the united methodist church tennessee conference nashville ... · full-time: elders, deacons and...

304 S. Perimeter Park Drive, Suite 4 Nashville, Tennessee 37211

(615) 327-1162 or (800) 359-1162

James R. Allen, Director

[email protected]

The United Methodist Church Tennessee Conference Office of Administrative Services

Tennessee Conference Benefits Enrollment Information

If you are newly eligible for participation in the Tennessee Conference Benefits, please review the documents and return the enrollment form(s) to the Office of Administrative Services.

IMPORTANT: If your health/dental plan enrollment form is not received within 31 days of your eligibility, you will not be eligible to enroll in these plans until the next open enrollment period (July). In addition, if your pension enrollment is not received with 60 days of eligibility, your pension benefits may be delayed.

HEALTH PLAN

Eligibility and Premiums – Page 3 2020 Summary Plan Description – Pages 4-9 Enrollment Form – 0 Notice of Availability of Important Documents – Page 11

DENTAL PLAN Summary of dental plans and premiums – Page 12 Voluntary Dental Enrollment Packet – Pages 13 - 18 Prepaid Dental Enrollment Packet – Pages 19 - 30

TENNESSEE CONFERENCE RETIREMENT BENEFITS – CRSP AND UMPIP Clergy Retirement Security Plan (CRSP) at a Glance – Pages 31 - 32 United Methodist Personal Investment Plan (UMPIP) at a Glance – Page 33 Enrollment Form – Pages 34 - 35 Designation of Beneficiary Form – Pages 36 - 39 UMPIP Contribution Agreement – Pages 40 - 43

If you have any question concerning clergy benefits contact the Office of Administrative Services.

Melinda Parker, Assistant Benefits Officer [email protected]

mailto:[email protected]

BENEFITS DISCLOSURE 2020 FULL-TIME: ELDERS, DEACONS and LOCAL PASTORS serving TN churches and clergy on conference payroll and campus ministers (¶344.1(a)(1) appointments).

Eligible for pension benefit (Clergy Retirement Security Program) Paid by the TN Conference *Required 1% contribution to UMPIP to receive the full 3% match from the Tennessee Conference. Refer to CRSP Summary Plan Description for more details. Eligible for Comprehensive Protection Plan (Disability & Death benefit) Paid by the TN Conference *Compensation must be 25% of the Denomination Average Compensation ($18,162 for 2020) Eligible for Health Insurance Paid by the TN Conference Eligible for Optional Dental Benefits Premiums Paid by the Participant THREE QUARTER TIME APPOINTMENTS: ELDERS, DEACONS and LOCAL PASTORS serving TN churches and clergy on conference payroll and campus ministers (¶344.1(a)(1) appointments).

Eligible for pension benefit (UMPIP) Paid by the TN Conference 12% of plan compensation. Plan compensation = salary + cash housing allowance, or 125% of salary if living in parsonage Eligible for Comprehensive Protection Plan (Disability & Death benefit) Paid by the TN Conference *Compensation must be 25% of the Denomination Average Compensation ($18,162 for 2020) Eligible for Health Insurance Paid by the TN Conference Eligible for Optional Dental Benefits Premiums Paid by the Participant ONE HALF OR ONE QUARTER TIME APPOINTMENT: ELDERS, DEACONS and LOCAL PASTORS serving TN churches and clergy on conference payroll and campus ministers (¶344.1(a)(1) appointments).

Eligible for pension benefit (UMPIP) Paid by the TN Conference 12% of plan compensation. Plan compensation = salary + cash housing allowance, or 125% of salary if living in parsonage PART TIME LOCAL PASTORS who are designated by the Tennessee Conference Board of Ordained Ministry as full time students (formerly Student Local Pastors)

Eligible for pension benefit (UMPIP) Paid by the TN Conference 12% of plan compensation. Plan compensation = salary + cash housing allowance, or 125% of salary if living in parsonage Eligible for Health Insurance Paid by the TN Conference Eligible for Optional Dental Benefits Premiums Paid by the Participant

ELDERS & DEACONS ON LEAVE Receive no benefits from the TN Conference. Optional Continuation of Coverage is available at clergy expense for the Tennessee Conference Heath Plan. Contact the Office of Administrative Services for more details. PERSONS IN OTHER EXTENSION MINISTRIES Receive no benefits from the TN Conference

2020 HEALTH PLAN ELIGIBILITY & PREMIUMS ELIGIBILITY: An eligible Plan Participant may be:

A) A clergy or layperson regularly employed 30 or more hours per week (1) who is on the Conference payroll or who is classified by The Conference’s Personnel Policy as a Plan Participant or (2) who is employed by a related ministry. Related ministries are the Area Foundation, Area Office, District Office, Wesley Foundation, and ministries that have entered into a formal covenant relationship recognized by the Conference Trustees; or

B) A clergy under full-time or 3/4 Episcopal appointment to a local United Methodist church within the bounds of the Tennessee Conference; or

C) A clergy who is recognized by the Conference Board of Ordained Ministry as a full-time student and who is serving a 1/4 time Episcopal appointment to a local United Methodist church within the bounds of the Tennessee Conference (formerly, a student local pastor).

Plan participants are eligible to be enrolled along with their eligible Dependents.

PREMIUMS: 2020 Premiums Monthly Yearly

Single (participant) $871 $10,452 Spouse (dependent) $968 $11,616 Family (dependent spouse and children) $1,265 $15,180 Children (dependents) $520 $6,240

a) All Clergy under Full-Time and 3/4 time Episcopal appointment to a local church within the bounds of the Tennessee

Conference; all 1/4 time Local Pastors who are designated by the Tennessee Conference Board of Ordained Ministry as full time students (formerly, student local pastors); and all Conference Staff who are scheduled to work 30+ hours per week. These participants’ individual premiums will be paid by the Conference.

b) Eligible Early Retirees: all Retired Clergy, Retired Conference Staff under age 65 who (1) have attained age 62 and have 10 years of full time service in the Tennessee Conference or (2) have 35 years of full time service, provided he or she was enrolled at the time of retirement. These participants’ individual premiums will be paid by the Conference.

c) Each spouse of a Retiree will remain eligible for all benefits under the Plan until the spouse attains age 65, provided he or she was enrolled at the time of the Retiree's retirement and he or she continued to be an Eligible Dependent as described in the Plan. Spouses who were enrolled at the time of the participant’s retirement will have 1/3 of their individual premium paid by the Conference, until they reach age 65. Retired Clergy under age 65–Spouse is covered as a dependent Retired Clergy age 65 and older–Spouse is covered as an individual until the spouse reaches age 65

d) All surviving spouses of deceased Full-Time Clergy, including Conference Staff can continue enrollment for all benefits under the Plan until age 65, provided they were enrolled under the Plan at the time of the decedent's death.

e) Disabled Participants whose premiums were paid in full by the Conference apportionment prior to their disability remain eligible for up to 24 months, with premiums paid by the Conference.

f) Participants whose eligibility ends may elect Optional Continuation of Coverage for up to 18 additional months.

g) Dependent Premium Discount for participants listed under letter “a” 2020 plan compensation at or below $54,086, the premium for dependent coverage will be reduced by one-half.

