Form ADM4302 "Group Life Insurance Continuation Laid off Employees" - Ohio

What Is Form ADM4302?

This is a legal form that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2015;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ADM4302 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form ADM4302 "Group Life Insurance Continuation Laid off Employees" - Ohio

237 times
Rate (4.6 / 5) 12 votes
ADM 4302
GROUP LIFE INSURANCE
CONTINUATION LAID OFF EMPLOYEES
Pursuant to Ohio Revised Code Section 124.81(C) and applicable Administrative Rules, you are
entitled to have life insurance coverage while in laid-off status for a period of one year providing
you pay the total year premium prior to leaving state service. You may be eligible for a partial
refund if you are recalled from layoff within 12 months.
Employee Name____________________________ State of Ohio User ID____________
Agency Name______________________________ Bargaining Unit # ____________
Amount of Coverage:_________________ (See the “Group Life” amount on your OAKS paystub).
Date of Layoff:_______________________
Rate: $0.130 per $1,000/month for bargaining unit members
$0.105 per $1,000/month for exempt employees
Examples: $40,000 = 40 units X $.130 X 12 months = $62.40 (bargaining unit employees)
$40,000 = 40 units X $.105 X 12 months = $50.40 (exempt employees)
TOTAL ANNUAL PREMIUM $____________
I elect coverage in the amount listed above and have attached a personal check or money order for the
annual premium amount.
__________________________________________________________________
Employee signature
Date
Payment Instructions:
Employees represented by a bargaining unit should make their check payable to Prudential and mail it
along with this form to: Union Benefits Trust, 390 Worthington Rd, Suite B, Westerville, OH 43082
Exempt employees should make their check payable to: Employee Benefit Fund 8100 and mail it along
with this form to: Benefits Administration Services, c/o Life Insurance Manager, 30 E. Broad St., 27th
Floor, Columbus, OH 43215.
DO NOT WRITE BELOW THIS LINE
Coverage begins (month after layoff):_________________Coverage expires:____________
Date paid:______________ Amount paid:____________ Date of refund:_______________
Adm4302 (rev 01/15)
ADM 4302
GROUP LIFE INSURANCE
CONTINUATION LAID OFF EMPLOYEES
Pursuant to Ohio Revised Code Section 124.81(C) and applicable Administrative Rules, you are
entitled to have life insurance coverage while in laid-off status for a period of one year providing
you pay the total year premium prior to leaving state service. You may be eligible for a partial
refund if you are recalled from layoff within 12 months.
Employee Name____________________________ State of Ohio User ID____________
Agency Name______________________________ Bargaining Unit # ____________
Amount of Coverage:_________________ (See the “Group Life” amount on your OAKS paystub).
Date of Layoff:_______________________
Rate: $0.130 per $1,000/month for bargaining unit members
$0.105 per $1,000/month for exempt employees
Examples: $40,000 = 40 units X $.130 X 12 months = $62.40 (bargaining unit employees)
$40,000 = 40 units X $.105 X 12 months = $50.40 (exempt employees)
TOTAL ANNUAL PREMIUM $____________
I elect coverage in the amount listed above and have attached a personal check or money order for the
annual premium amount.
__________________________________________________________________
Employee signature
Date
Payment Instructions:
Employees represented by a bargaining unit should make their check payable to Prudential and mail it
along with this form to: Union Benefits Trust, 390 Worthington Rd, Suite B, Westerville, OH 43082
Exempt employees should make their check payable to: Employee Benefit Fund 8100 and mail it along
with this form to: Benefits Administration Services, c/o Life Insurance Manager, 30 E. Broad St., 27th
Floor, Columbus, OH 43215.
DO NOT WRITE BELOW THIS LINE
Coverage begins (month after layoff):_________________Coverage expires:____________
Date paid:______________ Amount paid:____________ Date of refund:_______________
Adm4302 (rev 01/15)