What can your life insurance benefits do for you?

What can your life 
insurance benefits 
do for you?
Financial protection
for your family
• Optional universal life insurance
Inside:
• Description of benefits
• Frequently asked questions
• Application to enroll
Review
this booklet

Whatever your stage of life, there’s a good chance someone relies on you.
So if something happened to you, it could affect their finances as well.
You’d want to be sure your loved ones were taken care of. And you
wouldn’t want anyone left with the bills for your final arrangements.
Unum’s optional universal life insurance can help.
The State of Tennessee provides all
employees with at least $20,000 in basic
term life benefits. For many people, this
is enough coverage to provide for final
arrangements. However, the State also
recognizes that the kind of life insurance
you need can change according to your age
and stage of life. That’s why the State of
Tennessee is giving you the chance to buy
additional life insurance.
Optional Universal Lifeinsurance can gain

cash value over time, and you can pay the
premiums through payroll deduction.
It is also a plan you own as an individual
and the rates vary by age. That means you
can keep the coverage if you leave your job
or retire. You can apply for this coverage
without answering health questions.
Here is how it works:
•  You can apply for a benefit amount up to
three times your salary.
•  The amount of coverage you can get
without answering health questions is
called “guaranteed issue.”
•  You can apply for a higher benefit
amount but you will be asked health
questions. The limit for this is five times
your salary. You can’t request more than
$300,000.
Your life –
it’s worth it!
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Who relies on you?
• parent
• children/
grandchildren
• grandparent
• sibling
• niece/nephew
• spouse/
significant other
• anyone with whom
you share debt
(co-signer, etc.)
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Who is eligible?
•   Regular full-time employees scheduled to
work at least 30 hours each week
•   Seasonal or part-time employees with 24
months of prior service and certified by an
appointing authority to work at least 1,450
hours per fiscal year
•   Employees hired on or before December
31, 2012
How much universal life insurance
coverage can I get?
•   Employee:up to three times your annual
base salary, in $1,000 increments, without
answering health questions
•   Spouse under age 55:one times employee
annual base salary up to $30,000, in $5,000
increments
•   Spouse age 55 and over:$5,000, $10,000
or $15,000
•   Children up to age 24:you choose $2,500
or $5,000 in Children’s Term Rider coverage
In order to purchase the Children’s Term Rider
insurance coverage for your eligible children,
you must purchase coverage for yourself or
your spouse. The children’s coverage can
“ride” on or attach to either your or your
spouse’s policy, but not both.
Can I apply for more coverage?
Employee:up to five times your annual salary
up to a maximum of $300,000, in increments
of $5,000. You will be asked some health
questions.
You may apply to increase your coverage
during the annual enrollment transfer period
during 2013 and 2014.
Family coverage*
•   This insurance is available for your spouse,
by answering questions on his or her
medical history, even if you don’t apply for
your own coverage.
•   Coverage is available for your child(ren)
ages 24 hours to 24 years old.
Dependent children will not be covered if they
are married or in military service on a full-time
basis. Only one parent may cover your eligible
child(ren) under the Children’s Term Rider.
What are the features of universal
life coverage?
•   Your benefit and premium amount
is flexible.
•   This coverage can build cash value.
•   You can keep the coverage even if you
leave state employment or retire.
•   You can add universal life insurance to
enhance existing life coverage.
Cash accumulation and interest crediting
— You will begin gaining cash value during
the first month after the effective date
of coverage.
What other features are included?
Advance Benefit Rider — If you become
terminally ill and are not expected to live
more than six months, you may request up
to 50% of your life insurance amount, to a
maximum of $100,000. A doctor must certify
your condition. Any payout will reduce the
death benefit.
Waiver of premium— If you or your spouse
(if insured) become totally disabled before age
60 and remain disabled for nine consecutive
months, the premium payment will be waived
during the period of disability. Applicant must
complete a Waiver of Premium Claim Form
#1249-02 and submit to Unum within one
year of the date of disability.
You or your spouse (if insured) may continue
the waiver of premium provision up to age
95. Applies only to coverage for you and your
spouse and does not apply to coverage for any
dependent child.
