HomeMy WebLinkAbout900520.tiff RESOLUTION
RE: APPROVE INSURANCE CONTRACT WITH RELIANCE STANDARD LIFE
INSURANCE COMPANY AND AUTHORIZE CHAIRMAN TO SIGN
WHEREAS, the Board of County Commissioners of Weld County,
Colorado, pursuant to Colorado statute and the Weld County Home
Rule Charter, is vested with the authority o£ administering the
affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with an Insurance
Contract with Reliance Standard Life Insurance Company, and
WHEREAS , the terms and conditions of said Contract are as
stated in the Contract, a copy of which is attached hereto and
incorporated herein by reference, and
WHEREAS, after study and review, the Board deems it advisable
to approve said Contract.
NOW, THEREFORE, BE IT RESOLVED by the Board of County
Commissioners of Weld County, Colorado, that the Insurance
Contract with Reliance Standard Life Insurance Company be, and
hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and
hereby is, authorized to sign said Contract.
The above and foregoing Resolution was, on motion duly made
and seconded, adopted by the following vote on the 11th day of
June, A.D. , 1990 .
t1.27BOAR OF COUNTY COMMISSIONERS
ATTEST: WE UNTY, COLORADO
Weld County1erk and Recorder
and Clerk to the Board Gene R. Brant er, Chairman
BY: VrIP--rx4 Q.L.Li eorge I ennedy, Pro-Te'm
Deputy CounClerk
EXCUSED DATE OF SIGNING - (AYE)
APPROVED AS TO FORM: Constance L. Harbert
EXCUSED DATE OF SIGNING - (AYE)
V D C.W. Kirby
V ounty Atto ey GordA
e AZ" � 900520
Reliance Standard Life
Insurance Company
Home Office: Chicago, Illinois • Administrative Office: Philadelphia, Pennsylvania
POLICYHOLDER: Weld County POLICY NUMBER: LSC 62,333
EFFECTIVE DATE: January 1, 1985, as amended on April 1, 1990
ANNIVERSARY DATES: January 1, 1986 and each January 1 thereafter
PREMIUM DUE DATES: The first Premium is due on the Effective Date. Further Premiums are due monthly in advance,
on the first day of each month.
This Policy is delivered in Colorado and is governed by its laws.
Reliance Standard Life Insurance Company is referred to as "we", "our" or "us" in this Policy.
The Policyholder and any subsidiaries, divisions or affiliates are referred to as "you", "your" or "yours" in this Policy.
We agree to provide insurance to you in exchange for the payment of Premium and a signed Application. This Policy
provides income replacement benefits for Total Disability from Sickness or Injury. It insures those Eligible Persons for the
Monthly Benefit shown on the Schedule of Benefits. The insurance is subject to the terms and conditions of this Policy.
The Effective Date of this Policy is shown above. This Policy stays in effect as long as Premium is paid when due. The
"TERMINATION OF THIS POLICY" section of the GENERAL PROVISIONS explains when the insurance terminates.
This Policy is signed by our President and Secretary.
`Uad-1314 Q-
SECRETARY PRESIDENT
J
Countersigned
Linen _d R, 'dent Agent
GROUP LONG TERM DISABILITY INSURANCE
NON-PARTICIPATING
This Long Term Disability Policy amends the Long Term Disability Policy previously issued to you
by us.
900520
LRS-6564 Ed. 2/83
RELIANCE STANDARD LIFE INSURANCE COMPANY
Home Office: Chicago, Illinois
Administrative Office: Philadelphia, Pennsylvania
GROUP POLICY NUMBER: LSC 62,333 POLICY EFFECTIVE DATE: January 1, 1985, as
amended on April 1, 1990
POLICY DELIVERED IN: Colorado ANNIVERSARY DATE: January 1 in each year
Application is made to us by: Weld County
This Application is completed in duplicate, one copy to be attached to your Policy and the other returned to us.
It is agreed that this Application takes the place of any previous application for your Policy.
