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June 2007- 1 -

Table of ContentsCustomer Service Information

Aetna Plan Sponser Services ........................................................................................................................... 2Aetna Marketing ............................................................................................................................................. 3Aetna Disability Service Center ...................................................................................................................... 4Evidence of Insurability .................................................................................................................................. 4Forms and Supplies ......................................................................................................................................... 5

EnrollmentService Fee Billing

Definitions of Service Fee Invoice Fields ........................................................................................................ 2Sample Forms .................................................................................................................................................. 4

Summary BillingCustomer Identification Information ............................................................................................................... 2Insurance Information ..................................................................................................................................... 3Remittance Information ................................................................................................................................... 4Instructions for Completing a Billing Statement ............................................................................................. 4Rate Changes........................................ ................................................................................................................ 6Revisions – New Lines of Coverage ................................................................................................................ 7Sample Forms .................................................................................................................................................. 8

Disability CoverageShort Term Disability Benefits ........................................................................................................................ 1Long Term Disability Benefits ........................................................................................................................ 2Completing a Disability Employee Request Form .......................................................................................... 2Evidence of Insurability .................................................................................................................................. 5Completing an Evidence of Insurability Statement for Disability Coverage .................................................. 6Sample Forms .................................................................................................................................................. 7

June 2007-1-- 1 - May 2007-1- February 2007

Customer service information This section provides information and instructions for contacting us when you have a question or a problem with your group plan. It also provides instructions for ordering additional forms when needed.

Important: When contacting Aetna, please be prepared to give the person assisting you certain information specific to your group plan. For example, be prepared to provide your plan’s control, suffix and account number or group number whenever you make a call. If you are calling in regard to an employee matter, be prepared to provide the employee’sSocial Security number. Having this information readily available willhelp avoid delays in customer service.

General inquiries For questions or problems concerning your Billing Statement (e.g.,Summary Statement or Service Fee Invoice) or any other aspect of the administration process not covered in this manual, or for which a specific address or phone number has not been provided, contact the following in the order of presentation:

• Your servicing Aetna claims office (if it involves a claims issue).

• Your Aetna service representative.*

• The Customer Service Unit or contact name as it appears on your Billing Statement.*

• Or, you can write to the Aetna Plan Sponsor Services location that services your group plan.

* Contact your Aetna service representative when you have a question related to the renewal of your group plan. Otherwise, direct all calls, except for claims or benefits questions, to the Customer Service Unit at the toll-free number listed on your Billing Statement.


* Please note that this number is for the group benefits administrator or someone who has the authority to act on behalf of your company. This number is not for release to employees. Employee claims and benefits questions should bedirected to the toll-free number shown on the employee’s ID card.

Eligibility/enrollment information: Forward completed application information to the designated address on the application. Applications should be forwarded as soon as possible to ensure timely processing and accurate billing information. Questions regarding eligibility may bedirected to Plan Sponsor Services.

Payments: Payment of monthly Billing Statements should be forwarded to the address on the invoice. A copy of the invoice should be included to expedite the processing of your payment.

HMO claims/reimbursements

If a member receives a bill for covered services or wishes to submit a reimbursement for eyeglasses/contacts or prescriptions, he/she should send the itemized bill for payment with his/her member ID number clearly marked to Claims Reimbursements as indicated on the employee’s ID card:

Aetna Health Inc. Attn: Claims Reimbursement P.O. Box 14089 Lexington, KY 40512-4089

Aetna Health Inc. Attn: Claims Reimbursement P.O. Box 981107 El Paso, TX 79998-1107

Members should call the Member Services toll-free number on their ID cards with questions about claims. Members in the Quality Point-of-Service® (QPOS®) program should use the special claims envelope for this program when submitting a claim for an out-of-network provider.