Continuation of coverage— When you retire,
reduce your hours or leave the employment
of the State of Tennessee you may have
the option to continue your life insurance
coverage by paying your premiums directly to
Unum. A Unum representative will contact you
to discuss your options.
You may elect to continue your universal life
coverage regardless of your age.
Optional universal life insurance
If a primary wage
earner died:
1
• 34% of households
would have immediate
trouble paying
everyday living
expenses.
• 29% could cover
everyday living
expenses for only
several months.
• Only 37% could
cover everyday living
expenses well into the
future.
1
* For more information on family
coverage, please refer to the Eligibility
and Enrollment Guide. This is published
by Benefits Administration. If you would
like a copy, ask your Agency’s Benefits
Coordinator.
1
LIMRA, “Trillion Dollar Baby — Growing
Up: The Sales Potential of the U.S.
Underinsured Life Insurance Market,”
August 2011.
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Optional universal life insurance
Monthly premium rates per $1,000 of benefit amount* for employees and spouse
Age last
birthday
Monthly
rate
Age last
birthday
Monthly
rate
Age last
birthday
Monthly
rate
Age last
birthday
Monthly
rate
15 0.20 31 0.43 47 1.30 63 3.28
16 0.21 32 0.45 48 1.42 64 3.44
17 0.22 33 0.48 49 1.55 65 3.61
18 0.23 34 0.53 50 1.69 66 3.80
19 0.24 35 0.56 51 1.85 67 3.99
20 0.25 36 0.60 52 2.04 68 4.19
21 0.26 37 0.64 53 2.26 69 4.41
22 0.27 38 0.68 54 2.51 70 4.64
23 0.28 39 0.72 55 2.48 71 4.88
24 0.30 40 0.79 56 2.64 72 5.14
25 0.31 41 0.84 57 2.77 73 5.42
26 0.33 42 0.89 58 2.91 74 5.71
27 0.35 43 0.96 59 3.04 75 6.03
28 0.36 44 1.04 60 2.83
29 0.38 45 1.11 61 2.97
30 0.41 46 1.21 62 3.12
* Use this chart to figure out your total monthly premium. Multiply the desired amount of coverage by the appropriate rate per
thousand from the table, then add a $1 per month administrative charge.
Optional universal life insurance
Monthly premium rates for Children’s Term Rider
Amount Monthly Rate
$2,500 0.25
$5,000 0.50
There is no administrative charge for dependent children’s coverage.
Universal life worksheet
My rate$_______
x Amount
(in thousands)
_______
+ Admin. cost$ 1.00
=Total monthly cost $_______
My rate$.68
x Amount
(in thousands)
30
+ Admin. cost$1.00
=Total monthly cost $21.40
For example: Let’s say you are 38
and you would like to apply for
$30,000 in optional universal life
coverage. Your rate calculation
would look like this:
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What else do I need to know?
The amount of coverage you can have is limited:
•  You can apply for a benefit amount up to three times your
salary without answering any health questions.
•  You can apply for a higher benefit amount but you will be
asked health questions. The limit for this is five times your
salary. You can’t request more than $300,000.
What happens if my employment ends?
When you are no longer employed by the State, payroll
deduction will not be available. Unum will contact you at
your last known address to inform you of your options to
continue life insurance coverage once we receive notice
from the State.
Termination of insurance for employees and spouses
Your insurance will terminate:
•  If the monthly premium payment and cash value are no
longer adequate to support the coverage; or
•  If your loan balance exceeds the cash value of your
certificate.
If the covered employee stops “active” work for any
reason, Unum will mail to the employee’s last known home
address an offer to continue employee or dependent spouse
universal life insurance coverage by direct bill.
Termination of Children’s Term Rider
Dependent children are covered under a term rider which
cannot stand alone. Dependent coverage must “ride” on or
attach to the employee or spouse coverage.
The dependent Children’s Term Rider will terminate:
•  If the monthly children’s term premium is not paid;
•  If the certificate to which the Children’s Term Rider
attaches should terminate; or
•  If the dependent is no longer eligible.
