injury for specified losses. (Refer to booklet for 

details). 

Limited benefits payable to eligible survivor upon employee's death. 

- 38 -

HOW TO FILE A CLAIM FOR LONG TERM DISABILITY BENEFITS 

(Group Policy Number GLT-674263) 

A claim for Long Term Disability (LTD) Benefits should be filed: 

• when an eligible employee is absent from work due to illness or injury and 

• the eligible employee has filed for, and is receiving State Disability Benefits for at 

least four months and 

• based on evidence of disability, it is not anticipated that the eligible employee will be 

able to return to work before the six-month elimination period is exhausted. 

Procedure: 

• Contact the Hartford Life Insurance Company at: 1 800-538-0134 to advise the 

carrier of the anticipation of filing a Long Term Disability (LTD) claim for (name of 

employee), and request for an Application For Long Term Disability Income 

Benefits, and also ask any related questions. 

• Send both the Application For Long Term Disability Income Benefits and the 

Authorization to Obtain and Release Information forms to the employee to complete, 

sign and have their physician complete the Attending Physician’s Statement, and 

return all the completed forms to the Local Administrator (employer). 

• The Employer must complete the Employer’s Statement and provide required 

attachments (see section K of form). 

• All of the forms are then submitted to: 


Syracuse Benefits Management Service Center 

P.O. Box 4925 


• If your institution uses Hartford Life as their carrier for New York State Short Term 

Disability, Hartford will automatically send the disabled employee an application to 

apply for the Long Term Disability Benefits. If not, you will need to contact Hartford 

directly for the forms: Hartford Life changes forms, and Claim Filing Centers on a 

periodic basis, and this is why it is necessary to contact Hartford Life directly 

whenever a claim for LTD is anticipated, and forms will be required to file the claim. 

• Long Term Disability Benefits Plan ends on the employee’s date of termination of 

employment, or the date the employee begins to receive Long Term Disability 

Benefits, which ever occurs first. The employing Institution no longer needs to pay 

for the monthly LTD premium for the disabled individual once the disabled individual 

begins to receive the monthly LTD benefit. 

• There is no Portability or Conversion option available for this insurance. 

- 39 -

Section IX 


Dental Coverage


Benefit Highlights 

Group Dental Insurance 

Eligibility 


Premium Cost 

Types of Dental 

Coverage 

Member of the Clergy, or Religious Brother or Sister 

Date assigned to Institution 

Premium paid in full by Institution 

Dental PPO (Preferred Provider Organization) 

*Option I - Non-stipend Religious Brother & Sisters are eligible 

Maximum Annual Benefit - $750 

*Option II - Members of the Clergy, Religious Brothers & Sisters 

on stipend. Maximum Annual Benefit - $1,500 

Basic Benefit *Preventive, Restorative Services 

Coverage (Orthodontia services are not provided under Option I) 

*In-Network and Out-of-Network Benefits 

(Refer to Dental Schedule of Benefits for Details) 

- 40 -

CIGNA Dental for Religious and Clergy 

The Archdiocese offers the PPO Dental program through CIGNA. Plan participants can 

receive dental services at reduced fees from CIGNA PPO network dentists. In view of 

the $1,500 calendar year maximum, the reduced fees allow members to receive a higher 

level of benefit from the plan. Additionally the patient’s out-of-pocket cost is reduced, 

because the patient pays the member coinsurance on a reduced fee. 

• This dental plan for the Clergy under Option Plan II provides the following benefits: 

- The PPO network feature allows you to use a network or non-network dentist at 

any time. 

- Orthodontia services and appliances are covered at 50%. The maximum benefit is 

$1,500 per lifetime. 

• The Religious on stipend should have Option Plan II, which provides the same 

benefits as the Clergy dental plan. Religious who are not on stipend may also be 

enrolled in this plan provided their administrator selects this benefit for them. The 

maximum benefit is $1,500 per calendar year. There is a $1,500 per lifetime benefit 

for orthodontia. 

• Option Plan I, a less costly option, is also available as an option for institutions 

covering religious not on stipend. Plan I provides less coverage than Plan II, since it 

has a higher deductible and lower coinsurance levels than Plan II. The maximum 

benefit is $750 per calendar year. Option Plan I does not provide any coverage for 

orthodontia. 

- 41 -


CIGNA Dental PPO for Clergy Enrolled in High Option Plan II 

Benefit (1) In-Network (2) Out-of-Network 

Deductible (per calendar year $ 50 per individual, waived for D&P (3) 

Coinsurance: 

Class I – Diagnostic & Preventive (D&P) Services 

100% 100% 

- Oral Exams (2 per calendar year) 

- Cleanings (2 per calendar year) 

- Full mouth x-rays (complete every 3 calendar years) 

- Bitewing x-rays (2 per calendar year) 

- Panoramic x-ray (1 every three calendar years) 

- Space maintainers (limited to non-orthodontic treatment) 

- Emergency care to relieve pain 

Class II – Basic Restorative Services 

80% 80% 

- Fillings, root canal therapy osseous surgery, periodontal 

scaling and root planing, denture adjustments & repairs, 

anesthetics and oral surgery 

Class III – Major Restorative Services 

60% 60% 

- Crowns, dentures & bridgework 

Class IV – Orthodontia Services 

60% 60% 

(Treatment & Appliances) 

Maximum Plan Benefit $1,500 per calendar year (3) 

Lifetime Orthodontia Maximum $1,500 per lifetime (3) 

1. Missing Teeth Limit – The amount payable is 50% of the amount otherwise payable for replacement of teeth that are 

missing when a person becomes insured under the Archdiocese CIGNA dental plan. This limitation no longer applies after 

the person has been insured under the CIGNA dental plan for 24 months. 