94^-
Signed at r+-pee fedi 0 U this // day of
r
Policyholder: We I( anidi Agent: /
ci�,wNl� i/7�X
By: SA/ W., frfinf( ignatulI nre) (Lice sed R>: :ent Agent)
Oift'R�rnam Rofind Ul l l um„„„,neg2,
(Title)Ur/
900520
LRS-6564-1 Ed. 2/83
i
RELIANCE STANDARD LIFE INSURANCE COMPANY
Home Office: Chicago, Illinois
Administrative Office: Philadelphia, Pennsylvania
GROUP POLICY NUMBER: LSC 62,333 POLICY EFFECTIVE DATE: January 1, 1985, as
amended on April 1, 1990
I
POLICY DELIVERED IN: Colorado ANNIVERSARY DATE: January 1 in each year
i
Application is made to us by: Weld County
This Application is completed in duplicate, one copy to be attached to your Policy and the other returned to us.
It is agreed that this Application takes the place of any previous application for your Policy.
Signed at ee. I I 0 U this /� r„472 day of V Zinh-g—J I?to.
Policyholder: We l t1 Arzfr-il Agent:
By: S � K Aele.uts--'
//�� (Signature) (Licensed Resident Agent)
PiIttIZ n✓nayr» f go o n a l n nrssi-n.eitJ
(Title)
ATTEST:
WELD COUNTY CLERK AND RECORDER
.AND CLERK -TO TH' ARD
Dep y County Clerk
900520
LRS-6564-1 Ed. 2/83
•
TABLE OF CONTENTS
Page
SCHEDULE CF EENEFi T S 1.0
DEFINITIONS 2.0
GENERAL PROVISIONS 3.0
Entire Contract. Changes,Time Limit on Certain
Defenses, P.eccros Maintained,Clerical Error,
Misstatement cf Age, Not in Lieu of Worker's
Comcensacon, Conformity with State Laws,
Certificate of Insurance,Termination of this Policy
CLAIMS PROVISIONS 4.0
Notice of Claim, Claim Forms,
Written Proof of Total Disability, Payment of Claims,
Physical Examination and Autopsy, Legal Actions
INDIVIDUAL ELIGIBILITY, EFFECTIVE DATE AND TERMINATION
General Group, Eligibility Requirements,
Effective Date of Individual Insurance,
Termination of Individual Insurance,
Individual Reinstatement
PREMIUMS 6.0
BENEFIT PROVISIONS 7.0
EXCLUSIONS 8.0
LIMITATIONS 9.0
SPECIFIC INDEMNITY BENEFIT 10.0
COST OF LIVING BENEFIT 11.0
•
Effective Date; 4/1/90
Provision rnaf, of
LAS-6664.2(E) Ed. 2/83 Living Added.
900520
SCHEDULE OF BENEFITS
NAME OF SUBSIDIARIES, DIVISIONS OR AFFILIATES TO BE COVERED: Not Applicable
ELIGIBLE CLASSES: Each active, Full-time employee, except any person employed on a temporary or seasonal basis.
WAITING PERIOD: Present Employees: none
Future Employees: 30 days
INDIVIDUAL EFFECTIVE DATE: The first of the Policy month coinciding with or next following completion of the Waiting
Period, if applicable.
INDIVIDUAL REINSTATEMENT: 6 months
MINIMUM PARTICIPATION REQUIREMENTS: Percentage: 100% Number of Insureds: 10
LONG TERM DISABILITY BENEFIT
ELIMINATION PERIOD: 180 consecutive days of Total Disability.
MONTHLY BENEFIT: The Monthly Benefit is an amount equal to 60% of Covered Monthly Earnings, payable in accord-
ance with the section entitled Benefit Amount.
MINIMUM MONTHLY BENEFIT: In no event will the Monthly Benefit payable to an Insured be less than $50.00.
MAXIMUM MONTHLY BENEFIT: $5,000.00 (this is equal to a maximum Covered Monthly Earnings of $8,333.00).
MAXIMUM DURATION OF BENEFITS: Benefits will not accrue beyond the duration specified below:
Age at Disablement Duration of Benefits (in years)
61 or less To Age 65
62 3-1/2
63 3
64 2-1/2
65 2
66 1-3/4
67 1-1/2
68 1-1/4
69 or more 1
CONTRIBUTIONS: Insured: 0%
Effective Data; _11/1190
provision change* maximum
Monthly Benefit _ —
LRS-6564-3 Ed. 2/83 1.0
900520
DEFINITIONS
"Actively at Work" and "Active Work" mean actually performing on a Full-time basis the material duties' pertaining to
his/her job in the place where and the manner in which the job is normally performed. This includes approved time off
such as vacation, jury duty and funeral leave, but does not include time off as a result of an Injury or Sickness.