2020 plan compensation between $54,087 and $64,087, the premium for dependent coverage will be reduced by one-third. For pastors with parsonages, “plan compensation” is 125% of base compensation. For pastors without parsonages, “plan compensation” is base compensation plus housing allowance. An enrollment form must be completed and submitted to the Conference on or before the effective date of coverage. See the Tennessee Conference Health Plan Summary Plan Document for a complete definition of eligibility. In case of inconsistency, the Plan Document controls.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020

TENNESSEE CONFERENCE HEALTH PLAN: 7670-00-410524 001 Coverage for: Individual + Family | Plan Type: PPO

Page 1 of 6

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit https://www.tnumc.org/admin/finance-administrative-services/clergy-benefits/ or by calling 615 327-1162. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.umr.com or call 1-800-826-9781 to request a copy.

Important Questions Answers Why this Matters:

What is the overall deductible?

$500 person / $1,000 family In-network $1,000 person / $2,000 family Out-of-network

Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes for covered preventive services. No for all other covered services

For covered preventive care/screening/immunizations in network, the deductible is waived up to a $300 Maximum then 20% Coinsurance You will have to meet the deductible before the plan pays for any services.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is the out–of–pocket limit for this plan?

$2,000 person / $5,500 family In-network $5,800 person / $11,600 family Out-of-network

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out–of–pocket limit?

Copayments for medical services, penalties, premiums, balance billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less if you use a network provider?

Yes. See www.umr.com or call 1-800-826-9781 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (a balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

https://www.tnumc.org/admin/finance-administrative-services/clergy-benefits/

http://www.umr.com/

http://www.umr.com/

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information In-network

(You will pay the least) Out-of-network

(You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

20% Coinsurance 40% Coinsurance Virtual visits (Teladoc) – 100% paid by plan per visit by a designated virtual network provider. No virtual coverage out-of-network.

Specialist visit 20% Coinsurance 40% Coinsurance None

Preventive care/screening/ immunization

No charge; Deductible Waived up to $300 Maximum then 20% Coinsurance

No charge Flu shots; Not covered all other services

You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

If you have a test

Diagnostic test (x-ray, blood work)

20% Coinsurance 40% Coinsurance None

Imaging (CT/PET scans, MRIs)


If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.Caremark.com

.

Generic drugs (Tier 1) $10 (Retail) $25 (90 day Mail Order)

Not Covered

None

Preferred brand drugs (Tier 2)

$30 (Retail) $75 (90 day Mail Order

Not Covered

Non-preferred brand drugs (Tier 3)

$60 (Retail) $150 (90 day Mail Order

Not Covered

Specialty drugs (Tier 4) Same copays as retail Not Covered

http://www.caremark.com/

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If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)


Physician/surgeon fees 20% Coinsurance 40% Coinsurance None

If you need immediate medical attention

Emergency room care 20% Coinsurance 20% Coinsurance True ER; 40% Coinsurance Non-True ER

In-network deductible applies to Out-of-network benefits True ER

Emergency medical transportation

20% Coinsurance 20% Coinsurance In-network deductible applies to Out-of-network benefits

Urgent care 20% Coinsurance

20% Coinsurance True emergency; 40% Coinsurance Non-True emergency

In-network deductible applies to Out-of-network benefits True emergency

If you have a hospital stay

Facility fee (e.g., hospital room)

20% Coinsurance 40% Coinsurance

Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by $500 of the total cost of the service.

Physician/surgeon fee 20% Coinsurance 40% Coinsurance None

If you have mental health, behavioral health, or substance abuse needs

Outpatient services 20% Coinsurance 40% Coinsurance None

Inpatient services 20% Coinsurance 40% Coinsurance

Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by $500 of the total cost of the service.

If you are pregnant

Office visits 20% Coinsurance 40% Coinsurance Cost sharing does not apply to certain preventive services. Depending on the type of services, deductible, copayment or coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery professional services


Childbirth/delivery facility services


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If you need help recovering or have other special health needs

Home health care No charge; Deductible Waived

No charge; Deductible Waived

Preauthorization is required.

Rehabilitation services 20% Coinsurance 40% Coinsurance None

Habilitation services Not covered Not covered None

Skilled nursing care No charge; Deductible Waived

No charge; Deductible Waived

120 Maximum days per calendar year; Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by $500 of the total cost of the service.

Durable medical equipment 20% Coinsurance 40% Coinsurance Preauthorization is required for DME in excess of $500 for rentals or $1,500 for purchases.

Hospice service No charge home care; 20% Coinsurance facility; Deductible Waived

No charge home care; 40% Coinsurance facility; Deductible Waived

None

If your child needs dental or eye care

Children’s eye exam Not covered Not covered None

Children’s glasses Not covered Not covered None

Children’s dental check-up Not covered Not covered None

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Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Acupuncture Hearing aids Routine eye care (Adult)

Cosmetic surgery Infertility treatment Routine foot care

Dental care (Adult) Long-term care Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Bariatric surgery Non-emergency care when traveling outside the U.S. Private-duty nursing

Chiropractic care

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit

www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at www.HealthCare.gov and http://cciio.cms.gov/programs/consumer/capgrants/index.html.

Does this plan Provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan Meet the Minimum Value Standard? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-826-9781. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-826-9781.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-826-9781.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-826-9781.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

http://www.healthcare.gov/




http://cciio.cms.gov/programs/consumer/capgrants/index.html

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Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well-controlled condition)

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

About these Coverage Examples:

The plan's overall deductible $500 Specialist coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $7,500

In this example, Peg would pay:

Cost Sharing

Deductibles $500

Copayments $0

Coinsurance $1,400

What isn’t covered

Limits or exclusions $100

The total Peg would pay is $2,000


This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)


In this example, Joe would pay:

Cost Sharing

Deductibles* $500

Copayments $0

Coinsurance $980


Limits or exclusions $0.00

The total Joe would pay is $1,480


This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)


In this example, Mia would pay:

Cost Sharing

Deductibles* $500

Copayments $0

Coinsurance $280


Limits or exclusions $0

The total Mia would pay is $780

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of

costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Questions: Call 615-327-1162 or visit us at https://www.tnumc.org/admin/finance-administrative-services/clergy-benefits/ If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov or call 615-327-1162 to request a copy.

.

http://www.dol.gov/ebsa/healthreform

http://www.cciio.cms.gov/

TENNESSEE CONFERENCE HEALTH PLAN ENROLLMENT FORM

Open Enrollment ADDRESS CHANGE ONLY Change (indicate event requiring contract change below)

Name (Last)▼ (First)▼ (M)▼ Social Security No.▼

Soc. Sec. Disabled? Medicare Enrolled? Birth Date▼ Gender

Yes No Yes No Female Male

Address ► Telephone No.▼ Marital Status:

City, State, Zip► Single Married

Employment Status: Date of Hire: Medical Coverage for:

Employee Only

Effective Date of Coverage:

Full-Time

Part-Time (3/4 appointment & Approved Student Pastors Only)

COBRA

Add: Family (spouse & child(ren)

Spouse Only Children Only

Dependent Name (First, MI, Last) Social Security No. Birth Date Gender Full-Time Student?

