Certificate of Insurance

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

• Zurich Travel Assist offers comprehensive, world travel service, when you travel 100 miles or more from home. View the benefit summary or the complete Zurich Travel Assist brochure.

• Zurich Travel Assist provides a familiar standard of care in an unfamiliar place, putting you in contact with resources to get the medical, personal, informational and legal help needed for vacation or business travel.

• Your family members are eligible, too, provided you carry AD&D Family Plan coverage.
Eligibility

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

Enrollment

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

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

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

* To enroll domestic partners, you will need to complete an Affidavit of Domestic Partnership attesting to the relationship. Contact your Benefits Office for more information.

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

Coverage

* You may select coverage (Principal Sum) of $25,000, $50,000, $100,000, $150,000, $200,000 or $250,000.
* Coverage in excess of $200,000 may not exceed 10 times your annual salary.
* Under the Family Plan, dependent family members are covered at a percentage of your Principal Sum amount.
* At age 70, your coverage reduces to a percentage of the Principal Sum.
* This insurance does not cover any loss resulting from intoxication or while under the influence of alcohol or controlled substance unless administered on the advice of a physician and taken in the prescribed dosage.
* For limitations and exclusions, please refer to the certificate.

Premium

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

Program Features

o This insurance will pay benefits according to the Schedule of Coverage
o Education and training benefits for your spouse and dependent children if you are enrolled in the Family Plan at the time of your death.
o If you and your spouse suffer loss of life as result of a common accident while enrolled in the Family Plan, your spouse's coverage is equal to yours, to a combined maximum of $250,000
o A monthly payment for your spouse, in addition to the Principal Sum for the year following your death, if you select the Family Plan.
o If you become permanently and totally disabled within 180 days of an injury and conditions are met, you may be eligible for a Principal Sum payment.
o Special Air Ambulance coverage extension is available at additional cost for employees who ride on or operate the university air ambulance.
o A person covered in the plan may apply for pilot coverage.
o Continuation of insurance in the group plan is available at a reduced level of coverage for those retiring from the University.
o Conversion of coverage to an individual plan with the insurance company is available for those under age 70 who terminate employment or end an eligible position.
o Zurich Travel Assist puts you in touch with a global network of providers that can address medical, legal, in formational and personal assistance needs when traveling 100 or more miles away from home.
FAMILY PLAN

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

Spouse:
The spouse's coverage would be 50% of the Principal Sum, provided there are no covered children at the time. If there were covered children, the spouse's coverage would be 45% of the Principal Sum.

Children:
Each dependent child would be covered for 10% of the Principal Sum if there were a covered spouse, subject to a maximum of $25,000. If there were no covered spouse, each child's coverage would be 20% of the Principal Sum, subject to a maximum of $37,500.
COVERAGE FOR AGE 70 or OLDER

At age 70 the Principal Sum reduces to a percentage of the Principal Sum available prior to age 70. For example:
Age 70-74 65%
Age 75-79 45%
Age 80-84 30%
Age 85 and over 15%
SCHEDULE OF COVERAGE
FOR LOSS OF

AMOUNT
Life The Principal Sum
Both hands or feet, sight of both eyes The Principal Sum
One hand or foot and sight of one eye The Principal Sum
One hand and one foot The Principal Sum
Speech and hearing The Principal Sum
One hand or foot or sight of one eye One-half Principal Sum
Speech or hearing One-half Principal Sum
Thumb and index finger of same hand One-quarter Principal Sum


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

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