"Claimant" means an Insured who makes a claim for benefits under this Policy for a loss covered by this Policy as a result
of an Injury to or a Sickness of the Insured.
"Covered Monthly Earnings" means the Insured's monthly salary received from you on the day just before the date of
Total Disability. Covered Monthly Earnings do not include commissions, overtime pay, bonuses or any other special
compensation not received as Covered Monthly Earnings.
If hourly paid employees are insured, the number of hours worked during a regular work week, not to exceed forty (40)
hours per week, times 4.333, will be used to determine Covered Monthly Earnings. If an employee is paid on an annual
basis, then the Covered Monthly Earnings will be determined by dividing the basic annual salary by 12.
"Eligible Person" means a person who meets the Eligibility Requirements of this Policy.
"Elimination Period" means a period of consecutive days of Total Disability, as shown on the Schedule of Benefits page,
for which no benefit is payable. It begins on the first day of Total Disability.
Interruption Period: If, during the Elimination Period, an Insured returns to Active Work for less than:
(1) seven (7) days for Elimination Periods of one hundred and seventy-nine (179) days or less; or
(2) fourteen (14) days for Elimination Periods of one hundred and eighty (180) days or more;
then the same or related Total Disability will be treated as continuous. Days that the Insured is Actively at Work during this
interruption period will not count towards the Elimination Period. This interruption of the Elimination Period will not apply
to an Insured who becomes eligible under any other group long term disability insurance plan.
"Full-time" means working for you for a minimum of 32 hours during a person's regular work week.
"Hospital" or "Institution" means a facility licensed to provide care and treatment for the condition causing the Insured's
Total Disability.
"Injury" means bodily injury resulting directly from an accident, independent of all other causes. The Injury must cause
Total Disability which begins while insurance coverage is in effect for the Insured.
"Insured" means a person who meets the Eligibility Requirements of this Policy and is enrolled for this insurance.
"Physician" means a duly licensed practitioner who is recognized by the law of the state in which treatment is received
as qualified to treat the type of Injury or Sickness for which claim is made. The Physician may not be the Insured or a
member of his/her immediate family.
"Pre-existing Condition" means any Sickness or Injury for which the Insured received medical treatment, consultation,
care or services, including diagnostic procedures, or took prescribed drugs or medicines, during the 3 months imme-
diately prior to the Insured's effective date of insurance.
"Premium" means the amount of money needed to keep this Policy in force.
"Rehabilitative Employment" means work in any gainful occupation for which the Insured's training, education or experi-
ence will reasonably allow. The work must be supervised by a Physician or a licensed rehabilitation specialist approved
by us. Rehabilitative Employment does not include performing all the material duties of his/her regular occupation on a
Full-time basis.
"Retirement Benefits" mean money which the Insured is entitled to receive upon early or normal retirement or disability
retirement under:
(1) any plan of a state, county or municipal retirement system, if such pension benefits include any credit for em-
.ployment.with you; ',) •‘.l •s ,- a
beetsta0 min
900520
LRS-6564-4 Ed. 2/83 _� 2.0
(2) Retirement Benefits under the United States Social Security Act of 1935, as amended, or under any similar
plan or act; or
(3) an employer's retirement plan where payments are made in a lump sum or periodically and do not represent
contributions made by an Insured.
Retirement Benefits do not include:
(1) a federal government employee pension benefit;
(2) a thrift plan;
(3) a deferred compensation plan;
(4) an individual retirement account (IRA);
(5) a tax sheltered annuity (TSA);
(6) a stock ownership plan; or
(7) a profit sharing plan.
"Sickness" means illness or disease causing Total Disability which begins while insurance coverage is in effect for the
Insured. Sickness includes pregnancy, childbirth, miscarriage or abortion, or any complications therefrom.
"Totally Disabled" and "Total Disability" mean that as a result of an Injury or Sickness:
(1) during the Elimination Period and for the first 24 months for which a Monthly Benefit is payable, an Insured
cannot perform the material duties of his/her regular occupation. We consider the Insured "Totally Disabled"
if due to an Injury or Sickness he or she is capable of only performing the material duties on a part-time basis
or part of the material duties on a Full-time basis; and
(2) after a Monthly Benefit has been paid for 24 months, an Insured cannot perform the material duties of any
occupation. Any occupation is one that the Insured's education, training or experience will reasonably allow.