Aetna - plan sponsor services

Mailing Address: ____________________________________________________________________

Enrollment/Changes: Phone: (________)___________________________

Fax: (________)___________________________

Control: __________________ Suffix: ___________________ Account: ____________________

Aetna - marketing

Marketing Office:

Phone: (_______)_______________________ Service Representative

Fax: (________)_________________________


Aetna disability service center

Temporary Disability Coverage: Please send all STD Disability Employee Request forms and STD Disability Employer Verification forms to:

Aetna Disability Life Insurance Company PO Box 14560 Lexington, KY 40512-4562 866-667-1987 (fax)

If you have a question concerning the filing of a claim for short-term disability benefits or need to check on the status of a short-term disability claim, call or fax us at the following toll-free numbers:

Plantation, FL Service Center 1-800-688-6820 Non Family Medical Leave 1-800-552-5506 Family Medical Leave

Portland, OR Service Center 1-877-832-8241 Non Family Medical Leave 1-800-391-6111 Family Medical Leave

South Portland, ME Service Center 866-326-1380 Non Family Medical Leave 866-326-1379 Family Medical Leave

Evidence of insurability

Evidence of Insurability for Life Insurance and/or Disability Coverage: Please send all Evidence of Insurability Statements to:

Aetna Life Insurance Company Aetna Medical Underwriting Department

P.O. Box 14551 Lexington, KY 40512-4511

If you have a question concerning an Evidence of Insurability Statement or simply want to check on the status of a statement, call or fax us at the following numbers:

1-800-660-9913 (phone) 1-800-792-9710 (fax)


Forms and supplies

The necessary forms will be provided to you by your Aetna service representative for the administration of your plan.

When you need additional forms required for the administration of your group plan, order forms as follows:

EEnnrroollllmmeenntt ffoorrmmss

To order additional enrollment forms, please call your service office representative.

AAllll ffoorrmmss,, ootthheerr tthhaann eennrroollllmmeenntt

If the form number is GR-50000 - GR-59999 or GR-60000 - GR69000, please order additional copies from your Aetna service representative.

If the form number begins with the letters “GC”, please order additional copies and envelopes through the claims office or your Aetna service representative.

June 2007-1-

When Are employees considered late enrollees?

When employees do not elect coverage within the 31-day period followingtheir eligibility date, they are considered Late Enrollees. As a LateEnrollee, the applicant will need to submit evidence of insurability. Pleasesee the Evidence of Insurability chapter for more information.

Active at work rule

If an employee is away from work due to illness or injury on the dategroup disability coverage would otherwise take effect, such coverage willnot take effect until the employee returns to work for one full day.

Probationary period / effective date of coverage

As the employer, you have the discretion to decide whether or how longnewly hired employees must wait in order to be eligible for coverage. Atthis time, you have selected to allow employees to be eligible for coverageon their date of hire. You have also selected to automatically enrollemployees unless they sign a waiver requesting not to be enrolled.

Any employee who signs the waiver within 31 days of their eligibilitydate will be treated as a “late enrollee.” If the employee is a lateenrollee, coverage will be subject to the requirements outlined in the LateEnrollees section that follows.

What is an annual benefits election period?

The Annual Benefits Election Period is the time of year when youremployees can re-evaluate their benefits needs and select the coverage thatbest meets their needs for the following year.

For most companies, enrollment and benefit change activity constitutes thebiggest piece of the administration process. As such, Aetna recommendsthat you familiarize yourself with this chapter. Pay particular attention tothe information that must be included on an Enrollment/Change Requestform in order to prevent potential claim problems caused by delayedenrollment or missing information.

Enrollment

June 2007 -2-

There are ci rcumstances when th e emp loyee must submit eviden ce of

for late applicants.

E vid en c e o f ins u r abi l it y ( E O I )

How do I enroll new employees?

Enrol lm ent can b e mad e an integ ral p art of th e orient ation proce s s fo r new employees. By providing en rollment m ateri al and b en efits lit er ature to your employees when they first b egin work, you ar e assisting th em in making informed benefit dec isions. This als o helps prev ent pote nti al cl aims problems caused by del ayed e nrollment or missing inform ation. If you choo se to make enrollment a p art of th e hiring pro cess, you should provide the follo wing to ne w hire s:

In f orm ati on on t erm i n ati ons or ca n c ell ati ons

When processing a terminatio n or cancellation, pl ease use the dat e the employee’s emp loyment term inates or th e dat e th e employ e e ca ncels his/her cove rage. F or credit transitions (crediting premium), the effectivedate will be limited to 60 days from the date we receive your request.