Call the Contact Center when a dependent is no longer eligible
due to the plan’s eligibility rules. Upon notification that your
dependent is no longer eligible, Unum will send a letter to your
last known home address advising of the dependent’s options
to convert term coverage to permanent life. The dependent
will have 31 days from the date on the Unum letter to convert
to a permanent life insurance policy.
Failure to notify your employer and Unum of your dependent’s
change in eligibility status will result in termination of coverage
and a forfeiture of any conversion privilege. No refunds will be
made. If the dependent child/children do not wish to convert,
coverage will end on the last day of the month in which they
become ineligible.
Additional coverage
If you are applying for amounts over and above the guarantee
issue amount, call 1-866-310-6784.
Optional universal life insurance
Length of coverage — You are covered as long as your monthly
premium payment and cash value are adequate to support
the coverage.
Limitations/exclusions
If within 24 months from the date of issue of this coverage the
insured individual dies by suicide, while sane or insane, the
amount payable by Unum in place of all other benefits shall be
the sum of the premiums paid, without interest, less any debt
secured by this coverage.
What’s next?
Review the information
on the back cover,
complete the application
or call 1-866-310-6784
(8 a.m.–8 p.m. EST,
Mon–Fri) to apply.
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Who can choose to enroll in coverage?
You are eligible to enroll within the first 30 days of
employment in the optional universal life insurance
program if you are a regular full-time employee of the
State of Tennessee or higher education and are scheduled
to work at least 30 hours per week. If you do not enroll
during this period, you cannot apply for this coverage.
Can I apply for spouse coverage?
Yes, you are eligible to enroll your spouse within the
first 30 days of employment in the optional universal life
insurance program if you are a regular full-time employee
of the State of Tennessee and are scheduled to work at
least 30 hours per week. If you do not enroll your spouse
during this period, you cannot apply for this coverage. If
your spouse is also employed by the State of Tennessee,
he or she cannot be covered under spouse coverage.
They must apply for their own coverage as an employee.
Can I apply for child(ren) coverage?
Yes, the children must be at least one day or 24 hours
old, and they may remain covered until the end of the
month in which they turn 24 years of age as long as they
continue to meet eligibility requirements. If you do not
enroll within the first 30 days of employment, you cannot
apply for coverage for your existing child(ren). You can
add coverage for a newborn or adopted child within 30
days of the birth or adoption. If you do not add coverage
during this time, you cannot apply for this coverage.
If both parents are State or higher education
employees, can each employee carry coverage for the
child(ren)?
No, only one parent may cover the eligible children under
the Children’s Term Rider. If you purchase coverage,
children’s coverage must be attached to your coverage.
FAQ
Frequently
asked
questions
Is children’s coverage automatically terminated when
they reach age 24?
Children’s coverage will not be continued past age 24.
However, it will be your responsibility to notify Unum
when your child/children are no longer eligible.
Is guarantee issue coverage available for
new employees?
Yes, as a new employee, you are eligible to enroll for
an amount up to three times your annual base salary.
That amount is called “guarantee issue.” You must apply
during the first 30 days of employment. If you apply for
any amount over three times (up to the plan maximum
of five times), you will need to answer health questions.
Is guarantee issue coverage available for my spouse?
If you are a new employee, your spouse may apply for
coverage in $5,000 increments. If your spouse is under
age 55, you can choose coverage equal to one times your
annual base salary, up to a maximum of $30,000. If your
spouse is age 55 or older, the maximum available for
guarantee issue is $15,000. If the answer is “yes” to the
hospital/medical question in Section 3 of the application
(regardless of age), guarantee issue coverage will not be
provided, and he or she will be required to answer health
questions by completing a supplemental application.
Is guarantee issue coverage available for
my child(ren)?
Yes, you may choose either $2,500 or $5,000 in
coverage, and they will not have to answer any
health questions. This will be guarantee issue as long
as you apply for coverage within the first 30 days
of employment.
If I have to answer medical questions to qualify for
coverage, what kind of questions will I be asked?
You will be asked various questions about your medical
history over the last 10 years, such as, “Have you had a
heart attack, stroke, or been diagnosed with diabetes or
HIV?” etc.
When does my coverage take effect?