2. To locate a network dentist in your area or to find out if a particular dentist is in the CIGNA PPO Dental network, call 

800.244.6224, or access their website, cigna.com/dental. 

3. All deductibles, plan maximums and service specific maximums (dollar and occurrence) cross accumulate in and out-ofnetwork. 

The annual plan maximum does not apply to the orthodontia benefits, but the plan deductible applies. 

- 42 -


CIGNA Dental PPO for Religious Brothers and Sisters on Stipend 

and Institutions Electing High Option Plan for Religious 

Plan II 


Deductible (per calendar year $100 per individual, waived for D&P (3) 

Coinsurance: 


100% 100% 





- Panoramic x-ray (1 every three calendae years) 




80% 80% 





60% 60% 



60% 60% 


Maximum Plan Benefit $1,500 per calendar year (3) 

Lifetime Orthodontia Maximum $1,500 per lifetime (3) 





800.244.6224 or access their website, cigna.com/dental. 



- 43 -


CIGNA Dental PPO for Religious Brothers and Sisters 

Plan I 


Deductible (per calendar year $100 per individual, waived for D&P (3) 

Coinsurance: 


80% 70% 





- Panoramic x-ray (1 every three calendae years) 




70% 60% 





50% 40% 




Not covered 

Not covered 

Maximum Plan Benefit $750 per calendar year (3) 





800.244.6224, or access their website, cigna.com/dental. 



- 44 -

HOW TO FILE A DENTAL CLAIM 

There are several ways to file a claim with the dental insurance carrier. 

• Direct Claim – The participant’s dental office can file the claim electronically on his/her 

behalf with the dental insurance carrier. 

• Paper Claim – The dentist may also complete CIGNA’s ADA Dental Claim Form. 

Signatures of both the benefit participant and the dentist are required. The claim form 

should be mailed to: 

CIGNA HealthCare Service Center 

P.O. Box 188037 

Chattanooga, TN 37422-8037 

CIGNA Customer Service Telephone Number: 1.800.244.6224 

• Invoice – If a participant receives an invoice from a dental provider that lists an insurance 

information section, (most times this will be on the reverse side of the invoice), complete the 

insurance information section, and either return to the service provider, or send it directly to 

the insurance carrier (follow the directions on the invoice). 

If the invoice is itemized, and lists the date(s) of service, a diagnosis or diagnostic code, and a 

total dollar amount of charges, you can attach the invoice to a Dental Claim Form, complete the 

Employee Section and mail it to CIGNA at the address listed above. 

Important Note: Keep a copy of any claims that you submit to the insurance carrier 

- 45 -

Section X 


Vision Coverage

DAVIS VISION CARE 

VISION CARE BENEFIT PLAN 

- 46 -

Davis Vision for Religious and Clergy 

The Archdiocese sponsors the managed vision benefit available to the Diocesan Clergy 

and Religious through Davis Vision. The plan provides network and non-network 

benefits for routine eye exams, contact lenses, lenses and frames. Network benefits are 

subject to copays. Services and appliances received from non-network dentists will be 

reimbursed based upon a fee schedule. 

Clergy and Religious on stipend, who are covered under the Archdiocese plan for 

medical benefits, are also eligible to enroll in this vision plan. Each participating 

institution may elect to provide the vision coverage for their non-stipend Religious. 

- 47-


Benefit Highlights 

Group Vision Care 

Eligibility 


Participant Cost 

Type of Dental 

Coverage 

Basic Benefit 

Coverage 

Members of the Clergy, or Religious Brother or Sister 

Date assigned to Institution 

Non-contributory 

Vision PPO Coverage (Preferred Provider Organization) 

*Eye Examination 

*Other In-Network and Out-of-Network Benefits 

(Refer to Vision Schedule of Benefits for Details) 

- 48 -


Davis Vision PPO Plan for Clergy and Religious Brothers and Sisters (1) 

Benefit 

In-Network 

Copay 

Out-of-Network 

Allowance 

Eye Examination (Once every 12 months $10 $60 

Eyeglass Lenses (Once every 12 months) 

Single 

Bifocal 

Trifocal 

$15 $45 

$60 

$75 

Eyeglass Frames (Once every 24 months) $10 $75 

Contact Lenses (In lieu of eyeglasses, once 

every 12 months) (2) 

$25 $125 

1. The Vision Plan is automatically provided for Clergy and Religious Brothers & Sisters on stipend who are 

enrolled in an Archdiocese group medical plan. The plan is also available to non-stipend Religious if their 

congregation or employer elects the benefit on their behalf. 

2. The Contact Lens benefits are quoted for elective contact lenses. Medically necessary contact lenses purchased 

from a network provider will be covered in full (prior approval required) 

- 49 -

HOW TO FILE A VISION CARE CLAIM (Clergy and Religious only) 

The two most common ways to file a claim for vision care are a direct claim or a paper 

claim. 