Spouse M F Yes No

Dependent M F Yes No



Event Requiring Contract Change: Marriage Birth/Adoption Divorce Other

I HEREBY REQUEST to be covered and authorize deductions, if any, from my wages for my share of the benefits for which I am eligible or may be entitled, under

the coverage elected on this form.

Signature Date

Other Coverage Information – If your spouse or anyone named on this application has medical coverage through another company where the employer pays any portion of the cost or makes payroll deductions, please complete the following:

Name (First, MI, Last) Employer

Insurance Company Name Policy No.

Insurance Company Address (City, State, Zip) Contract Type Medical Single Medical Family

WAIVER OF COVERAGE I, the undersigned, hereby certify that I have been given an opportunity to enroll in the group plan sponsored by my employer. After careful consideration, I have elected not to participate in the following coverage(s). I further understand that should I decided to participate at a future date, I may have to furnish satisfactory evidence of insurability for myself and, if applicable, any eligible dependents. If I am declining enrollment for myself or my dependents (including my spouse) because of other insurance coverage, I understand that I may, in the future, be able to enroll myself or my dependents in this plan, provided that I request enrollment within 30 days after my other coverage ends. In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my dependents, provided that I request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

Employee Medical Dependent Medical

Signature Date

►

▲SIGN HERE IF YOU ARE WAIVING COVERAGE

EMAIL ADDRESS▼

304 S. Perimeter Park Drive, Suite 4 Nashville, Tennessee 37211

(615) 327-1162 or (800) 359-1162

James R. Allen, Director [email protected]

Melinda Parker, Assistant Benefits Officer [email protected]

The United Methodist Church Tennessee Conference Office of Administrative Services

Notice of Availability of Important Documents

Dear Employee,

This notice is to inform you of the availability of important benefit notification documents. In addition to those documents you are provided upon enrollment and through notifications including but not limited to Medicare Part D Creditable/Non-Creditable Coverage, Women’s Cancer Rights, Newborns Act and Children’s Health Insurance Protection Act (where applicable), more details can be found in the summary plan description, summary of material modifications, insurance contracts and other supporting documents.

The Tennessee Conference Health Plan has created a like on the TNUMC website where all of these documents can be viewed.

If you wish to receive a hard copy of this information, at no cost, please contact Melinda Parker by email, [email protected] or call 615-327-1162 with your preference.

Sincerely,

Melinda Parker Assistant Benefits Officer

Notices Included: Grandfathered Status Newborn and Mother’s Health Protection Act Women’s Health & Cancer Rights Act Notice of Special Enrollment Rights Children’s Health Insurance Program (CHIP) Notice of Medicare Creditable Coverage




TENNESSEE CONFERENCE DENTAL BENEFITS administered through Sun LIfe Financial

OPTION # 1 - Voluntary Dental PPO – Monthly Premiums effective 7/1/2019 – 12/31/2020

Employee $ 50.47 Employee + 1 Dependent $ 96.08 Employee + 2 or more Dependents $160.49

Plan Features: • Freedom to choose any dentist, including specialists• PPO options available• 12-month rate guarantee• No referrals required• Vision care program includes access to discounts (including contact lens exams)

How the Plan Works This dental plan provides a variety of benefits and allows you and your family to use any dentist or specialist you choose. Benefits are paid after any applicable deductible has been met, up to the annual maximum. Claim payments may be made to you or your dentist, whichever you prefer. You may find a DHA provider by visiting the Sun LIfe web site at www.sunlife.com/us - Select Find a dentist - Go to option 3, Select your Network and choose the Assurant Dental Network. Or call customer service at 800.442.7742.

OPTION #2 - Prepaid Dental Plan – Monthly Premiums effective 7/1/2019 – 12/31/2020

Employee $12.07 Employee + 1 Dependent $19.53 Employee + 2 or more Dependents $ 29.91

Plan Features • No Deductibles• No Waiting Periods• Coverage for Pre-existing Conditions• No Claim Forms to File for Plan Dentist and Plan Specialist Services• No Referrals Required for Specialist Services• No Annual Maximum for Plan Dentist and Plan Specialist Services

How the Plan Works This prepaid dental plan offers benefits through a network of Plan Dentists. When you enroll for benefits, treatments you receive from your selected Plan Dentist will be provided at reduced fees called copayments. You can find a dental provider in the Heritage Series Provider Network by visiting the Sun Life web site at www.sunlife.com/us – Select Find a dentist, Go to option 3, Select Prepaid Dental plan and the state of Tennessee, Select the Heritage Series. Or call customer service at 800.443.2995. Availability of Plan Dentist and Plan Specialist varies depending on location.

IMPORTANT: Contact Melinda Parker in the Office of Administrative Services to receive an Enrollment Packet. Email: [email protected] or call 615-327-1162

Coverage for eligible employees will begin the first day of the month following the eligibility period. You must sign up by the Initial Enrollment Deadline, or forfeit the opportunity until the next plan anniversary date (July 2019).


Kc:3161 (7/Z014)

Voluntary Dental PPO

Good news about dental benefits for employees of

TENNESSEE CONFERENCE, UMC

IN

Your Dental Plan

As a valued employee of THE TENNESSEE ANNUAL CONFERENCE OF THE UNITED METHODIST CHURCH, you have the opportunity to enroll in a payroll-deduction dental program.

Plan Features:

• Freedom to choose any dentist, including specialists• PPO options available 1

• 24-month rate guarantee• Vision care program includes access to discounts (including contact lens exams)

How the Plan Works

This dental plan provides a variety of benefits and allows you and your family to use any dentist or specialist you choose. Benefits are paid after any applicable deductible has been met, up to the annual maximum. Claim payments may be made to you or your dentist, whichever you prefer.

Assurant® Dental Network, the dental network for your plan includes 100,000+ unique dentists contracted with Dental Health Alliance, L.L.C.® (DHA®) and dentists under access arrangements with other dental networks. To find a dentist in your area, or to nominate your dentist to participate in our network, go to www.sunlife.com/us, select For Members, then Find a dentist, or call Customer Service at 800.442.7742.

IMPORTANT:

Coverage for eligible employees will begin July 1, 2019. You must sign up by theInitial Enrollment Deadline, or forfeit the opportunity until the next plan anniversary date.

'You are free to use the dentist or specialist of your choice. However, when you choose a dentist in our PPO network, you can save money. Using a network dentist may lower your out-of-pocket costs and can make your annual maximum go further.

Plan frequencies, limitations and waiting periods apply.

This notice only applies to employers with 50 or fewer employees. This coverage does not include and is not required to include the pediatric dental essential health benefit as required under the federal Patient Protection and Affordable Care Act.