The d ate the e mployee termin ates o r ca nce ls coverage is th e dat e th e employee ce ases a ctive wo rk, is no long er in an eligible cl ass, or can cels coverage.

There is an import ant d ist in ction between canceling an employ ee’s coverage and terminat ing an employee’ s cover age . Cance l lation should only b e listed when th e emplo yee can cels his/h er cov era ge but r emains active at work. Termination should b e list ed wh en the employee cea ses employ men t or becom es a m emb er of a cl ass of employ e es not eligible for coverage.

1. Enrollment Waiver 2. Booklet/Certificate – Your group policy’s Booklet/Certificate contains

a detailed description of the policy’s benefits and limitations. 3. Privacy Notice – The Privacy Notice describes certain aspects of

A copy of Aetna’s privacy policy appears later in this chapter for your convenience in providing notice to your employees of the policy.

who are covered under an Aetna group insurance policy. Aetna’s insurance privacy policy. This rivacy olicy applies to I p p

good health, referred to as “ Evidence of insurability ( E O I )” in order to be covered under the group policy. Aetn a re q u ire s Evidence of insurability

June 2007-3-

Evidence underwriting is based on the dollar amount of coverage beingrequested. Any employee who is late in applying for Long TermDisability benefits must complete an Evidence of Insurability Statement.They must submit this form for any coverage amount and be approved forthat amount before insurance can become effective.

All requests for additional medical information such as an Attending

expense.

Employees who undergo a family status change and want to add LongTerm Disability coverage are still considered a late applicant. They are

insurance can become effective.

When is evidence required for late applicants?

• Does not enroll for coverage when initially eligible (within 31 days ofcompleting their probationary period).

• Cancels or freezes coverage and then requests an opportunity to re-enroll at a later date.

• Requests to add coverage during the Annual Benefits Election, but didnot enroll when they were initially eligible.

”AA “Late pplicant is an individual who:

Evidence of insurability guidelines for late applicants:

Physician’s Report or a Paramedical Examination will be at the applicant’s

required to submit Evidence of insurability and be approved before

June 2007-4-

Evidence of insurability reports provided by theMedical Underwriting Department:

You may wish to receive a Customer Report tracking the Evidence ofInsurability Statements submitted by your employees. This report willshow the original receive date, who is applying for coverage, the benefitbeing requested and status of the application (pending, approved, denied,etc.)

You can elect to receive one of two types of reports.

Reports can be produced on a weekly basis. If a weekly report is chosen,no individual letters (i.e., approval, denial, or pending additionalinformation) will be provided to the customer. The employee will receiverequests for additional information and denial letters.

If you request a monthly report, individual letters of denial and pendingadditional information will be generated and sent to both the Plan Sponsorand the employee. In addition, the plan sponsor will receive the approvalletters and the report. Approval letters are mailed to the Employer only.An additional cost will apply, per letter, if one is mailed to the employee.

Follow the instructions on the Evidence form making sure that all theinformation in Section A (the Plan Sponsor/Employer’s section) iscompleted. You should indicate zero (0) for the current amount ofcoverage. The application will not be processed without the AuthorizedRepresentative’s signature.

Give the form to the employee for his/her submission to Aetna. Instructthe employee that all the information in Section B (the employee’ssection) must be completed, signed by the employee, and dated. In orderto expedite the processing of the Evidence of Insurability Statement, allinformation on the form must be completed. If any information ismissing, Aetna will return the form to the employee to complete themissing information.

How do I complete an Evidence of Insurability Statement?