•
0520
LRS-6564-4 Ed. 2/83 2.1
GENERAL PROVISIONS
ENTIRE CONTRACT: The entire contract between you and us is this Policy, your Application (a copy of which is at-
tached at issue) and any attached amendments.
CHANGES: No agent has authority to change or waive any part of this Policy. To be valid, any change or waiver must
be in writing, signed by either our President, a Vice President, or a Secretary. The change or waiver must also be at-
tached to this Policy.
TIME LIMIT ON CERTAIN DEFENSES: After this Policy has been in force for two (2) years from its Effective Date, no
statement made by you shall be used to void this Policy; and no statement by any Insured on a written application for
insurance shall be used to reduce or deny a claim after the Insured's insurance coverage, with respect to which claim
has been made, has been in effect for two (2) years.
RECORDS MAINTAINED: You must maintain records of all Insureds. Such records must show the essential data of the
insurance, including new persons, terminations, changes, etc. This information must be reported to us regularly. We re-
serve the right to examine the insurance records maintained at the place where they are kept. This review will only take
place during normal business hours.
CLERICAL ERROR: If a clerical error is made, it will not affect the insurance of any Insured. An error will not begin in-
surance or continue the insurance of any person prior to the date it should have begun or beyond the date it should have
ended under this Policy's terms.
MISSTATEMENT OF AGE: If an Insured's age is misstated, the Premium will be adjusted. If the Insured's benefit is af-
fected by the misstated age, it will also be adjusted. The benefit will be changed to the amount the Insured is entitled to
at his/her correct age.
NOT IN LIEU OF WORKER'S COMPENSATION: This Policy is not a Worker's Compensation Policy. It does not pro-
vide Worker's Compensation benefits.
CONFORMITY WITH STATE LAWS: Any section of this Policy, which on its Effective Date, conflicts with the laws of the
state in which this Policy is issued, is amended by this provision. This Policy is amended to meet the minimum require-
ments of those laws.
CERTIFICATE OF INSURANCE: We will send to you an individual certificate for each Insured. The certificate will outline
the insurance coverage, state this Policy's provisions that affect the Insured, and explain to whom benefits are payable.
TERMINATION OF THIS POLICY: You may cancel this Policy at any time by giving us written notice. This Policy will
be cancelled on the date we receive your notice or, if later, the date requested in your notice.
This Policy will terminate at the end of the Grace Period if Premium has not been paid by that date.
We may cancel this Policy within thirty-one (31) days of written notice prior to the date of cancellation, only:
(1) if the number of Insureds is less than the Minimum Participation Number shown on the Schedule of Benefits;
(2) if the percentage of Eligible Persons insured is less than the Minimum Participation Percentage shown on the
Schedule of Benefits; or
(3) on any Policy Anniversary.
You will still owe us any Premium that is not paid up to the date this Policy is cancelled. We will return, pro-rata, any part
of the Premium paid beyond the date this Policy is cancelled.
Termination of this Policy will not affect any claim which was covered prior to termination, subject to the terms and con-
ditions of this Policy.
LRS-6564-5 Ed. 2/83 3.0 900520
CLAIMS PROVISIONS
NOTICE OF CLAIM: Written notice must be given to us within thirty-one (31) days after a Total Disability covered by this
Policy occurs, or as soon as reasonably possible. The notice should be sent to us at our Administrative Office or to our
authorized agent. The notice should include your name, the Policy Number and the Insured's name.
CLAIM FORMS: When we receive the notice of claim, we will send the Claimant the claim forms to file with us. We will
send them within fifteen (15) days after we receive notice. If we do not, then proof of Total Disability will be met by giving
us a written statement of the type and extent of the Total Disability. The statement must be sent within ninety (90) days
after the loss began.
WRITTEN PROOF OF TOTAL DISABILITY: For any Total Disability covered by this Policy, written proof must be sent
to us within ninety (90) days after the Total Disability occurs. If it is not reasonably possible to give proof within ninety (90)
days, the claim is not affected if the proof is sent as soon as possible.
PAYMENT OF CLAIMS: When we receive written proof of Total Disability covered by this Policy, we will pay any benefits
due. Benefits that provide for periodic payment will be paid for each period as we become liable.
We will pay benefits to the Insured, if living, or else to his/her estate.