Freedom - page 1 01/08/2015 17:30:39 3068328/1

Group Insurance Enrollment Card

Check one - Employer Use 0 Initial Employee:

O Transfer from Prior Dental O Non-Transfer

0 New Employee 0 Change

(Please print clearly.) 0 Ooen Enrollment

Effective Date Location/DivisionEmployer TENNESSEE CONFERENCE OF THE UNITED METHODIST CHURCH

Employee First Name Ml Last Name

Address City State Zip

Social Security No. ] Birthdate Date of Hire Phone ] Sex OM OF

DENTAL COVERAGE

I APPLY FOR: 0 I DECLINE COVERAGE FOR:

o Employee only O EmployeeO Employee and eligible dependents 0 Spouse

0 Child(ren)For children age 19

Do you have eligible dependents? O Yes 0 No or older, indicate if If "Yes," complete below to enroll them. Birthdate a full-time student.

Spouse

Child(ren)

- - -- ------

- - -- ----- - - - ------- "·----------

--·----·----- --

----------------

. . ---

-- - -

..

□ List additional Children on reverse side and check box.

Relation Sex Mo Dav

-----

Year

. ------

··--

Yes No

---------

• If the address of any child is different than the employee's address, please show that child's name and address below .

• If requesting coverage for a dependent child other than a son or daughter, please forward legal custody papers .-----. To the best of my knowledge and belief, each of the statements and answers supplied in this form is complete and true, and they constitute the sole basis for, and are the inducement for, the issuance of any insurance.

I hereby apply as indicated herein for the insurance for which I am not now insured and for which I am or may becomeeligible under the terms of Union Security Insurance Company's group policy or policies (including any future amendments) applying to, or requested to apply to, the employer named above. If such insurance becomes effective, I authorize deductions from my earnings of my contributions required from time to time toward the cost of such insurance. Irepresent that I am an active full-time employee of that employer. When necessary, I may be asked to execute a HIPAA authorization form, allowing Union Security Insurance Company to use and disclose protected health information.

Date Signature

Union Security Insurance Company Mail to: Assurant Employee Benefits 2323 Grand Boulevard Kansas City Missouri 64108Form 59 (8/02) (TN) KC3018BTN{02/201 0)

VOLUNTARY DENTAL PLAN

KC3161 (7/2014)

Prepaid Dental

Good news about dental benefits for employees of

THE TENNESSEE ANNUAL CONFERENCE OF THE UNITED

METHODIST CHURCH

A Dental Plan Means Healthy Smiles Because you are a valued employee, Assurant Employee Benefits* is pleased to offer you the opportunity to enroll in a dental benefit plan provided and administered by Union Security Insurance Company. This prepaid dental plan offers benefits through a network of Plan Dentists. When you enroll for benefits, treatments you receive from your selected Plan Dentist will be provided at reduced fees called copayments. For your information, a partial list of frequently used dental treatments is included.

Plan Features • No Deductibles

• No Waiting Periods

• Coverage for Pre-existing Conditions

• No Claim Forms to File for Plan Dentist and Plan Specialist Services

• No Referrals Required for Specialist Services

• No Annual Maximum for Plan Dentist and Plan Specialist Services

Important Enrollment Information To enroll, just follow three simple steps:

1. Select a general dentist from the Directory of Dentists for yourself and every eligible member ofyour family. Each family member may choose a different Plan Dentist. You must select a PlanDentist to receive services. Except for certain specialist services, all services must beperformed by this selected Plan Dentist. You may change your Plan Dentist(s) throughout thePlan Year in accordance with the provisions of the group agreement. However, all servicesmust be performed by a Plan Provider.

2. Complete the enclosed enrollment form, being sure to include the Dental Facility Number ofeach Plan Dentist selected.

3. Return your completed enrollment form to your Personnel Department or Benefits Managerauthorizing payroll deductions for your coverage.

Finding a Provider You can find a dental provider in the Heritage Series Provider Network by visiting our web site at www.sunline.com/us, and clicking on the "Find a dentist" link found under "Tools for Members". Next click "DHMO or Prepaid Dental Plan?", select your state from the drop down list, and then select "Heritage Series". Availability of Plan Dentists and Plan Specialists varies depending on location.

If you have any questions, call Customer Service at 800.443.2995.

Prepaid - page 1 GOSA Form No. BDC-GDSA-TN

01/08/2015 17:30:39 3068328/2

SHOWN AS EXAMPLE ONLY

Specialty Benefit Amendment Copayment Schedule for the Heritage Series

How Your Specialty Benefit Amendment (SBA) Works

Should you need the services of a dental care specialist, you may receive those services without a referral from your Plan Dentist.

To find a Plan Specialist (SBA or Non-SBA), refer to the provider directory. SBA Plan Specialists are indicated with "SBA". All other listed specialists are Non-SBA Plan Specialists. Or, you may visit the web site at www.sunlife.com/us (click on Provider Search, and then on Heritage Series). For more information about the SBA plan or for assistance in finding a Plan Specialist, call Customer Service at 800.443.2995.

If you use an SBA Plan Specialist (a specialist who is a part of the plan provider network and accepts SBA copayments) for a service listed on the schedule below, you will pay the corresponding Member Copayment shown in the "SBA Plan Specialist Copayment" column at lhe lime of service.

All other services obtained from an SBA Plan Specialist, and all services oblained from a Non-SBA Plan Specialist (a specialist who is a part of the plan provider network but does not accept SBA copayments), will be provided to you at a reduction in that Plan Specialist's normal retail charges. A 15% reduction applies if that Plan Specialist is an endodonlist. A 25% reduclion applies if that Plan Specialist is any other type of specialist, including but not limited to an orthodontist. You will be responsible for paying the enlire reduced charge at the time of service or in accordance with that Plan Specialist's billing procedures.

If you choose to go to a Non-Plan Specialist (a specialist who is not a part of the plan provider network), you may still receive benefits!

If you obtain a service listed on the schedule below from a Non-Plan Specialist, you will be responsible for paying that specialist's entire normal retail charge for the service at the time of service or in accordance with that specialist's billing procedures. You may then submit a completed claim form, with an itemized bill attached, to Union Security Insurance Company. (You may obtain claim forms by contacling Customer Service at 800.443.2995.) Union Security Insurance Company will reimburse you the lesser of (a) the corresponding amount shown in the "Maximum Reimbursement with a Non-Plan Specialist" column of the schedule below or (b) the amount charged by that specialist for the service.

Payment for any other service of a Non-Plan Specialist, at that specialist's normal retail charge, is your responsibility, except for limited Plan Benefits for covered dental Emergency Services for temporary pain relief.

Annual Maximum Benefit

There is no annual maximum benefit for services of an SBA or Non-SBA Plan Specialist. For services of a Non-Plan Specialist, there is a $2,000 annual maximum benefit.

