SCPMG Group Personal Excess Enrollment

1
Would you like to enroll, change limits, or cancel coverage with the Chubb Group Personal Excess Liability Program?* This field is required.Enrollments/Changes/Cancellations will be processed Quarterly. Submission Date Effective Date May 21 – June 20, 2024 July 1, 2024 June 21 – September 20, 2024 October 1, 2024 September 21 – Dec 20, 2024 January 1, 2025 Dec 21, 2024 – March 20, 2025 April 1, 2025 To be eligible for coverage, you must be actively employed by SCPMG as of the effective date of coverage.
Enroll as a new participant
Make changes to my existing coverage
Cancel coverage
2
Please select a Group Personal Excess Liability Limit with corresponding annual premium* This field is required.Excess coverage above your current homeowners and auto liability limits. Premiums below reflect annual premiums. Premium will be pro-rated to your policy term.
$1,000,000 - $837.61
$2,000,000 - $1,149.70
$3,000,000 - $1,328.70
$5,000,000 - $1,609.89
$10,000,000 - $2,576.25
3
Please select Group Personal Excess Liability Insurance Uninsured Motorist/Underinsured Motorist Limit with corresponding annual premium* This field is required.Please select a limit equal or less than Group Personal Excess Liability Limit chosen previously. Uninsured/Underinsured liability coverage protects you if you are involved in an accident and the person that caused the accident either does not have any insurance, or does not have enough liability insurance, to pay for you or your passenger injuries. Premium noted is in addition to the Group Personal Excess Liability Limit. Premiums below reflect annual premiums. Premium will be pro-rated to your policy term.
$1,000,000 - included
$2,000,000 - $154.50
$3,000,000 - $358.44
$5,000,000 - $631.39
4
Select Employment Practices Liability CoverageThis covers employment-related discrimination, sexual harassment, and wrongful termination for five or fewer residence employees working 15 hours or more per week. Premium noted is in addition to the Group Personal Excess Liability Limit. Premiums below reflect annual premiums. Premium will be pro-rated to your policy term.
$250,000 per Occurrence/$500,000 Aggregate - $894.04
$500,000 per Occurrence/$500,000 Aggregate - $1,340.03
5
Total Annual PremiumBased on the coverage limits selected previously, your annual premium has been calculated below. The below annual premium is for the coverage period between 7/1/2024 to 7/1/2025. Premiums below reflect annual premiums. Premium will be pro-rated to your policy term.
USD
6
Total Annual Premium (double check)
USD
7
Full Legal Name* This field is required.
Prefix
Legal First Name*
Middle Name
Last Name*
Suffix
8
SCPMG Email Address* This field is required.IF YOU EXPERIENCE AN ISSUE ACCESSING THIS PLATFORM, YOU MAY HAVE SUCCESS USING YOUR PERSONAL DEVICE. OUR TEAM STANDS READY TO HELP IF YOU NEED ADDITIONAL ASSISTANCE. PLEASE CALL US AT 503-601-6877.
9
Please select the classification that best fits you.* This field is required.
Active Partner Physician
Active Associate Physician
Active Oral Surgeon
Active Podiatric Physician
Active Administrative Leader
10
What is your NUID Number?* This field is required. If you need help finding your NUID number, please contact PHR Shared Services at 1-877-608-0044 or PHRSharedServices@kp.org
11
What is your SCPMG ID (i.e. EMPLID or 22#)?* This field is required. If you need help finding your SCPMG ID number, please contact PHR Shared Services at 1-877-608-0044 or PHRSharedServices@kp.org
12
What is your home address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Personal Email Address* This field is required.
example@example.com
14
Work Phone Number* This field is required.
Area Code
Phone Number
15
Mobile Phone* This field is required.
Area Code
Phone Number
16
Acknowledgement* This field is required.The information provided herein is for general information only and does not reflect all of the terms, conditions or exclusions of the policy being offered. The insurance afforded by this enrollment form will be subject to all terms, conditions and exclusions provided under the Chubb Group Personal Excess Liability Insurance policy.
By submitting here, I acknowledge enrollment or changes to the Chubb Group Personal Excess Liability Insurance program and agree to pay the policy premium. (If you make a change that results in a refund, it will be mailed to you within 45 business days of the effective date of the change. If you make a change that results in an increase to premium, you will be payroll deducted after the coverage effective date. Premium will be payroll deducted in most cases.)
17
Are you an Active Partner Physician, Associate Physician, Oral Surgeon, Podiatric Physician, or Administrative Leader?* This field is required.
YESNO
18
What is your reason for canceling coverage?* This field is required.
19
Did you replace coverage? If so, with what carrier? * This field is required.
Should be Empty: