State of Connecticut

This page was last updated on: June 22, 2015


Exhibit A

Sample Statement

Table of Contents  




Important Information About Your Retirement Benefits

 2, 3

Pension and Health Care Benefits for Same Sex Domestic Partners


Additional Benefits for Active Employees


Your Benefits at Retirement

 4, 5

Your Disability Benefits


Your Survivors' Benefits


Medical and Dental Benefits as an Active Employee


Personal Information


Additional Service Credit



Page 1

Dear Fellow Employee:

We are pleased to provide you with this statement of your benefits as a Connecticut State Employees Retirement System member.

This statement is designed to help you understand the scope and value of the benefit plans available to you as a retirement system member and active state employee. These benefits are a significant part of your total compensation and play an important role in maintaining you and your family's financial security and well-being. Therefore, we encourage you to review all of the information contained in your statement and share it with your family. Your clear understanding of these plans will ensure that they meet your expectations and enable you to derive the greatest benefit from them.

For your reference, general State employee benefit information is available on the Internet at

This year's cover design honors the University of Connecticut men's and women's basketball teams - the 2004 NCAA National Champions. Way to go Huskies!


Nancy Wyman
State Comptroller
Office of the State Comptroller

Thomas C. Woodruff, Ph.D.
Director, Retirement & Benefit Services Division
Office of the State Comptroller

* Image used by permission of the State of Connecticut

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Page 2

Important Information About Your Retirement Benefits

The retirement benefits shown on this statement assume that all years of plan service you have at retirement will be as a State Employees Retirement System (SERS) member. If you have periods of service in another Retirement System, please consult that system for details.

The benefit estimates for the Payment Options shown on page 5 of this statement in the section entitled "Your Retirement Benefits" are for illustrative purposes only. At retirement, you must choose the form of payment which best suits your personal needs. Your payment option should be chosen with care since it cannot be changed after retirement benefits commence. The figures reflect the assumptions that you will work and participate in the Retirement Plan on a continuous and full-time basis from the employment date shown until the age indicated and that you are married to a spouse the same age as you are. These amounts are intended to familiarize you with the optional forms of payment available at retirement; they do not portray actual benefits. Additional service credit, breaks in service, leaves without pay, and part-time service will affect the amounts shown. In most cases, so will the age at which you retire and the age of your spouse or other contingent annuitant. You should not act in reliance on the amount of the benefits indicated without verification of the amount of such benefits. When you retire, your actual service credit and average salary will be determined precisely and used to calculate your retirement benefit.

At retirement, you have the following payment options available to you:

If you have been married for at least one year prior to the commencement of your retirement benefits, written consent from your spouse will be required if you do not provide a lifetime (50% or 100%) option for that spouse.

If you elect the straight life annuity option, at the time of your death not only do all pension payments stop, but health insurance through the State Employees Retirement System also ends for any dependents you were covering.

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Page 3

If you elect the 50% Spouse, Contingent Annuitant, or a 10 Year or 20 Year Period Certain Option, the State-sponsored health coverage may be extended at the time of your death to your designated contingent annuitant(s) and his or her eligible dependents for as long as the monthly benefit continues provided certain conditions are met.

Pension and Health Care Benefits for Same Sex Domestic Partners

Same sex domestic partners of state employees are now eligible for coverage under the pension and health benefit plan provisions discussed in this statement. To that end, the term "spouse" is also intended to mean "same sex domestic partner" whenever it appears herein. Please note that, in order for a state employee to access these benefits for his or her same sex domestic partner, an "Affidavit of Domestic Partnership" (Form CO-1049) must be filed with and accepted by the Retirement & Benefit Services Division. Further, the "Affidavit" must be in effect for at least one year before certain survivorship benefits become activated. Pension and health care benefits for same sex domestic partners of state employees are more fully discussed in Comptroller's Memorandum No. 2000-13 which, along with the "Affidavit" is available on the Internet at, directly from the Comptroller's Office or from your agency personnel/payroll office.

Additional Benefits for Active Employees

The Supplemental Employee Benefits Program is designed to provide employees with access through the State Payroll System to offerings that complement those basic benefits the state funds either in whole or in part. All benefits under the Program are paid for in their entirety by voluntary employee payroll deduction. Certain benefits are available to the employee's spouse, same sex domestic partner, and children. The following seven supplemental benefits are offered: (1) Short Term Disability, (2) Long Term Disability, (3) Auto & Homeowners Insurance, (4) Cancer Insurance, (5) Universal Life Insurance, (6) Term Life Insurance, and (7) Long Term Care. Eight vendors are authorized to participate in the Program.