Direct Claim - The insured is responsible for all applicable co-pays. The participating 

in-network eye care provider will submit the claim directly to Davis Vision on the 

insured’s behalf. 

Paper Claim - If the insured uses an out -ofnetwork provider, he/she should complete 

and sign a Davis Vision Direct Reimbursement Claim Form. The insured should have the 

vision care provider complete and sign the “Provider Information” Section and send the 

claim to: 

Vision Care Processing Unit 

P.O. Box 1525 

Latham, NY 12110 

Invoice – If the insured receives an invoice from an eye care facility, and the reverse side 

of the bill has a section to list insurance information, he/she can complete the 

information, and submit it directly to Vision Care Processing Unit at the address above or 

return it to the facility (following the directions on invoice). If there is an itemized bill 

with the date(s) of service listed, the insured should complete the Member/Employee and 

Patient Information sections, attach a copy of the invoice and submit it to Vision Care 

Processing Unit at the address listed above. (address is also listed on the claim form). 

The insured (patient) is responsible for all charges above the reimbursable scheduled 

amount(s) 

Important Note: The insured should keep a copy of any claims that you submit for 

payment 

- 50 -

Direct Reimbursement Claim Form 

Important Information: 

1. Use this form to request reimbursement for services received from providers who do not participate in the Davis Vision network. 

2. Expenses for both examinations and eyewear can be claimed on this form. Only services listed on this form will be considered for 

reimbursement. 

3. Make sure that all sections are completed, that you and the providers(s) have signed the form, and that all services, charges, and 

service dates have been entered. If the form is incomplete, additional information may be required. This may result in a delay of 

payment for eligible benefits. 

4. Please submit claim reimbursement for each patient on a separate claim form. 

5. Please note that the member’s (or employee’s or authorized person’s) signature is required on this form. 

6. Mail completed claim form to: Vision Care Processing Unit, P.O. Box 1525, Latham, NY 12110. 

7. The completion and submission of this form does not guarantee eligibility for benefits. Please verify your coverage with your benefits office 

or call 1-800-999-5431 or visit www.davisvision.com. The patient is responsible for the costs of all treatment and materials provided. 

8. FOR PATIENTS RESIDING IN TN ONLY: Tennessee state law stipulates that it is a crime to knowingly provide false, incomplete or 

misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and 

denial of insurance benefits. 

Member/Employee Information * Your Member Identification No. is the number by which the company that sponsors your vision care benefits identifies you. 

(PLEASE PRINT CLEARLY) 

Member Name: _____________________________________________________________ Member Identification No*.:______________________ 

First Middle Initial Last 

Mailing Address: _____________________________________________________________________________________________________________ 

Street City State Zip 

Business Phone: ________________________________________________ Home Phone: _______________________________________________ 

Patient Information 

Patient Name: 

Area Code 

________________________________________________________ 

First Middle Initial Last 

Relationship: Member Spouse Child DOB: ______________ If student aged 19 or over, attach written proof of attendance at school (if required) 

Are you and your spouses benefits both provided by the same agency? Yes No 

Area Code 

FOR INTERNAL USE ONLY 

Auth #: ________________________________ 

Paid Denied Pended 

Provider Information 

Examiner 

Name: ________________________________________________________ 

Address: _______________________________________________________ 

Dispenser 

Name:________________________________________________________ 

Address:______________________________________________________ 

City: __________________________ State: ____ Zip: ________________ City: __________________________ State: ____ Zip: ______________ 

Federal Tax I.D. Number: ________________________________________ Federal Tax I.D. Number: ________________________________________ 

Phone Number:__________________________________________________ 

Phone Number: ________________________________________________ 

Provider Signature: _____________________________________________ 

Member/Employee Certification 

Provider Signature: ____________________________________________ 

Service Date of Service Amount 

1. Eye Examination $ 

2. Frames $ 

3. Single Vision Lenses (not plano) $ 

4. Bifocal Lenses $ 

5. Trifocal Lenses $ 

6. Contact Lenses $ 

7. Cataract S.V. Lenses $ 

8. Cataract Bifocal Lenses $ 

9. Medically Necessary Contact Lenses $ 

Total $ 

I certify that the information on this form is correct and authorize the Provider to release appropriate information necessary to process this claim to plan provisions. Additionally, 

I have read and understand item 8, under Important Information, above. 

Required 

_____________________________________________________________ ___________________ 

Member/Employee or authorized person’s signature 

Date 

SC00015A 1/2/04

Section XI 


Voluntary Plans

VOLUNTARY PLANS 

The Archdiocese offers an opportunity for the lay employees to enroll in several voluntary plans. They 

are: 

♦ 

♦ 

Hartford Supplemental Life Insurance 


The Hartford Supplemental Life Insurance plan will be administered through Hartford. Eligible 

employees should contact their local employer for additional eligibility information. Premiums are paid 

through payroll deductions. 

Employees also have the option of participating in the Northeast Dental Plan of America at a discounted 

membership fee. This insurance carrier will administer the voluntary dental plan. All premiums and fees 

will be billed directly to the employees. 

