Date



BENEFIT BASED EMPLOYEES

SEPARATION INFORMATION

THE FOLLOWING APPLIES TO EMPLOYEES WHO ARE BENEFIT PLAN PARTICIPANTS

Health, Dental and Vision Insurance and Health Care Spending Account: If you are currently covered under the university’s plans, you will receive a letter from USD’s COBRA administrator, Benesyst explaining the options on continuing health, dental or vision insurance, and the health care spending account. Your COBRA letter will be mailed within two weeks from the date of your separation. Benesyst can be reached toll-free at 1-877-401-9807 for any questions regarding COBRA continuation coverage

Life Insurance: You have the option to continue your basic and/or voluntary life insurance at group rates if you do not have an illness or injury which has a material effect on your life expectancy at termination. You also have an option to apply to convert your USD Group Life insurance coverage to a personal life insurance policy. The amount of personal life insurance can be less than or equal to the amount available while employed at USD. If you have questions regarding Policy FLX964920 please contact CIGNA at 1-800-423-1282.

Accidental Death & Dismemberment (AD&D) Insurance: You do not have the option to convert the AD&D plan to an individual policy. Coverage ends at the end of the month in which you terminate employment.

Long Term Disability: You do not have the option to convert the LTD plan to an individual policy. Coverage ends at the end of the month in which you terminate employment. If you have questions regarding Policy LK-963432, contact CIGNA at 1- 800-423-1282.

Retirement 403(b) Investments: You are not required to withdraw your funds. However, if you are interested in withdrawal or want rollover information, please contact the Fund Administrator.

TIAA-CREF: 1-800-842-2776* AIG VALIC: 800-448-2542 FIDELITY: 1-800-343-0860

* Participants interested in a TIAA-CREF distribution rollover or withdrawal should contact TIAA-CREF within 120 days)

Tuition Remission: Undergraduate tuition remission is available to IRS defined dependent children if you retire after 15 years of service at age 65 or older. If you terminate during a semester in which you or a dependent are attending classes using tuition remission, the tuition will be pro-rated for the remainder of the semester.

Post Retirement Medical: If you are retiring with at least 10 years of benefit based service and are 59 ½ years old, you may be eligible for Post Retirement Medical Reimbursement of up to $1,194* per year. You must meet the following criteria:

• At least age 65

• Enrolled in Medicare Part B and/or a supplemental health plan

You may apply by submitting a written request and proof of payment for Medicare Part B (SSA-1099) or supplemental insurance. Reimbursements are prepared at the end of each quarter for those who have submitted proper documentation.

*The annual reimbursement amount is subject to review for change or cancellation each calendar year.

For questions about health, dental, vision, life and disability Insurance, post-retirement medical, retirement plans, tuition remission or tuition exchange, please contact – Benefits 619-260-4594.

I acknowledge receipt of the information provided above.

Employee Name:___________________________________________ Date:______________________

Signature:_________________________________________________

I: Benefits; benefits department forms; term post retire

Rev. Sept 17, 2014

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