ADA Codett

00140 00150

00160 00170

00180

03320 03330 03346 03347

Service Description*

Appointments

SBA Plan Specialist

Copayment

Maximum Reimbursement with A Non-Plan Specialist

Limited oral evaluation - problem focused .. . ............................................................... 35.00 ...... 20.00 Comprehensive oral evaluation - new or established patient ........... . ..................................... 45.00 ..................................... ..... 25.00 (once in any 6 calendar months) (may only be obtained once in any six calendar months, except for medically necessary more frequent prophylaxis as determined by Members Plan Dentist) Detailed and extensive oral evaluation - problem focused, by report ...................................... ............... 67.00 ............. . . 45.00 Re-evaluation - limited, problem focused (established patient; not post-operative visit) .......................................................................................................................................................... 35.00 .... . Comprehensive periodontal evaluation - new or established patient................ . ....... 80.00.

Endodontics

. ............ 25.00 . ................ 50.00

Endodontic therapy, bicuspid tooth (excluding final restoration) ............................................................ 280.00.. . ........ 320.00 Endodontic therapy, molar (excluding final restoration) ......................................................................... 395.00. . .................. 405.00 Retreatment of previous root canal therapy- anterior ................................................ 360.00 ............ ............................ 230.00 Retreatment of previous root canal therapy- bicuspid .......................................................................... 525.00...... . ........................ 265.00

Continued On Next Page

Prepaid - page 7

SHOWN AS EXAMPLE ONLY

Learn more about the prepaid dental plan being offered to you!

Your employer is offering you an attractive prepaid dental plan. This Q&A will help provide you more information about the plan being offered to you.

What is a prepaid plan?

With a prepaid plan you pay a monthly prepayment fee plus you pay reduced fees called "copayments" for dental services provided. To receive the reduced fees you must use a Plan Dentist selected at the time of enrollment.

What are copayments and where can I locate the copayment schedule?

A copayment is the set fee that you pay to the Plan Dentist at the time of treatment for covered services that are being performed.

The copayment schedule is a listing of covered services and copayments for your plan. The schedule is included in the Evidence of Coverage. It is helpful to bring your copayment schedule to your dental appointment.

How do I select a Plan Dentist?

You should select your Plan Dentist when you enroll. You can find a dentist in the Heritage Series Provider Network by visiting the SunLife Financial, US web site at www.sunlife.com/us and clicking on the "Find a Dentist" link found under "Tools for Members". Next, click "DHMO or Prepaid Dental Plan?", select your state from the drop down list, and then select "Heritage Series". Note that your Plan Dentist must be a general dentist, not a specialist.

How long does it take to appear on the patient list/roster of my Plan Dentist that I select at time of enrollment?

If Sun Life Benefits receives your Plan Dentist selection by the 10th of the month, you will appear on the roster the 1st of the next month. If we receive the selection after the 10th, you will appear on the roster the 1st day of the second following month. If you are not listed on the roster, please contact us at 800.443.2995.

Prepaid - page 9

How will the Plan Dentist know I am a patient?

The Plan Dentist receives a patient listing, called a roster, from Sun Life Benefits each month that includes all members who have chosen that individual as their dentist.

Please confirm at the time of making your appointment with the Plan Dentist that you are on the provider's roster.

Can I change my Plan Dentist?

Yes, you can. To change your Plan Dentist, contact Customer Service at 800.443.2995.

What if I choose to see a dentist other than my selected Plan Dentist?

The costs will not be covered by your dental plan and you will be responsible for the full payment to the dentist. This is why it is important for you to seek treatment from your selected Plan Dentist.

If I have a dental emergency, do I need to see my Plan Dentist?

First, contact your Plan Dentist to make an appointment. If your Plan Dentist is unable to see you, you may seek treatment from any licensed dentist in the United States.

Please be informed that the emergency benefit in your plan is limited to the temporary relief of pain and has limited benefits.

If I need to see a specialist, how do I go about finding a Plan Specialist in my area?

You may find a list of Plan Specialists by looking in the plan network directory, visiting the web site at www.sunlife.com/us or calling 800.443.2995 for assistance. No referrals are necessary from your Plan Dentist to seek treatment from a Plan Specialist.

What if I lose my Dental ID card or have a question about my plan?

Contact Customer Service by calling 800.443.2995.

01/08/2015 17:30:39 3068328/2

PREPAID DENTAL ENROLLMENT FORM

Melinda Parker

Highlight

The Clergy Retirement Security Program (CRSP) is a retirement program that offers:

1 security through a defined benefit (DB) component that gives you lifetime retirement income, and

2 flexibility through a defined contribution (DC) component that provides you with an account balance you can access as your retirement needs require.

ELIGIBILITY

You are eligible to participate if you are a clergy member or local pastor under full-time Episcopal appointment to a conference, church, charge, district or conference-controlled entity or unit and you are receiving compensation. Your conference may also elect to cover clergy appointed at least half-time or at least three-quarter time.

CRSP FEATURES

• You are automatically enrolled by your plan sponsor.

• You receive account statements quarterly or upon demand.

• Account information is accessible through the website (www.benefitsaccess.org) and the automated phone system at 1-800-851-2201.

• Representatives are available to answer calls at 1-800-851-2201 Monday through Friday from 8:00 a.m. to 6:00 p.m., Central time.

DEFINED BENEFIT (DB) COMPONENT

• Provides a monthly retirement benefit that is calculated using the following formula:

1.25% x Denominational Average Compensation (DAC)1 at retirement x years of credited service2

from 1/1/07 through 12/31/13

1.00% x DAC1 at retirement x years of credited service2 after 12/31/13

÷ 12

• You will have various DB payment options when you retire

• There are annual cost-of-living increase options for retirees

Clergy Retirement Security Program At-a-Glance

The Clergy Retirement Security Program (CRSP) is an Internal Revenue Code section 403(b) retirement plan administered by Wespath Benefits and Investments (Wespath)—the largest denominational pension fund in the world. It is designed to provide you with one element of your overall retirement portfolio.

Effective January 1, 2014

1 Final compensation substitutes for DAC for periods of service as a bishop.

2 Reduced for less-than-full-time appointments.

+

(over)

a general agency of The United Methodist Church

http://www.benefitsaccess.org

DEFINED CONTRIBUTION (DC) COMPONENT

• Every month, the Church contributes 2% of your compensation to your DC retirement account. In addition, the Church will match your personal contributions to the United Methodist Personal Investment Plan (UMPIP) up to 1% of your plan compensation (cash salary plus housing).

• Your account—both earnings and contributions—grows tax deferred until you withdraw money.

• Provides convenient distribution options when you are eligible to access the money in your account—including lump sum or partial distributions, or a series of regular payments.

• Account balance can remain in the plan until the later of participant retirement, termination or the age 70½.

Clergy Retirement Security Program At-a-Glance(continued)

Investment and Distribution Assistance Wespath offers services at no cost that can help you manage your DC account:*

• LifeStage Investment Management is an investment service that selects a mix of Wespath funds for your retirement account(s) based on your individual circumstances.

• EY Financial Planning Services assists you with financial planning and investment needs.