If you enroll as a new employee, your coverage will
become effective the first day of the month after
you have completed three full calendar months
of employment and you meet the eligibility requirements.
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When does coverage take effect for my dependents?
If your dependents enroll at the same time you enroll,
their insurance will become effective on the same date as
yours. (See previous question.)
Is there a waiver of premium benefit?
Yes, if you or your spouse (if insured) become totally
disabled before age 60 and remain disabled for nine
consecutive months, you will no longer be required to
pay the insurance premium for the disabled person, as
long as disabled.
What happens if my employment ends?
Unum will contact you at your last known address
to let you know what options you may have to
continue coverage.
Can I decrease my coverage?
Yes, a request to decrease your coverage may be
submitted for any policy anniversary (January 1 of each
year), provided you request the decrease at least 45
days prior to that date. Decreases may not reduce the
coverage to less than $5,000.
How are employee and dependent claims filed?
You may download a claim form from unum.com, or you
may call the Contact Center at 1-866-298-7636
(8 a.m.–8 p.m. EST, Mon–Fri).
Who do I contact if my spouse or I become disabled?
Call the Contact Center at 1-866-298-7636 to
report your disability.
How do I apply for an advanced benefit?
You may download a claim form from unum.com, or you
may call the Contact Center at 1-866-298-7636.
What happens if I recover?
If you recover, you will not be required to refund your
benefit. Simply notify Unum of your recovery and resume
paying the premiums for your coverage.
What can the Contact Center do for me?
Contact Center representatives are there to answer your
questions and guide you through the claims process.
Who do I call about questions on eligibility
and enrollment?
Call 1-866-310-6784 for questions about eligibility
and enrollment, Monday through Friday 8 a.m. to 8 p.m.
Eastern Standard Time.
Can I cancel coverage?
Yes, you can cancel your coverage at any time by
completing a Customer Service Request Form (L-52490).
What if I need to make changes on a policy?
You can make changes such as name, address, or
beneficiary by completing a Customer Service Request
Form (L-52490). However, changes regarding face
amount such as an increase or decrease may only be
processed during the annual enrollment transfer period,
as described previously.
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You can apply for up to
5 times your annual earnings,
up to $300,000, by answering
a few health questions.
Call 1-866-310-6784
(8 a.m.–8 p.m. EST, Mon–Fri)
and speak to a benefits
representative to apply.
Don’t miss your opportunity
to apply!
Instructions for completing
State of Tennessee Universal Life
Form #AE-1115
Insurance enrollment application
Employee/spouse (Section 1/Section 3)
Please note: If applying for spouse coverage, the
employee portion on the application must also
be completed.
•  Enter the full name of the employee/spouse
(first, middle, last).
•  Enter the full street address or post office box number.
•  Enter the full city, state & ZIP.
•   Enter employee e-mail address.
•   Enter the annual base salary, excluding over-time and
longevity (employee only).
•  Enter Social Security number.
•   Enter gender.
•   Enter birth date.
•   Enter daytime and cell phone numbers.
WE MUST HAVE THIS INFORMATION(employee only).
•  Enter date of hire (employee only).
Employee/spouse (Section 2/Section 4)
•  For employees:Enter the amount of insurance
desired. Coverage cannot exceed three times
the employee’s salary (without answering health
questions) or up to five times the employee’s salary
(by answering health questions), excluding over-time and longevity, rounded to the next $5,000,
with a maximum of $300,000. Optional universal life
insurance may be selected in $1,000 increments.
•  For spouse:Enter the amount of insurance desired.
The amount of coverage cannot exceed one times
employee’s annual base salary, excluding overtime
and longevity, rounded to the next $5,000 with a
maximum of $30,000. For spouses age 55 and older
the maximum amount is $15,000.
•  Enter amount of Children’s Term Rider (if applying).
You may apply for a Children’s Term Rider on one
certificate (employee or spouse) only.If applying for
employee and spouse coverage, the Children’s Term
Rider will be added to the employee’s certificate.
•  Enter the full name and address of the
beneficiary(ies) and the relationship to the employee.
•  If you have multiple beneficiaries, indicate the
benefit amount you would like to designate to
each beneficiary.