June 2007-1-

Service Fee Billing If your group plan includes benefits that are funded through an Administrative Services Contract (ASC), with or without Stop Loss, you will receive an Administrative Services Contract — Service Fee Invoice and/or Stop Loss Invoice (Billing Statement) in advance of your billing due date. The invoice shows the amount due Aetna on or before your payment due date. When you receive your billing statement, you are responsible for updating and reporting the accurate number of lives (volume), along with recalculating the amount due, based on your current reporting for the statement period. The new amount due is the amount you should remit to Aetna on or before the payment due date. The following pages contain the definitions of the fields you will see shown on your billing statement, along with an example of a Service Fee Invoice and Stop Loss Invoice. If you have any questions regarding the information shown on your statement, please contact your Aetna service representative. Important: Whenever your billing statement contains multiple pages, remit all pages and display the total amount due on the last page. All pages must be returned, since those figures are used in the preparation of your employee benefits plans annual financial reports.

June 2007-2-

Definitions of service fee invoice fields

1. Invoice Header Identifies the type of invoice being produced: Administrative Services Contract/Service Fee Invoice, Administrative Services Contract/Stop Loss Invoice. This section also includes the address for you to use when remitting payment. 2. Customer Number The equivalent of the policyholder number. This information should be included on all correspondence to Aetna. 3. Billing Arrangement Number Identifies the billing structure for a particular group of benefits for a customer.4. SFO/Customer TeamIdentifies the servicing field office. The customer team field, when applicable, is a field used for for internal purposes only. 5. Invoice MonthIdentifies the month in which the activity takes place. For example, 12/08 would represent the activity from 12/1/08 to 12/31/08. 6. Prepared DateThe actual date the invoice was prepared. 7. Page Number Some invoices will have multiple lines and require more than one page. A page number will be shown on all pages. 8. Invoice TypeIdentifies the invoice as an Administrative Services Contract or Stop Loss type. 9. Wire Line Number If applicable, identifies the wire line number used to wire transfer funds. 10. RegionInternal use only. 11. Customer Mailing Address The name and address of customer to which the invoice will be sent. 12. Enter Payment TotalThis box should be used to enter the amount of total current due plus any outstanding due amounts not paid to date. (To be filled in by customer.)

June 2007-3-

Definitions of service fee invoice fields (Continued) 13. Coverage Service Describes the benefits or services that are being billed in each service line. 14. Volume The volume equals number of lives for the corresponding benefit/service. 15. Billing Rate/Basis Indicates what rate basis will be used to calculate the premium or fee for a particular benefit or service. • PER EE —Per Employee • NA/Special Charge — A Service Line billed on a flat fee • NS/EE — No Structure Per Employee 16. Amount DueThe amount due for the coverage or service in the service line. 17. Adjustment Amount The adjustment amount will include any adjustments due to retroactive rate changes or volume changes. 18. Amount DueThe total current (month) due including adjustments. 19. Messages If applicable, messages will display pertaining to specific items on the invoice.20. Signature of Contract Holder The signature of the contract holder. 21. Change Space and Mailing Instructions Instructions for changing the mailing address.

June 2007-4-

June 2007-1-

Summary Billing If your group plan is Summary Billed (note — the Summary Billing option may not be available under all group plans), you will receive a billing statement based on the billing frequency of your policy, in advance of the statement due date. Under the Summary Billing process, our administrative system calculates a “Total Premium Due” using the last finalized number of employee and dependent lives and the volume of Life Insurance reported to us. If your group plan does not include Life Insurance, the Total Premium Due will be calculated using only the finalized number of employee and dependent lives from the prior month’s statement. When you receive your billing statement, you are responsible for updating and reporting the accurate number of lives and volume of Life Insurance, along with recalculating the new total premium due based on your current reporting for each statement period. The new total premium due is the amount you should remit to Aetna on or before the statement due date. If you wish to validate your Summary Billing statement membership, please refer to your AAS Audit Certification List. If you do not currently receive an AAS Audit Certification List or if you have any other questions, please contact your Aetna service representative. A Summary Billing statement consists of the Customer Identification, Insurance and Remittance Information sections. A more detailed description of each section, instructions for calculating the Total Premium Due, and an example of a Summary Billing statement are shown on the following pages.