The State of Connecticut Deferred Compensation (457) Plan is a convenient, tax-deferred long-term savings plan designed to supplement your retirement income and help you achieve your retirement lifestyle goals. There are three financial services organizations authorized to participate in the Plan.

The State of Connecticut 403(b) Program is an employer sponsored, tax-sheltered retirement supplement similar to the Deferred Compensation (457) Plan. However, pursuant to federal law, participation in the 403(b) Program is limited to eligible state educational employees. There are six financial services organizations authorized to participate in the Program.

The Qualified Transportation Fringe Benefit Program allows State of Connecticut Employee Commuters to pay for transportation expenses on a pre-tax basis.

For complete information on benefits offered and participating vendors, you may refer to the Internet at or contact your agency personnel/payroll office.

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Page 4

Your Benefits at Retirement

Your benefit thus far . . . You earn retirement benefits over your years of participation in the plan. Should your State employment end before you retire, the Plan will provide you with a vested right to a monthly benefit if you meet the terms of either the 5 year or 10 year service requirement. Note: under the 5 year vested rights retirement, benefits may not commence until the first of the month on or following age 65.

If you do not qualify for retirement when you leave State service, you may elect to receive a refund of your contributions and interest in lieu of any other benefits from the Plan.

Contributions and Interest, 7/1/2003 $2,403
Interest earned 7/1/2003 - 6/30/2004 $120
Contributions made, 7/1/2003 - 6/30/2004 $855
Your current contribution balance with interest, as of 7/1/2004 $3,378

Your benefit at normal retirement . . . The retirement income you receive will depend on your length of service and your average annual covered salary for the three highest 12 consecutive month periods prior to retirement. By counting the years of service you will have in the Pension System at retirement, and by approximating what your average annual covered salary will be, you can find your estimated retirement benefit in the chart below.

Please realize that this chart is provided only as a guide. If your salary falls between two of the figures in the chart, your retirement benefit will fall between the two monthly benefit amounts shown for those salaries.

Years of Straight Life Monthly Benefit, if
Plan Service Average Annual Salary is:
at age 62 $45,000 $50,000 $55,000 $60,000
5 $249 $277 $304 $332
10 $498 $554 $609 $665
15 $748 $831 $914 $997

20 $997 $1,108 $1,219 $1,330
25 $1,246 $1,385 $1,523 $1,662


$1,496 $1,662 $1,828 $1,995
35 $1,745 $1,939 $2,133 $2,327
40 $2,050 $2,278 $2,505 $2,733

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Page 5

As a Tier IIA member, you may retire with a normal retirement benefit at age 62 if you have 5 years of actual state service or 10 years of vesting service. You may also retire with a normal retirement benefit at age 60 if you have 25 or more years of vesting service. A reduced benefit may be paid at age 55 if you have 10 years of vesting service. You may use the early retirement benefit formula in the Tier IIA summary plan description booklet to determine your approximate benefit.

Your benefit payment options at retirement . . . When you retire, you must choose to receive your retirement income in a form of benefit payment best suited to your needs and the needs of those who may rely upon you to provide continuing income. An option should be chosen with care since it cannot be changed after retirement benefits commence.

The chart below illustrates the various payment options calculated based upon the following assumptions: you have continuously participated in the Pension System from 10/29/1997 as a full-time employee, your average salary is $50,000, you are married, your spouse is your sole contingent annuitant and is the same age as you. Please refer to the section entitled "Important Information about Your Retirement Benefits" on page 2 of this statement for more information regarding payment options. 

Estimated Monthly Benefit At Age 62 Beginning 7/1/2027:
Payment Options Income During Your Lifetime Beneficiary Income After Your Death
Straight Life Annuity $1,644 $0
50% Spouse $1,474 $737
100% Contingent Annuitant $1,336 $1,336
10 Year Period Certain $1,569 $1,569
payable only for 10 years after retirement

20 Year Period Certain $1,365 $1,365
payable only for 20 years after retirement

Life Insurance

For members who participate in Group Life Insurance, a reduced amount of insurance will be provided.

Medical and Dental Benefits

When you retire, if eligible, you may elect medical and dental coverage for yourself and eligible dependents. You may be responsible for a share of the medical insurance premiums depending upon the plan you select; the state currently pays a percentage of your dental insurance premium.

If you are considering retirement, you should see your agency personnel office or the Retirement & Benefit Services Division's Counseling Services Unit for more accurate estimates.

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Page 6

Your Disability Benefits Your Survivors' Benefits
Sick Leave Benefits In the event of your death, your survivors may receive:
If you are unable to work due to sickness, the State will continue your salary for a limited time, based on accumulated sick leave.