• LifeStage Retirement Income automatically creates pension-like monthly benefit payments from your DC account.**

For more information about LifeStage Investment Management, EY Financial Planning Services and LifeStage Retirement Income, please visit www.wespath.org/retirement/services/lifestage.

3412/050815

* Costs for these services are included in Wespath’s operating expenses that are paid for by the funds.

** Lifetime payments are not guaranteed (for example, in the event of extreme market conditions or longevity).

http://www.wespath.org/retirement/services/lifestage

http://www.wespath.org/retirement/services/lifestage

The United Methodist Personal Investment Plan (UMPIP) is a retirement plan administered by Wespath Benefits and Investments (Wespath)—the largest denominational pension fund in the world. UMPIP is designed to provide one piece of your overall retirement portfolio.You are immediately eligible to participate if your employer or salary-paying unit sponsors the plan. Participation for plan sponsor contributions begins once you meet the eligibility requirements established by your plan sponsor.

PLAN FEATURES• Convenient before-tax, Roth and/or after-tax contributions in a flat dollar

amount or percentage of your eligible compensation, up to Internal Revenue Code limits

• Plan sponsor may elect to contribute matching contributions or a percentage of your eligible compensation to your account1

• Taxes are deferred on before-tax contributions and investment earnings until distribution

• Roth contributions are made after taxes are withheld, but Roth contributions and earnings are not taxable at distribution if qualified2

• After-tax contributions are made after taxes are withheld, but earnings on after-tax contributions are taxable at distribution

• Accepts eligible rollovers from most retirement plans (including Roth accounts) and traditional IRAs3

• Variety of investment fund options• LifeStage Investment Management and LifeStage Retirement Income account

management suite• Hardship loans and withdrawals• Age 59 ½ and rollover account withdrawals• Distributions available upon termination of employment, retirement, disability

or death • Lump sum, partial lump sum or cash installment distribution options• On-demand and quarterly account statements• Access account information 24/7 through Benefits Access

(www.benefitsaccess.org) and through our automated phone system• Participant forms and other information available at www.wespath.org• Representatives available to answer calls at 1-800-851-2201 Monday through

Friday from 8:00 a.m. to 6:00 p.m., Central time

United Methodist Personal Investment PlanAt-a-Glance

3272/020816

EY Financial Planning Services offers valuable investing and financial planning guidance. This program is available to:• active participants with an

account balance,

• surviving spouses with an account balance, and

• retired and terminated participants with an account balance of at least $10,000.

EY Financial Planning Services are available at no cost to you.* Just call EY directly at 1-800-360-2539 Monday through Friday between 8:00 a.m. and 7:00 p.m., Central time.

1 Contribution rates may vary for each plan sponsor 2 See Roth Contribution Guide 3 Roth IRAs are not accepted

* Costs for these services are included in Wespath’s operating expenses that are paid for by the funds.


http://www.benefitsaccess.org

http://www.wespath.org

Part 1 – Participant Information. To be completed by the clergyperson or plan sponsor or salary-paying unit.

Participant name Primary phone # ( )

Home address Alternate phone # ( )

Spouse name

E-mail address Spouse Social Security #

Participant Social Security # Spouse birth date

Participant birth date Marriage date

Participant gender: q Male q Female Effective date of status

Member conference

The clergyperson is appointed:q To a local church q To attend school q To an extension ministryq To a conference responsible unit such as the conference or district office

Check one of the statuses below:q Provisional Elder* q Elder in Full Connection* q Associate Member*q Provisional Deacon* q Deacon in Full Connection* q Member of Other Denomination*q Student Local Pastor* q Full-time Local Pastor q Part-time Local Pastor*q Full Member* under The Book of Discipline, 1992

* If serving less than full-time, check one: q¾ q½ q¼ q Less than ¼ (applies to Part-time Local Pastors and Deacons only)

Part 2 – Church/Employer Information. To be completed by the plan sponsor or salary-paying unit.

Church/employer name(s) Church/Employer #(s)

Address Conference

Phone # ( )

Hours of availability E-mail address

Part 3 – Reason for Enrollment. To be completed by the plan sponsor.

q First-time enrollee (never previously enrolled in any plan) q Re-enrollment after previous participationq Addition of a plan q Transferred from another plan sponsor

Enrollment

Clergy Retirement Security Program (CRSP), United Methodist Personal Investment Plan (UMPIP), Comprehensive Protection Plan (CPP), UMLifeOptions

3436/091815

(continued)

1901 Chestnut AvenueGlenview, Illinois 60025-16041-800-851-2201wespath.org


COMPLETE PART 1 ONLY

Melinda Parker

Highlight

Melinda Parker

Highlight

Part 7 – Plan Sponsor Information. To be completed by the plan sponsor.

Plan sponsor name Employer #

Plan sponsor address Phone # ( )

Authorized representative Title

Authorized signature Date

Part 4 – Plan Enrollment. To be completed by the plan sponsor.

q UMPIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effective dateq CRSP 1

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effective dateq CPP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effective dateq UMLifeOptions—Clergy Supplemental Life Insurance Plan2, 4

. . . . . . . . . . . Effective dateq UMLifeOptions—Lay Long-Term Disability/Life Insurance Plan3, 4

. . . . . . Effective date1 Only a conference may sponsor CRSP 2 Only available for clergy enrolled in CPP and appointed to at least ½ time appointment3 Only available for lay employees, and for local pastors and Members of Other Denominations appointed to ½ or ¾ time appointment4 Participants are enrolled automatically if the plan sponsor has adopted the plan and the participants meet the eligibility criteria

Part 5 – Participant Contributions to UMPIP. To be completed by the plan sponsor or salary-paying unit.

Effective date

The participant completed a Contribution Election form (or a Contribution Election/Automatic Enrollment Notice) andelected to contribute at the following rates. If you elected Automatic Enrollment on your UMPIP Adoption Agreementand the participant did not complete one of these forms, insert the before-tax default percentage below. Enter either thepercentage or dollar amount, but not both.

Before-tax contributions: % or $ per monthRoth contributions: % or $ per monthAfter-tax contributions: % or $ per month

Part 6 – Compensation Information. To be completed by the plan sponsor or salary-paying unit.

Effective date of compensation

1. Total Cash Salary: $(Cash paid to clergyperson by the church/charge and/or conference. Total cash salary consists of base pay, cashbonuses, equitable compensation, cash allowances, cash to clergyperson for benefit programs, before-tax, Rothand after-tax contributions to UMPIP and other 403(b) programs, Section 125 medical reimbursement anddesignated housing exclusion.) Total cash salary does not include cash allowances provided in lieu of parsonage.

IRC Section 107 Housing Exclusion: $(Amount included in Total Cash Salary above that has been designated by the charge conference for housing expensesand not subject to federal income taxation.)

2. Housing (check only one):q Parsonage providedq Housing allowance in lieu of parsonage: $

(Cash provided to clergyperson in lieu of parsonage.) This amount should not be included in Total Cash Salary.