June 2007-2-

Customer identification information

1. Change Space Space to record any address and/or telephone changes. 2. SCD Number A self-checking digit for internal use. 3. Control Number Identifies your account. Consists of the control, suffix and account numbers. This information should be included on all correspondence to Aetna.4. Due Date The due date for which the statement is being prepared and on which payment is to be expected. 5. Account Name The identifying name on the account. 6. Account PhoneYour business telephone number. 7. Servicing Field Office The name and number representing the field office responsible for your account.8. Customer Team Name Applicable to National Accounts customers only. 9. Prep Date The actual date the invoice was prepared. 10. Contact Name The name and phone number of the individual responsible for your group plan. If an individual is not assigned to your group plan, it will show a toll-free number to call. 11. Customer Name and Address Your company’s name and mailing address. 12. Billing Line Name Describes the line of coverage being billed.

June 2007-3-

Insurance information

13. Billing Line Code Internal code for company use to further identify the billing line. 14. Number of Employees Number of employees who are covered as of the due date (to be filled in by the customer). The number in the shaded area reflects the estimated number of covered employees, based on the latest finalized statement. 15. Volume Reflects the total amount of coverage for all covered employees (to be filled in by the customer). The number in the shaded area reflects the estimated volume, based on the latest finalized statement. This amount should be rounded to the nearest dollar and should not include cents. 16. Rate Represents the rate that is charged for the line of coverage. 17. AmountAmount that is due for that line of coverage (to be filled in by customer). The number in the shaded area reflects the estimated total amount, based on the latest finalized statement

18. Adjustment This field should notate errors in payments from previous statements. The error could be a result of incorrect reporting of lives and/or volume. The correction is accomplished by taking a credit or a charge by the appropriate billing line. To avoid any delays in processing your payments, please provide an explanation of the adjustments in the space provided. 19. Explanation of Adjustment When making any type of adjustment exceeding three percent of the total premium, please provide us with an explanation in this space. 20. Total Amount DueThe recalculated amount based on changes or adjustments. If you have a multiple-page statement, the total amount due goes on the last page of the statement. 21. Estimated Amount Due Estimated amount based on the latest finalized statement.

June 2007-4-

Remittance information

22. To properly credit your account, send statement with payment This is an important item; you must include a copy of the entire statement to ensure proper posting of your payment to your account and to avoid any applicable late charges. 23. Lock Box Remittance Address The address to which the payment and completed statement must be sent. 24. Please provide control number on your checkIn order to ensure proper posting of your check, it is very important that you include your group plan’s control number on your check. 25. Signature of an Authorized Company RepresentativeThe statement must be signed by a representative of your company having the proper authority to sign such statement.

Instructions for completing a billing statement

1. Complete Number of Employees Above the shaded area to the right of the asterisk, enter the total number of employees who are covered as of the current statement date. If no one is insured for a specific billing line, enter zero (0) in the appropriate column. Please do not cross out applicable billing lines, even when there are no lives to report.2. Complete Volume, if Applicable Above the shaded area to the right of the asterisk, enter the total volume as of the current statement date. The volume equals the total amount of covered benefits or covered payroll. Entries in this column should be rounded to the nearest dollar amount and should not include cents (correct: 2,175,001 / incorrect: 2,175,000.50). If the number of employees increases, the volume should also increase. Volume is used mainly for non-medical coverage. For example, if you have 10 employees and each has $10,000 worth of life insurance, your total volume would be $100,000. Calculating Volume for Disability

For Short Term Disability:TDI coverage (also called STD coverage) is billed on a benefit basis rather than a payroll basis. Typically, it is billed at $10 of covered weekly benefit. Volume threshold is calculated by: • Multiplying the maximum weekly benefit percentage by the

employee’s weekly salary and comparing it to the plan maximum benefit.

• If the weekly benefit is under the maximum volume threshold, then the volume reported would be the full amount of the benefit.

• If it is over the threshold, the volume reported would be no more than the amount of the plan's weekly maximum benefit.

June 2007-5-

Instructions for completing a billing statement (Continued)

• For example, assume XYZ company has a plan benefit with a 50 percent benefit, while the maximum weekly dollar benefit is $1,000.00. XYZ company also has four employees, as listed below:

Jane Bell, with a weekly salary of $923. Joe One, with a weekly salary of $ 1,846. John Doe, with a weekly salary of $1,038. Deb Smith, with a weekly salary of $2,800.