Lump-Sum Benefits
$38,000 Group Life Insurance (as of 6/30/2004)
$3,378 Retirement Plan Contributions Plus Interest
Life Insurance Monthly Benefits
If you participate in Group Life Insurance and you are totally disabled, your insurance may be continued at no cost to you. Please refer to the Total and Permanent Disability provision in the Group Life Insurance summary plan document that may be accessed on the Internet at or contact your agency personnel/payroll officer for more information. If you have been married for at least one year and either have 25 years of service or are eligible for regular retirement, upon your death your spouse would be eligible for a monthly benefit from the Retirement Plan, in lieu of your Retirement Plan Contributions and Interest.
Retirement Plan Medical and Dental Benefits
If you experience a job-related disability, you may qualify for a monthly disability benefit from the Retirement Plan.

If the disability is not job-related, you must have 10 years of service with the State.

This benefit may be coordinated with other sources of income. Your monthly disability benefit from the Retirement Plan plus Social Security benefits and Workers' Compensation benefits will not be less than 60% of your State salary.
If your spouse is receiving monthly retirement benefits, medical and dental coverage will continue for the duration of the monthly payments provided certain conditions are met. The State pays towards the cost of this coverage. If not receiving monthly benefits, your surviving spouse and/or children may continue their medical and dental coverage at their expense for a limited period of time following your death.

If You Become Seriously Ill or Injured While in State Service . . .

Should you become seriously ill, injured, or have a life threatening condition, you or someone on your behalf should contact the Retirement & Benefit Services Division's Counseling Services Unit as soon as possible to ensure receipt of benefits, if eligible. Contact with the Counseling Services Unit may be made directly or through your employing agency.

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Page 7

Medical And Dental Benefits as an Active Employee

Medical Benefits

For employees residing in Connecticut, the following options are available from Anthem Blue Cross/Blue Shield, Health Net and ConnectiCare:

Employees residing outside of Connecticut have the option of enrolling in the State Preferred Point of Service plan; the employee cost is the same as the State BlueCare Point of Service plan. Additionally, Health Net and ConnectiCare each have networks in certain areas of surrounding States. Contact the respective health plan for network participation.

Anthem Prescription administers pharmacy benefits for all covered employees, retirees, and dependents regardless of medical carrier. All prescription drugs must be dispensed by pharmacies participating in the Anthem Prescription network.

Dental Benefits

Employees have the option of enrolling in the Indemnity Dental Plan offered by Anthem Blue Cross/Blue Shield or in the CIGNA Dental Care Plan, a dental HMO.

Each Spring, an annual summary of health care options, prepared jointly by the Office of the State Comptroller and the Labor-Management Health Care Cost Containment Committee, is mailed to employees' home addresses; please refer to that summary or contact your agency personnel/payroll office for more information regarding the plan options as well as information about enrollment procedures. The summary of health care options may also be accessed on the Internet at

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Page 8

Personal Information

Your benefits and personal data have been valued as of: June 30, 2004

This statement has been based on the following information:

Social Security Number -
Employee Number - 333333
Date of Birth - 6/13/1965
Retirement Plan coverage - TIER IIA
Retirement Plan beneficiary(ies) Life Insurance beneficiary(ies)
Retirement Beneficiary I Life Beneficiary I


If You Have Questions . . .

While retirement may be far in the future for most of us, it is a time of life that should be planned for. If you have any questions about any portion of this statement or need more specific information regarding your retirement benefit, see your agency personnel officer. If any of the personal data shown on this statement is incorrect, your agency will provide the forms to correct it. Any changes to your name, address, and beneficiaries will not be made without the proper form.

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Page 9

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Additional Service Credit Sample Employee IIA 333333

Listed below is miscellaneous service for which our records indicate you have additional retirement credit. If any of the information is incorrect or incomplete, tear off the panel and return it directly to the Retirement & Benefit Services Division, 55 Elm Street, Hartford, Connecticut 06106, Attention: Data Base Unit. You must forward a copy of the acknowledgement or credit letter with the panel; Tier II non-contributory members may forward a copy of Form CO-922 instead. If you did not retain this documentation, see your agency. Please note: Purchases in progress are not reflected.

Our records indicate you have no miscellaneous service for additional retirement credit.

There are certain limited types of additional service credits that may be purchased by Tier IIA members.

Contact your agency personnel officer or the Retirement & Benefit Services Division's Counseling Unit for information.


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Back Cover

Department of Transportation
Personnel Office
2800 Berlin Turnpike
Newington, CT 06111

Especially prepared for:

GH 333333 3
Sample Employee IIA
55 Elm Street
Hartford, CT 06106

As of: June 30, 2004