Enrollment Form
Non-Contributory Long Term Disability Plan
UNUM Life Insurance Company of America

Name _______________________________ Soc Sec # _________________________________

Birth Date __________________________ Employment Date __________________________

Position _______________________________________

Quarterly Premium Calculation:
1. Your Annual Church Salary                                                                                $ _ _ , _ _ _

2. Annual Housing Allowance and/or Fair Rental Value
    of Manse As Reported on IRS Form 1040 - Schedule SE
    (for most recently completed tax year)                                                                           $ _ _ , _ _ _

3. Total (add lines 1. and 2.)                                                                                        $ _ _ , _ _ _

4. Quarterly Salary (divide line 3. by 4)                                                                       $ _ _ , _ _ _

5. Group Rate                                                                                                               . 0 0 5 0

6. Quarterly Premium (multiply line 4. times line 5.)                                                       $ _ _ _ . _ _

Benefit Summary:
Disability Defined: you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and, you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury
Monthly Benefit: 60% of monthly earnings to a maximum benefit of $5,000 per month
Elimination Period: 180 days (disabled participant would have to wait this length of time before benefits would begin)
Duration of Benefits: if under age 62 when disabled then to age 67; if age 62 then 60 months; if age 63 then 48 months; if age 64 then 42 months; if age 65 then 36 months; if age 66 then 30 months; if age 67 then 24 months; if age 68 then 18 months; if age 69 and over then 12 months
Deductible Income: benefits are reduced for Social Security retirement/disability payments received by employee and dependents, Worker's Compensation, and certain other income
Pre-existing: a condition existing 3 months before enrollment will be excluded for 12 months

Please complete, sign and return this form to the Board of Stewardship.

I understand that the presbytery or agency is providing this coverage as a benefit to its full-time ministers and, in some cases, other eligible employees. Moreover, the information submitted on this form will determine the premium and, therefore, will impact any future benefits.

Employee Signature ________________________________ Date _______________________