• The volume is calculated as follows: EE Weekly Weekly Benefit Covered

Salary (Salary x benefit %) BenefitJane Bell $923 $461.50 $461.50 Joe One $1,846 $923.00 $923.00 John Doe $1,038 $519.00 $519.00 Deb Smith $2,800 $1,400 $1,000.00 (plan max) Total Covered Weekly Benefit $2,912.50

For Long Term Disability

LTD (Long Term Disability) is generally billed at $100 of covered monthly payroll. For example, let's assume customer XYZ has a plan of benefits with a maximum monthly benefit of $3,000 and a 60 percent benefit. To determine the volume threshold: • The employer would divide the maximum monthly benefit of $3,000

by .6 (for 60 percent plan). The result would be $5,000 monthly covered payroll threshold.

• Each employee would then be compared to that monthly covered payroll threshold. For instance, company XYZ has three employees who have LTD benefits as listed below:

Jane Bell's monthly salary totals $4,000 Joe One's monthly salary totals $8,000.00

John Doe's monthly salary is $4,500. Comparing to the threshold of $5,000.00, Jane's monthly salary of $4,000 would be reported in full as volume, as it falls below the $5,000 threshold. However, Joe One’s monthly salary is over the $5,000.00 threshold, so the total of $5,000 would be reported as Joe's monthly volume. John Doe’s monthly salary would also be reported in full as it falls under the $5,000 threshold.

• Assuming this customer employed only Jane Bell, Joe One and John Doe, the total monthly volume for LTD would be:

Jane Bell $4,000.00 Joe One $5,000.00 John Doe $4,500.00Total Volume $13,500.00

June 2007-6-

Instructions for completing a billing statement (Continued)

3. Rate Multiply the rate by the entry for the number of employees or volume, whichever is followed by an “X,” and enter the result in the amount column.If your benefit is calculated by volume, multiply the volume by the rate and divide by the rate basis. For example, to calculate the amount for the life benefit on the example above: multiply the volume (100,000) by the rate (.090) and divide by the rate basis ($1,000) = $9.00. If your benefit line is calculated by number of employees, multiply the number of employees by the rate.

Note: Do not enter the result in the adjustment column.

4. The Adjustment Column Use the Adjustment column by each billing line to enter any back charge (+) or credit (-) for prior months. When making an adjustment, please provide an explanation for the adjustment in the space provided at the top of the statement. Credits for retroactive terminations may be limited. Adjustments should be included when calculating the total amount due. 5. Total Amount DueThe recalculated net total of all billing line amounts and adjustments should be entered in the total amount due box, located in the lower right corner on the last page of the statement, if there are multiple pages. Do not total each page. All pages must be returned. 6. ChecksPlease make your check payable to Aetna and remit both the statement and check to the lock box address.

Rate changes Occasionally, it may be necessary to adjust your billing rates. If this happens, you will be notified of the new rates prior to the effective date. 1. If the billing area is notified prior to the effective date of the change,

the revised rates will appear on the next Billing Statement. 2. If the revised rates are not shown on the Billing Statement, you should

adjust the statement to reflect the proper billing rates and calculate the amount due based on the new rates.

3. If the rate change occurs prior to the current billing, but statements have already been paid based on the old rates, you will be informed of any additional amounts due or credits available.

June 2007-7-

Revisions —new lines of coverage

In the event your benefits are being revised (that is, coverages are being added or changed), the current billing statement will reflect the change. If the revision is made before the current effective date and your statements have been paid incorrectly, the following procedures should be followed:1. You will receive re-billed statements back to the effective date of the

change. 2. You should complete the entire re-billed statement and remit the

payment (if applicable) for the difference.

June 2007-8-

June 2007-1-

Disability coverage If your group plan includes disability coverage, employees who are away from work due to disease or injury may be eligible to receive a short-term disability weekly income benefit while they remain absent from work. Once disabled for the elimination period in the policy, employees may also be eligible for long-term disability monthly income benefits. If the employee is eligible to receive a disability income benefit, you are responsible for making sure that the necessary forms to support a claim are filed and submitted properly. The following pages provide information concerning our group disability coverage, instructions for completing the necessary claim and evidence forms, and copies of the forms.