•  Employee MUST sign and date the application.
Mail your application to:
Unum
Attention: VB New Business, 2W
P.O. Box 190002
Chattanooga, TN 37401-7210
or to apply, call:
1-866-310-6784
STATE OF TENNESSEE
APPLICATION FOR OPTIONAL UNIVERSAL LIFE
Provident Life and Accident Insurance Company
Chattanooga, TN 37402
SECTION 1: Employee Information – Always Complete
Employee Name (First, Middle, Last)    Social Security Number
Home Address (Street/PO Box)    Gender
 F   M
City    Date of Birth (mm/dd/yyyy)
State  ZIP Code     Daytime Phone
Email Address      Cell Phone
Employee Annual Base Salary      Date of Hire (mm/dd/yyyy)
$
SECTION 2: Employee Certificate Information
Employee Coverage
Minimum - $5,000
Maximum - Five times your annual base salary, rounded to the next higher multiple of $5,000 up to $300,000. A
supplemental application must be completed and submitted for amounts over three times annual base salary.
Universal Life
Employee Coverage Amount $
Beneficiary Relationship Beneficiary Relationship
Address  Percentage  Address  Percentage
Children’s Coverage
Children’s coverage will be automatically attached to the employee certificate if employee coverage is selected.
If coverage is attached to the employee certificate, it cannot be attached to the spouse certificate.
Children's Term Rider   2,500   5,000
SECTION 3: Spouse Information – Always show name – Fully Complete for Coverage
Name (First, Middle, Last)    Social Security Number
Home Address (Street/PO Box)    Gender
 F   M
City    Date of Birth (mm/dd/yyyy)
State  ZIP Code  
Has spouse been hospitalized, advised to seek medical treatment, or received disability benefits during the last 6 months?
 Yes   No
If yes, submit supplemental application.
AE-1115 (09/12)  1
AE-1115 (09/12)  2
SECTION 4: Spouse Certificate Information
Spouse Coverage
Minimum - $5,000
Maximum - Less than Age 55: one times employee’s annual base salary up to $30,000 in $5,000 increments
Maximum - Ages 55 and Over: $15,000
Universal Life
Spouse Coverage Amount $
Beneficiary Relationship Beneficiary Relationship
Address  Percentage  Address  Percentage
Children’s Coverage
Please note you can not add children’s coverage to the spouse certificate if children’s coverage has already been added
to employee certificate.
Children’s Term Rider   2,500   5,000
The beneficiary of children’s term insurance is the employee, if living, otherwise the estate of the covered child.
I certify that the information on this application is true and complete and that I am an eligible Employee and Actively at
Work/Positive Pay Status on the date of my signature below. I understand that if I have selected insurance for myself, it
will begin on the Certificate Issue Date; provided I am an eligible Employee and Actively at Work/Positive Pay Status on
that date.
Dependent Spouse and/or Dependent Children’s Coverage, if selected, will begin on the Certificate Issue Date; provided:
(1) I am an eligible Employee and Actively at Work/Positive Pay Status on that date; and (2) my Dependent Spouse and/
or Dependent Child(ren) is/are able to engage in normal activities on the date the coverage is to become effective.
I authorize the State Group Insurance Plan to release to Unum on behalf of myself and all family members information
(name, address, social security number, age, gender, salary, enrollment effective/termination dates) required to establish
eligibility and coverage levels for the purpose of obtaining life insurance coverage. This authorization shall be in force for
the time period I have a pending application or am enrolled with this life insurance company. The State Group Insurance
Plan will not condition treatment, payment, or enrollment eligibility on the signature of this authorization and may not have
the right to control further disclosures of this information.
I understand that I, as the Employee, am the owner of all coverages applied for. I authorize my Employer to deduct the
proper premiums for this insurance from my earnings.
Any person who, knowingly and with intent to defraud or deceive any insurance company, submits an insurance
application or files a claim containing any false, incomplete or misleading information may be subject to civil or
criminal penalties, depending upon state law.
Employee Signature __________________________________________________Date ________________________
FOR HOME OFFICE USE ONLY
DEDUCTION AMOUNT:  E ________________ S ________________ C _______________ TD ________________