Hartford Supplemental Life Insurance 

This is an opportunity for the employees to secure additional life insurance that has cash accumulation or 

cash value built into the coverage. An employee must work at least 20 hours to be eligible to participate. 

The premiums are entirely paid by the employee through payroll deduction. The employees should call 

(800) 228-6108 and ask for Laura Gibbons at extension 2201 for further information. The employees 

should contact their local administrator; the Benefits Department at 212.371.1000, Ext. 3026 or the 

Employee Benefits Connections Department at 212.371.1000, Ext. 3060 to obtain a copy of the 

application form. The completed form should be returned to the Employee Benefit Connections, 1011 

First Avenue, Room 1679, New York, NY 10022. 


This plan is composed of a preferred provider network of participating dentists in New York, New Jersey 

and Connecticut. The Northeast Dental Plan of America allows the employees to obtain dental services at 

discounted service fees from network dentists. In order to be eligible for these discounts the employees 

must pay an annual fee directly to the company. This is not an insurance plan and there is no minimum 

participation requirement among eligible employees. There are no payroll deduction requirements. At 

present the annual fees are: 

Single Employee $ 60.00 

Two Person $120.00 

Family $140.00 

To participate in this plan, an employee should call Northeast at either (800) 828-2222 or 

(212) 688-5555 and request an enrollment package for an employee of the Archdiocese of New York. 

- 51 - 11/08


SUPPLEMENTAL LIFE INSURANCE - Policy #GL-674263 

Eligibility 

Options 

Employee must be enrolled in basic group life insurance sponsored by the Archdiocese of New York and 

assigned to work 20 hours or more weekly. 

Employee may purchase additonal life insurance in $10,000 increments on his/her life to the lesser of 5x 

of his/her basic annual salary to the lesser of $500,000. A participant may purchase amount up $150,000 

(guarantee issue) without completing a Personal Health Statement. 

Employee may also purchase additional life insurance on the life of his/her spouse in $5,000 increments 

to a maximum of $100,000 (not to exceed 50% of employee's supplemental life benefit). The 

employee may purchase the spouse's supplement insurance up to $50,000 (guarantee issue) without 

completing a Personal Health Statement for the spouse. 

Employee may also purchase additional life insurance on the life of his/her dependent child (up to age 

19 ) in increments of $2,000 to the maximum of $10,000. (Employee must purchase same amount for 

each child). 

Evidence of 

Insurability 

Beneficiary 

Designations 

Premium 

Payments 

Suicide 

Exclusion 

Clause 

Accelerated 

Death Benefit 

Conversion 

A Personal Health Statement will be required for purchase amounts exceeding $150,000 on the life of 

employee and $50,000 on the life of dependent spouse. This form is also required for late entrants 

(employees who did not elect enrollment during eligibility period-usually 31 days from the date of hire or 

change in family status). 

The names and relationships of employee's primary and secondary beneficiaries must be provided. The 

employee must be the beneficiary for the spouse and dependent child coverages 

Premiums wil be paid through payroll deductions. This benefit also has the Premium Waiver feature in 

the event the employee becomes disabled prior to age 60. Premium waiver continues until employee no 

longer disabled or normal retirement age. Premium Waiver for spouse & dependent child is available 

only if employee qualifies for waiver . 

Payment of full face amount will be incontestable if death is caused by suicide within two years of the 

effective date of coverage. 

Yes. Up to 80% of Life amount with minimum of $10,000 to maximum of $500,000. Must have a life 

expectancy of 12 months or less. Also available for spouse up to 80%of Life amount to max of 

$50,000. 

Participant may convert benefit to individual coverage within 31 days of a qualifying event up to the same 

amount of coverage that was in place prior to qualifying event. Available to spouse & dependent child. 

Portability 

Participant may port 50%, 75% or 100%of amount of insurance being termed due to a qualifying event 

without evidence of insurability. Employee port amount not to exceed $250,000. Also available to 

spouse up to $50,000 and dependent child up to $10,000. 

Rates per 

$1,000 Age Employee Spouse Dependent Child 

Supplemental Term Life Insurance 

FOR EMPLOYEE TO COMPLETE 

Employee Name (last name, first, middle initial) 

GROUP PLAN #: GL-674263 

Employer Name: Archdiocese of New York 

Location Name: 

Employee Address (street, city, state, zip code) Social Security Number Date of Birth 

Annual Earnings Date of Employment Marital Status Sex 

Single Divorced Male 

Married Widowed Female 

BENEFIT SELECTION 

Choose any amount from $10,000 to $500,000 for yourself (in increments of $10,000) not to exceed five times your 

annual salary. For amounts over the Guarantee Issue Amount ($150,000) a Health Statement is required. 

______ x Basic Annual Earnings 

Other $ ______________ 

Choose any amount for your spouse from $5,000 to $100,000 (in increments of $5,000). Not to exceed 50% of 

Employee Supplemental Life Benefit. For amounts over the Guarantee Issue Amount ($50,000) a Health 

Statement is required. 

Amount $ _______________ Name of Spouse: _______________________ Birth Date: ___________ 

Select an amount from $2,000 to $10,000 (in increments of $2,000) for each dependent child. Each child in a 

family must be insured for the same amount. 