Short-term disability benefits

If an employee is eligible for a weekly short-term disability benefit, the benefit may be based on the percentage you have selected for your group plan, multiplied by the employee’s pre-disability earnings not to exceed your plan’s overall maximum benefit. Benefits will not be payable for more than the maximum payment period (e.g., 13, 26, 39 or 52 weeks). If the employee’s benefits are based upon earnings, it is important that you report all earnings changes to Aetna so that you will be billed for the correct amount of coverage. We recommend that you make this part of your salary adjustment process. This will prevent claim problems due to underbilling when a disability claim is presented. If at any time the employee is eligible to receive “Other Income Benefits” due to his/her absence, the amount that will be paid out under this short-term disability benefit will be reduced by that amount so that the total amount will not be more than your plan’s benefits percentage. Other income benefits: These include benefits that may be payable under the federal Social Security Act. Included are benefits that, due to the employee’s disability or retirement, are payable to the employee, his/her spouse, their children or their covered dependents. Other Income Benefits are considered payable if they are actually received, or if they would have been payable had the employee made a claim for them.

June 2007-2-

Short-term disability benefits (Continued) If the employee is eligible to receive a weekly temporary disability benefit, benefits generally become payable after the first seven calendar days of a disability period due to disease or injury. The above terms apply in most instances; however, some plans do vary. Please refer to the Temporary Disability Income Coverage section of your plan documents for the specific terms that apply to your plan.

Long-term disability benefits

Once an employee has reached his/her maximum short term disability benefit period (e.g. 26 weeks), he/she may be eligible for monthly long term disability benefits. An Aetna rehabilitation consultant will also be available to work with you in returning an employee to work (in same or similar function) when reasonably safe to do so.

Completing the Employee Request For Information form

As soon as an employee (or a relative or friend on the employee’s behalf) notifies you of his/her intent to begin short-term disability or long-term disability (only necessary if Aetna Inc. does not administer or insure your short term disability coverage) you will need to do the following: 1. Give the employee the Employee Request For Information form and

instruct him/her to fill out the Employee portion of the form. You, as a company representative, should complete the Employer Information section and ensure the Employee Information section is properly completed by the employee. This will prevent a possible delay in processing the form. Please refer to the sample of this form later in this section.

June 2007-3-

Completing the Employee Request For Information form (Continued)

• As your company’s representative, please complete the following within the Employer Information section on the form:

• Employer Name, EIN Number and Address • Work Location: Indicate name of your company’s location and its

address.• Supervisor’s Name and Phone Number: Indicate the employee’s

supervisor name and phone number. • Control #: Indicate the six-digit control number assigned to your

company. • Suffix: Indicate the two-digit suffix number assigned to your

location.• Account: Determine the account number that is specific to your

location from the following list and identify it on the form. • STD Plan: Check if for a short-term disability or salary

continuation request.• LTD Plan: Check if for long-term disability coverage only. • Employee’s Name: Indicate full name of the employee. • Employee’s Gender: Indicate gender of the employee. • Employee’s SS#: Indicate the Social Security number of the

employee. • Date of Hire: Indicate the employee’s date of hire. • STD Coverage Effective Date: Indicate the date the employee’s

eligibility for short-term disability or salary continuation became effective. This takes into effect the probationary period the employee would have to satisfy before eligibility becomes effective.

• LTD Coverage Effective Date: Indicate the date the employee’s eligibility LTD coverage became effective. This takes into effect the probationary period the employee would have to satisfy before eligibility becomes effective.

• Date Last Worked: Indicate the date the employee last worked prior to the disability.

• Employee’s Occupation: Indicate the employee’s job title. • Occupation: Indicate the employee’s line of work. • Salary continuation was paid through (date): Indicate date in which

any salary continuation ends.