Please complete this form and send it by:• E-mail (scanned copy) to [email protected]• Mail to Office of Administrative Services, 304 S. Perimeter Park Dr., Suite 4, Nashville, TN 37211• Be sure to keep a copy for your records.

Information

This form allows you to choose one or more beneficiaries for the Wespath-administered retirement and welfare plans indicated below. A beneficiary receives plan benefits, if any, after you die or if you cannot be located when a benefit is payable.

A beneficiary can be a person, an organization (religious, educational, charitable, etc.), a trust or another legal entity. More than one beneficiary may share benefits. Your spouse is your primary beneficiary if you are married at the time of your death, unless your spouse has provided written consent for another beneficiary.

Beneficiaries may receive:

• Any amount remaining in a plan account,• Any monthly payments due under a term-certain annuity or life-and-term-certain annuity, if the participant dies before the

end of the term-certain, or• Death or survivor benefits under certain welfare plans

Beneficiary designations may apply to the following plans:

• United Methodist Personal Investment Plan (UMPIP)• Clergy Retirement Security Program Defined Contribution plan (CRSP DC)• Ministerial Pension Plan (MPP) • Pre-1982 Plan (Pre-82)• Retirement Plan for General Agencies (RPGA)• Horizon 401(k) Plan (Horizon)• Comprehensive Protection Plan (CPP)• Collins Pension Plan for Missionaries (Collins)

Check your beneficiary designations periodically (e.g., each birthday or after a life event like marriage, birth of a child or divorce), and make adjustments as needed. If Wespath cannot locate a beneficiary, that beneficiary will not be able to collect any benefits due.

Your beneficiary designation regarding Wespath-administered plans is binding and supersedes the provisions of your will, your divorce decree or your other wishes.

A beneficiary is not the same as a contingent annuitant. A contingent annuitant is an individual who you elect to receive monthly defined benefits (DB) or annuity benefits upon your death when you apply for these benefits (e.g., MPP, CRSP DB, Pre-82 and Collins monthly benefits). Contingent annuitants cannot be changed.

Beneficiary designations made using this form apply to all Wespath-administered plans listed above. To designate beneficiaries for specific plans, complete your designations online. To designate beneficiaries for UMLifeOptions contact Unum Life Insurance Company at 1-800-985-0242. For more information regarding beneficiary designations, visit wespath.org/retirement/resources/beneficiary-designation-guidelines.

This designation will apply to all accounts you have as a participant, surviving spouse and/or alternate payee.

Beneficiary Designation—Information and Instructions



Page 1 of 4

3017/072817

Instructions

You are encouraged to manage your beneficiaries online. To add or change beneficiaries, or to update beneficiaries’ personal information, login to benefitsaccess.org and select “Take Action” from the toolbar, then under Update Personal Data, choose “Update beneficiary designations.”

Part 1 – Personal Information Complete your personal information. Use a black pen and print clearly in CAPITAL LETTERS.

Part 2 – Marital Status Indicate whether you are single or married. If you are married, provide your marriage date, spouse’s name, Social Security number and birth date. If you are changing your beneficiary due to divorce, submit a photocopy of your Divorce Decree or similar court order, if you have not already done so.

Part 3 – Primary Beneficiary(ies) Enter the personal information for the individual(s) you choose as your primary beneficiary(ies).

If one or more primary beneficiaries is living and can be located at the time of your death, he/she/they will receive 100% of eligible benefits, depending on spousal consent, if applicable.

Wespath-administered plans generally require your surviving spouse to be your sole beneficiary—even if you have submitted a form naming other beneficiaries—unless your spouse has consented to other beneficiaries in Part 5 of this form. Spousal consent is not required for designations relating to accounts you have as a surviving spouse or alternate payee.

If a trust is being named as a beneficiary, a good format to use is:

John Smith, not personally, but as trustee of the Mary Smith Trust (under an agreement dated Month/Day/Year).

If an estate is being named as a beneficiary, a good format to use is:

The estate of John Smith.

If you need more space, complete your beneficiary designations online or print an additional copy of the form, then sign and date both copies.

Part 4 – Secondary Beneficiary(ies) Enter the personal information for the individual(s) you choose as your secondary beneficiary(ies).

Secondary beneficiaries, if any, are eligible to receive your benefits only when all of your primary beneficiary(ies) die(s) before you or cannot be located.

If you need more space, complete your beneficiary designations online or print an additional copy of the form, then sign and date both copies.

Part 5 – Spousal Consent Your spouse will be your primary beneficiary if you are married at the time of your death, unless he or she has consented otherwise on this form (or you have named other individuals and are receiving benefits as an alternate payee or beneficiary of a participant who has died). Your spouse can consent to your designation of other beneficiaries named in Part 3 by completing this section of the document.

Your spouse must consent to the statements that appear on the form, and sign the form in the presence of a Notary Public. Spousal consent is not valid without notarization.

Individuals who are accountholders as a result of divorce or inheriting benefits (i.e., as an alternate payee or beneficiary, including surviving spouses) do not need spousal consent when naming someone other than a spouse.

Part 6 – Signature Read the statement and, if you agree, sign and date the form. Then, mail it to Wespath at the address indicated. Keep a copy of the submitted form for your records.

Wespath will send a confirmation once this form is processed. You should review the confirmation and keep it for your records.

Page 2 of 4

3017/072817


You are encouraged to manage your beneficiaries online at benefitsaccess.org. Log in and select “Take Action” from the toolbar, then under UPDATE PERSONAL DATA, choose “Update beneficiary designations.”

Part 1 – Personal Information

Name ________________________________________________________________________ Social Security # ___ ___ ___ – ___ ___ – ___ ___ ___ ___

Mailing address _______________________________________________________________ Birth date ____________________________________________

________________________________________________________________________________ Primary phone # _____________________________________

Country of citizenship _________________________________________________________ E-mail ________________________________________________

Part 2 – Marital Status

Marital status: q Single q Married; date _______________________ Spouse Social Security # ___________________________

Spouse name ___________________________________________________________ Spouse birth date _________________________________

If you are submitting this form due to divorce, please submit a photocopy of your Divorce Decree or similar court order, if you have not already done so.

Part 3 – Primary Beneficiary(ies)

For additional primary beneficiaries, see instructions and check here: q Social Security # Date of Birth Relationship* Percentage**

Name __________________________________________

Address ________________________________________

________________________________________________

Name __________________________________________

Address ________________________________________

________________________________________________

Name __________________________________________

Address ________________________________________

________________________________________________

Name __________________________________________

Address ________________________________________

________________________________________________

Name __________________________________________

Address ________________________________________

________________________________________________

* Specify “spouse,” “child,” “legal dependent,” “estate,” “trust,” “organization” or “other.”** Percentages must total 100%.