Amount per Child $ _______________ 

Names of Child(ren) Birth Dates Relationship 

Name of Primary Beneficiary: _______________________________ 

Secondary Beneficiary: _____________________________________ 

Relationship: __________________ 

Relationship: __________________ 

I hereby apply for the coverages I have indicated above on behalf of myself and all dependents listed. 

I authorize my Employer to make the appropriate deductions from my salary or wages to pay for the cost. 

I understand that the coverages available to me are in accordance with the provisions of the contract. 

Employee Signature 

Date 

IMPORTANT: INTERNAL OFFICE AND WAIVER INFORMATION REQUIRED ON BACK OF FORM

INTERNAL USE ONLY 

Institution Name: 

Institution Number: 

Street Address: 

City: State: Zip: 

Claim Division Number: 

Insurance Effective Date: 

Covered by Collective Bargaining Agreement? Yes No 

WAIVER OF SUPPLEMENTAL LIFE INSURANCE 

Employee Name ___________________________________________________ 

(Please Print) 

I have been given an opportunity to apply for Supplemental Life Insurance as offered by my 

Employer and have decided not to take advantage of this offer for myself and all eligible 

dependents. 

Should I desire to apply for this insurance in the future, I realize that satisfactory evidence 

of insurability must be furnished to the Insurance Company at my expense. I understand 

that the Insurance Company reserves the right to reject such future application. 

Employee Signature 

Date 

Suicide Exclusion 

This plan includes a Suicide Exclusion for employees and dependents. It applies to 

coverage amounts which became effective within two years of the date of death.

SAMPLE FORM 

This is a Sample for not to be used for an actual enrollment. 

Contact Hartford Life at 1.800.331.7234 for a valid enrollment form

PERSONAL HEALTH APPLICATION 

Thank you for choosing The Hartford. All sections of this form must be completed and received by The Hartford within 30 days 

of the signature date. 

Employers: Please completely fill out Section 1 and Section 2 on this page and forward the entire form to the employee. Refer to 

your Policy and employee records for this information. These records are your property and are not on file with The Hartford. An 

incomplete form will result in a delay in processing your employee’s request for insurance. 

Section 1: Employer Details (to be completed by Employer) 

Employer Name: 

PLEASE PRINT CLEARLY 

Policy Number: 

Division (if applicable): 

Employer Mailing Address (Street, City, State, Zip Code): 

Benefits Contact Name (First, Last): 

Benefits Contact Email Address: Benefits Contact Phone: ( ) - 

Section 2: Employee Details (to be completed by Employer) 

Employee Name (First, MI, Last): 


Base Annual Earnings*: Social Security Number: - - Date of Hire (mm/dd/yyyy): / / 

* Base annual earnings as described in the contract with The Hartford. 

Coverage Details 

• Check the applicable box(es) in each row to reflect the applicant’s current coverage and new election. 

• Enter the amount of any existing coverage (including Guarantee Issue (GI)**) in Current Coverage. Please include the current 

amount of Basic Life coverage even if the applicant is not requesting Basic Life coverage at this time. 

• Enter the amount of Additional Coverage Requested that requires medical underwriting. 

• Enter the Total Coverage Amount that will be in force if the additional coverage requested is approved. 

• If the applicant is enrolling after his/her initial eligibility period and does not have current coverage they will be responsible for 

all fees incurred during the medical underwriting process. 

Current Coverage 

(including GI Amount) 

Additional Coverage 

Requested 

Total Coverage Amount 

Life Insurance Coverage Enter all amounts as dollars. Include Basic Life Current Coverage Amount 

even if not requesting this coverage type. 

Employee Basic Life $ $ $ 

Employee Supplemental or Voluntary Life $ $ $ 

Spouse Basic Life $ $ 

$ 

Spouse Supplemental or Voluntary Life $ $ $ 

Disability Insurance Coverage 


Enter all amounts as dollars or as percentage of Base Annual Earnings 

** Guarantee Issue (GI) is the maximum amount of coverage, as defined in the contract with The Hartford, which does not require 

evidence of good health. 

Is the employee electing an amount greater than 

$15,000 for a child? Yes No 

Number of Children: Amount Requested Per Child: $ 

Employees: Please complete pages 2 thru 5. It should take you about 10 minutes to complete this form. 

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident 

Insurance Company. Policies in New York are underwritten by Hartford Life Insurance Company. 

PA-9199 

(Rev. 3/07) 1 of 5

Applicant Section: Please answer all questions on this page completely and accurately and certify your answers on page 4. 

Leaving information blank will result in delays and may result in your file being closed. 

Section 3: Employee Information (Complete even if employee is not applying for coverage) PLEASE PRINT CLEARLY 

First Name: Last Name: Social Security # : - - 

Home Mailing Address (Street, Apt. #): 

City: 

State: Zip Code: Employer: 

Daytime Phone: ( ) Evening Phone: ( ) Height: ___Ft. ___In. Weight:________ lbs. 

Gender: 

Date of Birth: / / 

M F 

Email Address: 

Section 4: Spouse Information (Complete only if applying for this coverage) 


First Name: Last Name: Social Security # : - - 

Daytime Phone: ( ) Evening Phone: ( ) Height: ___Ft. ___In. Weight:________ lbs. 