June 2007-4-

Completing a Disability Employee Request form (Continued) • Reason Employee Ceased Work: Indicate the reason why the

employee is disabled and unable to work. • Employee’s Earnings: Indicate the employee’s earnings as defined

within your plan documents. • Number of Hours Per Week: Indicate the number of hours the

employee was expected to work.

Note: Earnings and number of hours worked are necessary for Aetna to calculate the LTD benefit the employee would be entitled to should he or she become eligible for LTD benefits in the future.

• Enter the amount of premium the employee pays toward the cost of medical, life, or other coverage that is to be deducted from the employee’s disability payment. Then, for each deduction, indicate the percentage that should be deducted on a pre-tax or post-tax basis.

• Enter the percentage of the cost of short-term disability and/or long-term disability coverage that was deducted from the employee’s pay on a post-tax basis or that you added to the employee’s gross taxable income.

• Amount of Life Insurance (i.e., Basic and Supplemental): Indicate the amount of Life Insurance the employees is eligible for.

• Name and Phone Number of Person Providing the Information Above: Indicate your name and phone number. Note: If Aetna is administering or insuring the short-term disability coverage, there will be a seamless transition into long-term disability status. Once an employee has reached his or her maximum short-term disability benefit period, we will confirm long term disability eligibility and if approved, provide each disabled with monthly benefit payments. There will be no additional forms required to begin this process unless supplemental medical information is required.

2. When you and the employee have completed the form, mail or fax it to the address indicated on the form.

3. Once Aetna has the completed form and reviewed it, a communication will be provided to you indicating the status of the disability. This includes the following:

CERTIFIED DISABILITY: Once all information is collected (job description, Attending Physician Reports, etc.) you will receive notification of approved disability benefit and expected short-term disability duration based on industry standard guidelines.

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Completing a Disability Employee Request Form (Continued)

DENIED DISABILITY: Once all information is collected (job description, Attending Physician Reports, etc.) you will receive notification of denial confirming when disability has not been certified. This denial is based on Aetna’s contractual obligations, plan features (i.e., introductory period requirements) and the nature of disability.

In many routine cases, this will be the extent of the needed information and the employee will return to work on the date indicated. In some cases, however, the expected disability duration stated may only be the first certification. If necessary, Aetna will provide additional notification extending the length of disability as follows: RECERTIFIED DISABILITY: Aetna continues to monitor the employee’s disability through the expected disability duration. Upon determining that the expected disability duration should be extended, you will receive an e-mail notification confirming the additional length of disability certified for the employee. Please note that you should instruct employees to submit forms for occupational and non-occupation based disability. Although we may manage your company’s workers’ compensation program, we will need to receive the information to determine potential candidates for long-term disability coverage.

Evidence of insurability

If an employee does not enroll for short-term disability coverage or long-term disability coverage within 31 days of his/her eligibility date and elects to enroll for coverage later (e.g., during your plan’s next open enrollment period) he or she may be required to complete and submit an Evidence of Insurability Statement for Disability Coverage. (If evidence is also being requested for life insurance, use the combined Life and Disability coverage form. Both are included at the end of this section.)

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Completing an Evidence of Insurability Statement for Disability Coverage

Section A As the employer, you are responsible for completing Section A. When completing Section A, be sure that: • Both the employee’s and your addresses are shown in the spaces

provided.• You have included the employee’s Social Security number. • Section A is signed by a representative of your company having

authority to sign such forms. Once you have completed the above, give the form to the employee for completion of Section B and his/her confidential submission to the Aetna — Medical Underwriting Unit. Upon review of the evidence statement, we will advise you and the employee of our coverage decision. Section B The employee is responsible for completing Section B. The form itself gives the employee step-by-step instructions for completion. When giving the form to the employee, ask the employee to verify the accuracy of his/her address and Social Security Number you have listed in Section A. If the information in Section A is accurate, the employee should complete Section B and send it to the address shown on the form. If the employee does not complete Section B entirely and signs the form, it will be returned to the employee for completion. If the employee has any questions when completing the form, the employee should be instructed to call the Medical Underwriting Unit’s toll-free at the number listed in the Customer Service Information section of this manual.Section C An Aetna representative, upon submission to the Medical Underwriting Unit, will complete this section.

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