Beneficiary Designation

( )

Last name first name middle initial

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

Page 3 of 4

3017/072817

Please complete this form and send it to:

Office of Administrative Services Attention: Melinda Parker 304 S. Perimeter Park Drive, Suite 4 Nashville, TN 37211

Part 4 – Secondary Beneficiary(ies)

For additional primary beneficiaries, see instructions and check here: q Social Security # Date of Birth Relationship* Percentage**

Name __________________________________________

Address ________________________________________

________________________________________________

Name __________________________________________

Address ________________________________________

________________________________________________

Name __________________________________________

Address ________________________________________

________________________________________________

Name __________________________________________

Address ________________________________________

________________________________________________

* Specify “spouse,” “child,” “legal dependent,” “estate,” “trust,” “organization” or “other.”** Percentages must total 100%.

Part 5 – Spousal Consent. Generally required if married and spouse is not named as the sole beneficiary in Part 3 (see instructions). This section must be notarized.

I consent to the specific beneficiary(ies) named on this form. (If your spouse later changes the beneficiary(ies), your consent will be revoked.) I understand that: 1) if I do not sign here, I will receive my spouse’s death benefits, if any, if I am married to my spouse at his or her death; 2) by signing here, I consent to the beneficiary(ies) named in this form; and 3) the effect of this consent is to cause any benefits payableupon my spouse’s death to be paid to those beneficiary(ies) instead of me.

Spouse signature _________________________________________________________________ Date ____________________________________________

Signed in the presence of _______________________________________________________

Notary Public signature _________________________________________________________

Subscribed and sworn before me on this ________________________________________

My commission expires _________________________________________________________

Part 6 – Signature

I have read the instructions and understand that:• I designate the person(s) and/or entity(ies) named on this form as my beneficiary(ies) for Wespath-administered plans.• I reserve the right to revoke the designation(s) at any time by submitting a new beneficiary designation form with spousal consent,

if required.• Information provided here shall replace and supersedes all previous beneficiary designation(s) I have made.• I understand that naming or changing my beneficiary does not affect any contingent annuitant elections I have made or will make.

Print name ________________________________________________________________________________

Signature _________________________________________________________________________________ Date ______________________________________

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

NOTARY SEAL

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3017/072817

• $18,500 if you are under age 50 with less than 15 years of service• $24,500 if you will be 50 or older by December 31• Possibly higher if you have at least 15 years of service with all United Methodist-related organizations—call Wespath

for further information

Your total before-tax, Roth and after-tax contributions (but not including “catch-up” contributions), plus any plan sponsor contributions to UMPIP [and any other 403(b) plans sponsored by your plan sponsor] cannot exceed your compensation for the 2018 plan year or $55,000, whichever is less.

For these limit purposes, compensation does not include the value of any parsonage or housing allowance that is excluded from your taxable income.

You cannot withdraw contributions from UMPIP unless you have a financial hardship as defined under UMPIP, attain age 59½, are disabled as defined under UMPIP, retire, terminate employment and/or terminate your relationship with the annual conference.

Instructions

Part 1 – Personal Information Complete your personal information. Use a black pen and print clearly in CAPITAL LETTERS. If you enter a new address that should be used to update your participant record, contact Wespath at 1-800-851-2201.

Part 2 – Before-Tax Contribution Indicate the dollar amount or percentage that you elect to have withheld from your compensation as a before-tax contribution and contributed to UMPIP.

Your compensation (including the value of any parsonage or housing allowance) will be reduced before withholding taxes are calculated. When you take distributions from UMPIP, your before-tax contributions and earnings will be taxable.

Part 3 – Roth Contribution Indicate the dollar amount or percentage that you elect to have withheld from your compensation as a Roth contribution and contributed to UMPIP.

Your compensation (including the value of any parsonage or housing allowance) will be reduced after withholding taxes are calculated. When you take distributions from UMPIP, your qualified Roth contributions are non-taxable. See the Roth Contribution Guide at wespath.org/assets/1/7/4834.pdf for more information about the tax implications of Roth account distributions.


Contribution Election—Information and InstructionsUnited Methodist Personal Investment Plan (UMPIP)

Information

This form allows you to elect to make before-tax, Roth and/or after-tax contributions to your United Methodist Personal Investment Plan (UMPIP) account.

UMPIP is a 403(b) plan, subject to contribution limits under the Internal Revenue Code. Your total before-tax and Roth contributions for the year to UMPIP (and any other qualified retirement plans) cannot exceed the lesser of your compensation or the 2018 limit of:

a general agency of The United Methodist ChurchPage 1 of 4

3255/110117

http://www.wespath.org/assets/1/7/4834.pdf


Part 4 – After-Tax Contribution Indicate the dollar amount or percentage that you elect to have withheld from your compensation as an after-tax contribution and contributed to UMPIP.

Your compensation (including the value of any parsonage or housing allowance) will be reduced after withholding taxes are calculated. When you take distributions from UMPIP, your after-tax contributions are non-taxable but the earnings on those contributions are taxable.

Part 5 – Signature Read the statement and, if you agree, sign and date the form. Then, return it to your employer or plan sponsor. Keep a copy of the submitted form for your records.

Part 6 – Acceptance by the Plan Sponsor/Salary-Paying Unit Your plan sponsor must sign and date this form and return it to Wespath as indicated.

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Contribution ElectionUnited Methodist Personal Investment Plan (UMPIP)


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Part 1 – Personal Information

Name Social Security # ___ ___ ___ – ___ ___– ___ ___ ___ ___

Mailing address Primary phone # ( )

E-mail

Country of citizenship q Clergyq Layq Bishop

Part 2 – Before-Tax Contribution

Choose one:

q Percentage of compensation: % of compensation

q Dollar amount: $ per month (cannot exceed your monthly compensation)

q I elect not to make before-tax contributions

Part 3 – Roth Contribution

Choose one:



q I elect not to make Roth contributions

Part 4 – After-Tax Contribution

Choose one:



q I elect not to make after-tax contributions

Pastors: Your local church is the plan sponsor for your personal contribution. This form should be signed by the church treasurer prior to being submitted.


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Part 5 – Participant Signature

I have read the instructions, and understand and accept the actions I have taken with this Contribution Election. I acknowledge that:

• The indicated before-tax, Roth and/or after-tax contributions will be withheld from my pay and contributedto my UMPIP account.

• I cannot withdraw contributions from UMPIP unless I have a financial hardship as defined under UMPIP, attainage 59 ½, am disabled as defined under UMPIP, retire, terminate employment and/or terminate my relationshipwithmy annual conference.

• This agreement will remain in effect with my current plan sponsor until I submit a new form.

Print Name

Signature Date

Part 6 – Acceptance by the Plan Sponsor/Salary-Paying Unit

Effective date of this contribution 1, 20 .

This date must be the first day of a month on or after the participant signed this form.

Plan sponsor name Employer #

Plan sponsor address Phone # ( )

Authorized representative Title

Authorized signature Date

Complete this form and send it to: * Email (scanned copy) to [email protected]* Mail to: Office of Administrative Services

304 S. Perimeter Park Dr., Suite 4, Nashville, TN 37211

The plan sponsor/salary-paying unit should keep the original form for its payroll records.

Pastors: Church Treasurer should sign this form

Melinda Parker

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Melinda Parker

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