Gender: 

Date of Birth: / / 

M F 

Email Address: 

Section 5 – Medical Information (to be completed only by applicants required to provide evidence of good health) 

If you or anyone proposed for coverage can answer Yes to any of the Questions below, check the appropriate box and provide additional 

details in Section 6. If you are a resident of one of the following states: Connecticut, Florida, Kentucky, Maine, Maryland, Minnesota, 

New York, North Carolina, Vermont, or Wisconsin then please go to the State Variable Question section on page 3 and answer or review the 

appropriate question for your state. After you have read that information, proceed with completing this section. 

1. Within the past 5 years, with the exception of a past pregnancy, have you lost time from work for more than 

10 work days for the same physical, mental, or emotional condition, disability, injury, or sickness? 

Employee Spouse 

2. Within the past 5 years, have you used any controlled substances, with the exception of those prescribed by 

your physician, received medical advice or sought treatment for drug or alcohol abuse, or been charged with Employee Spouse 

operating a motor vehicle under the influence of drugs or alcohol? 

3. Are you currently undergoing any diagnostic testing for symptoms without a final diagnosis or resolution? Employee Spouse 

4. Are you currently pregnant? If yes, what was your pre-pregnancy weight?_________ lbs. Employee Spouse 

5. During the past 5 years have you been diagnosed with or treated by a member of the medical profession for 

Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or any other immune Employee Spouse 

deficiency disorder? 

6. During the past 5 years have you been diagnosed with, treated for, treated with, or had any symptoms due to any of the following 

conditions or treatments listed below? Please check all that apply: 

Employee Spouse Employee Spouse 

Heart-Related Surgery or Heart Attack 

Crohn’s Disease 

Stroke 

Kidney Failure/Dialysis 

Heart Disease (excluding high blood 

pressure & heart murmur) 

Hepatitis (excluding Hepatitis A) 

Blocked Arteries (including 

arteriosclerosis, atherosclerosis, aneurysm, 

Diabetes 

or deep vein blood clot) 

Chronic Obstructive Pulmonary Disorder 

(COPD) 

Knee Disorder, Injury, or Surgery 

Emphysema 

Back or Neck Disorder, Injury, or Surgery 

Adjustment Disorder 

Joint/Ligament Disorder, Injury, or Surgery 

Bipolar Disorder 

Osteoporosis or Osteopenia 

Depression (single episode) 

Multiple Sclerosis (MS) 

Depression (multiple episodes) 

Amyotrophic Lateral Sclerosis (ALS) 

Psychotic/Personality Disorders 

Muscular Dystrophy 

Other Mental/Nervous/Psychiatric 

Disorders (including Anxiety) 

Arthritis 

Cancer (excluding Basal Cell Carcinoma) 

Fibromyalgia 

Cirrhosis 

Chronic Fatigue Syndrome 

Ulcerative Colitis 

Sleep Apnea 



PA-9199 


Employee: First Name_____________________________________ Last Name_____________________________________________ 

Section 5 Continued: State Variable Questions 

For residents of Connecticut, Florida, Kentucky, Maine, Maryland, Minnesota, New York, North Carolina, Vermont, and Wisconsin review 

or answer, where applicable, the question listed below instead of the corresponding question listed in the Medical Information section on 

page 2. Any “Yes” responses can be explained in the Additional Details section of this form. Once you have reviewed/answered these 

questions, please return to Section 5 and proceed with completing the rest of the form. 

Information to be Reviewed 

Florida, Kentucky, and Maryland Residents- Please review this question prior to answering Question 6 in the Medical Information 

Section on Page 2: 

Question 6: During the past 5 years have you been diagnosed with, treated for, or treated with any of the following conditions or treatments 

listed below? Please check all of the conditions on page 2 that apply. 

Maine Residents- Please review this statement prior to answering the medical questions in Section 5 on Page 2: 

You are not required to disclose whether you have been tested for HIV, if you have not developed symptoms of the disease AIDS or 

ARC, in your answer to any of the questions in the Medical Information section. 

Minnesota Residents- Please review this statement prior to answering the medical questions in Section 5 on Page 2: 

You need not disclose an HIV (aids virus) test which was administered: (1) to a criminal offender or criminal victim as a result of a crime 

that was reported to the police; (2) to a patient who received the services of emergency medical services personnel at a hospital or medical 

care facility; (3) to emergency medical personnel who were tested as a result of performing emergency medical services. 

Please review this question prior to answering Question 6 in the Medical Information Section on Page 2: 

Question 6: During the past 5 years have you been diagnosed by a physician with, treated for, or treated with any of the following 

conditions or treatments listed below? Please check all of the conditions on page 2 that apply. 

Questions to be Answered 

Connecticut and Minnesota Residents: Do not answer Question 2 in the Medical Information section. Answer the following 

question below. 

Question 2: Within the past 5 years, have you used any controlled substances, with the exception of those prescribed by your physician, 

received medical advice or sought treatment for drug or alcohol abuse, or been convicted of operating a motor vehicle under the influence of 

drugs or alcohol? Employee Spouse 

Florida residents: Do not answer Question 5 in the Medical Information section. Answer the following question below. 

Question 5: Have you ever tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the HIV 

infection or other sickness or condition derived from such infection or had unexplained weight loss or enlarged lymph nodes? 

Employee 

Spouse 

New York Residents: Do not answer Question 5 in the Medical Information section. Answer the following question below. 

Question 5: During the past 5 years have you been diagnosed with or treated by a member of the medical profession for Acquired Immune 

Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or any other immune deficiency disorder excluding HIV? 

Employee 

Spouse 

North Carolina Residents: Do not answer Question 5 in the Medical Information section. Answer the following question below. 

Question 5: Have you ever been diagnosed or treated by a member of the medical profession for Acquired Immune Deficiency Syndrome 

(AIDS) or AIDS Related Complex (ARC) or any other immune deficiency disorder? AIDS Related Complex (ARC) is a condition with 

signs and symptoms which may include generalized lymphadenopathy (swollen lymph nodes), loss of appetite, weight loss, fever, oral 

thrush, skin rashes, unexplained infections, dementia, depression, or other psychoneurotic disorders with no known cause. “Disorder of the 

Immune System” includes the hyperimmune conditions, disorders of gammaglobulin synthesis (hypogammaglobulinemia), of white blood 

cell production and maturation, and the immune-deficiency disorders both congenital and acquired. Also included in disorders of immunity 

are lupus erythamatosus, Grave’s Disease, rheumatoid arthritis, primary biliary cirrhosis, and others. 

Employee 

Spouse 

Vermont Residents: Do not answer Questions 3 or 5 in the Medical Information section. Answer the following questions below. 

Question 3: Are you currently undergoing any diagnostic testing (excluding prior HIV related testing) for symptoms without a final 

diagnosis or resolution? Employee Spouse 

Question 5: Have you been diagnosed as having or been treated for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related 

Complex (ARC) by a licensed medical physician? 

Employee 

Spouse 

Wisconsin Residents: Do not answer Question 3 in the Medical Information section. Answer the following question below. 

Question 3: Are you currently undergoing any diagnostic testing, excluding AIDS or HIV tests, for symptoms without a final diagnosis or 

resolution? Employee Spouse 

Please proceed with completing the rest of the medical questions on Page 2 once you have completed/reviewed this page. 



PA-9199 


Employee: First Name_____________________________________ Last Name_____________________________________________ 

Section 6: Additional Details: If you or anyone proposed for coverage checked any box related to Questions 1 – 6, please provide 

details in the space below. If you need more space, please attach, sign and date an additional sheet. The Hartford may contact you for 

additional or missing information. 

Question # 

or Condition 

Applicant Name 

Medications/ 

Treatment 

Date of 

Diagnosis 

Date of Last 

Symptom 

Current Status 

of Condition 

Physician’s Name, Address, and 

Phone # 

Section 7: Health Question Certification Statement (To be completed by all applicants) 

By checking this box: Employee Spouse 

I hereby certify that I have reviewed each of the above questions and conditions. 

I also certify that I have checked all of the questions and conditions that apply to my health history. 

Section 8: Authorization (To be reviewed by all applicants) 

New York Residents: I understand the Medical Information Bureau, Inc. will release records or information only to The Hartford. I 

authorize The Hartford to give information about me to: its reinsurer(s); the Medical Information Bureau, Inc.; any other insurance company 

to whom I may apply for Life or Health Insurance; or other persons or organizations handling a claim, underwriting coverage applied for or 

administering coverage issued as a result of this application; or as required by law. 

I understand that upon written request I may revoke this authorization except to the extent that action has already been taken in reliance on 

this authorization. This authorization expires 24 months from the date of this application. I understand that a photocopy of this form is as 

valid as the original and that I have a right to receive a copy of this form upon request. 

Residents of All States Except New York: I understand the Medical Information Bureau, Inc. will release records or information only to 

The Hartford. I authorize The Hartford to give information about me to: its reinsurer(s); the Medical Information Bureau, Inc.; any other 

insurance company to whom I may apply for Life or Health Insurance; or other persons or organizations handling a claim, underwriting 

coverage applied for or administering coverage issued as a result of this application; or as required by law. 

I understand that upon written request I may revoke this authorization except to the extent that action has already been taken in reliance on 

this authorization. This authorization expires 24 months from the effective date of my coverage or, if no coverage has been issued, one (1) 

year from the date of this application. I understand that a photocopy of this form is as valid as the original and that I have a right to receive 

a copy of this form upon request. 

Additional Language for Maine Residents: This authorization excludes disclosure of the result of a test for HIV if the applicant has not 

developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in this caveat will prohibit this 

authorization from including the fact that the applicant has AIDS or ARC. I understand that my failure to sign this authorization may 

impair the ability of The Hartford to process this application or evaluate claims and may be a basis for denying this application or a claim 

for benefits. 

Additional Language for Minnesota Residents: This authorization excludes the release of information about HIV (AIDS Virus) tests 

which were administered (1) to a criminal offender or criminal victim as a result of a crime that was reported to the police; (2) to a patient 

who received the services of Emergency Medical Services personnel at a hospital or medical care facility; or (3) to emergency medical 

personnel who were tested as a result of performing emergency medical services. The term “Emergency Medical Personnel” includes 

individuals employed to provide pre-hospital emergency services; crime lab personnel, correctional guards, including security guards at the 

Minnesota security hospital, who experience a significant exposure to an inmate who is transported to a facility for emergency medical care; 

and other persons who render emergency care or assistance at the scene of an emergency, or while an injured person is being transported to 

receive medical care and would qualify for immunity under the Good Samaritan Law. 



PA-9199 


Employee: First Name___________________________________ 

Last Name____________________________________________ 

Section 9: Certification (To be reviewed by all applicants) 

Residents of All States: I hereby certify (“represent” for Kansas residents) that all statements and answers contained herein, are full, 

complete, and true to the best of my knowledge and belief. 

Residents of All States Except New York: I also understand that any misrepresentation contained herein or relied upon by the company 

may be used to contest the validity of the coverage, within the contestable period if such misrepresentation materially affects acceptance of 

the risk. This information may be used by The Hartford for plan administration purposes to decide if the person(s) is/are eligible for 

coverage. 

I understand that coverage will not become effective until The Hartford grants it’s underwriting approval. I do not receive temporary or 

conditional insurance coverage just because I submit an application and pay the first premium. 

I agree that this document and all its contents shall form a part of my request for group benefits. 

Section 10: Fraud Statement (To be completed by all applicants) 

Residents of All States Except California, Pennsylvania, and New York: Any person who knowingly presents a false or fraudulent claim 

for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be 

subject to fines and confinement in prison. 

California Residents: For your protection, California law requires the following to appear on this form: any person who knowingly 

presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. 

Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application 

for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information 

concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects a person to criminal and civil 

penalties. 

New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application 

for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information 

concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to 

exceed five thousand dollars and the stated value of the claim for each such violation. 

Notice: To the best of their knowledge, an Applicant is required to notify The Hartford in writing of any changes in any applicant’s medical 

condition between the date the Applicant signs this form and the date the coverage is approved. 

___________________________________ 

Employee’s Signature 

or Legal Representative/ Relationship to 

Employee (Required) 

____/____/____ 

Date Signed 

____________________________________ 

Spouse’s Signature 

or Legal Representative/Relationship to Spouse 

(Required only if applying for coverage) 

____/____/____ 

Date Signed 

Please return the completed Employer and Employee sections to: 

The Hartford, Medical Underwriting 

P.O. Box 2999 


After submitting this application, you can check your status on line at www.TheHartfordAtWork.com. 

If you have any questions or concerns, please call The Hartford Customer Service Department toll-free at 

1-800-331-7234, Monday through Friday, 8:00 a.m. to 6:00 p.m., Eastern Time, or email us at medical.uw@hartfordlife.com. 



PA-9199 


NORTHEAST DENTAL PLAN OF AMERICA 

Enroll by Phone (via Credit Card) & Receive Immediate Benefits 

(800) 828-2222 or Fax us (212) 688-9708 

845 Third Avenue – 20 th Floor - New York, NY 10022 

SPECIAL APPLICATION FOR EMPLOYEES OF THE 


• Membership cards will be mailed to you within 5 to 10 business days. 

• Your membership is valid for 12 months. Renewal notices are mailed 

approximately 45 days prior to your renewal date. 

• Most current NDPA information can be obtained via our Web Site at 

www.dentalsave.com. 

Please Check Annual Membership Fee: 

___Single $60.00 ___Couple $120.00 ___Family $140.00 

(any 2 household members) (3 or more household members) 

LAST NAME_________________________ FIRST NAME_________________ M.I. __ 

ADDRESS_____________________________________________________________________ 

CITY_______________________________ STATE__________________ ZIP______________ 

HOME PHONE (____) ________________ DAY/WORK (____) _________________________ 

SOCIAL SECURITY #________________ E-MAIL ___________________________________ 

Other Household Members 

Name________________________________ Relationship_______________________________ 



Name________________________________ Relationship______________________________ 

The Dentist I have selected from the Directory of Dentists is: 

Name_________________________________________________________________________ 

Address___________________________ City____________________ State________________ 

Enclosed is my payment for: $ ____________ 

I am paying by: ___ Check 

___ Money Order ___ Discover ___ Master Card ___ Amex ___Visa 

Card Number: ___________________________________ Expiration Date: ________________________ 

=============================================================== 

For Office Use Only: Rep/574 ____________ Check # ____________ 

- 53 -

IMPORTANT NOTICE 

The Archdiocese of New York reserves the right to modify or discontinue any 

of the group plans at any time. 

The benefits described in the Resource Guide are subject to the terms, 

conditions, limitations, and exclusions of the plan contracts issued by the 

individual insurance carriers to your group. If a difference exists between the 

information in the Resource Guide and the actual contract, the contract 

governs. 

Participation in any of the group plans is limited to individuals who otherwise 

satisfy the specific eligibility requirements for such group plans, and are 

either (i) employed by the Archdiocese of New York; or (ii) employed by an 

institution or agency properly listed in the Official Catholic Directory, which 

has adopted and participates in such group plans with the consent of the 

Archdiocese of New York. 

Nothing contained in this guide should be construed as creating an 

employment relationship of any kind between the Archdiocese of New York 

and any individual, nor should it be interpreted as affecting any employment 

relationship between an employee and his or her actual employer. 

- 54 -

the archdiocese of new york benefits administration resource guide

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