If the Insured has died and we have not paid all benefits due, we may pay up to $1,000.00 to any relative by blood or
marriage, or to the executor or administrator of the Insured's estate. The payment will only be made to persons entitled
to it. An expense incurred as a result of the Insured's last illness, death or burial will entitle a person to this payment. The
payments will cease when a valid claim is made for the benefit. We will not be liable for any payment we have made in
good faith.
PHYSICAL EXAMINATION AND AUTOPSY: We will, at our expense, have the right to have a Claimant interviewed
and/or examined:
(1) physically;
(2) psychologically; and/or
(3) psychiatrically;
to determine the existence of any Total Disability which is the basis for a claim. This right may be used as often as it is
reasonably required while a claim is pending.
We can have an autopsy made unless prohibited by law.
LEGAL ACTIONS: No legal action may be brought against us to recover on this Policy within sixty (60) days after written
proof of loss has been given as required by this Policy. No action may be brought after three (3) years (Kansas, five (5)
years; South Carolina, six (6) years) from the time written proof of loss is received.
.LRS-6564-6'Ed. 2/83 4.0 90052+0
INDIVIDUAL ELIGIBILITY, EFFECTIVE DATE AND TERMINATION
GENERAL GROUP: The general group will be your employees and employees of any subsidiaries, divisions or affiliates
named on the Schedule of Benefits page.
ELIGIBILITY REQUIREMENTS: A person is eligible for insurance under this Policy if he/she:
(1) is a member of an Eligible Class, as shown on the Schedule of Benefits page; and
(2) has completed the Waiting Period, as shown on the Schedule of Benefits page.
WAITING PERIOD: A person who is continuously employed on a Full-time basis with you for the period specified on the
Schedule of Benefits page has satisfied the Waiting Period. The Waiting Period for Present Employees applies to persons
who are members of the Eligible Classes on this Policy's Effective Date. The Waiting Period for Future Employees applies
to persons who become members of the Eligible Classes after this Policy's Effective Date.
EFFECTIVE DATE OF INDIVIDUAL INSURANCE: If you pay the entire Premium due for an Eligible Person, the insur-
ance for such Eligible Person will go into effect on the Individual Effective Date, as shown on the Schedule of Benefits
page.
If an Eligible Person pays a part of the Premium, he/she must apply in writing for the insurance to go into effect. He/she
will become insured on the latest of:
(1) the Individual Effective Date as shown on the Schedule of Benefits page, if he/she applies on or before that
date;
(2) on the date he/she applies, if he/she applies within thirty-one (31) days from the date he/she first met the El-
igibility Requirements; or
(3) on the date we approve any required proof of health acceptable to us. We require this proof if a person applies:
(a) after thirty-one (31) days from the date he/she first met the Eligibility Requirements; or
(b) after he/she terminated this insurance but remained in an Eligible Class as shown on the Schedule of
Benefits page.
The insurance for an Eligible Person will not go into effect on a date he/she is not Actively at Work because of a Sickness
or Injury. The insurance will go into effect after the person is Actively at Work for one (1) full day in an Eligible Class, as
shown on the Schedule of Benefits page.
TERMINATION OF INDIVIDUAL INSURANCE: The insurance of an Insured will terminate on the first of the following
to occur:
(1) the first of the Policy month coinciding with or next following the date this Policy terminates;
(2) the first of the Policy month coinciding with or next following the date the Insured ceases to meet the Eligiblity
Requirements;
(3) the end of the period for which Premium has been paid for the Insured; or
(4) the first of the Policy month coinciding with or next following the date the Insured enters military service (not
including Reserve or National Guard).
INDIVIDUAL REINSTATEMENT: The insurance of a terminated person may be reinstated if he/she returns to Active
Work with you within the period of time as shown on the Schedule of Benefits page. He/she must also be a member of
an Eligible Class, as shown on the Schedule of Benefits page, and have been:
(1) on a leave of absence approved by you; or
(2) on temporary lay-off.
The person will not be required to fulfill the Eligibility Requirements of this Policy again. The insurance will go into effect
after he/she returns to Active Work for one (1) full day. If a person returns after having resigned or having been dis-
charged, he/she will be required to fulfill the Eligibility Requirements of this Policy again. If a person returns after termi-
nating insurance at his/her request or for failure to pay Premium when due, proof of health acceptable to us must be
submitted before he/she may be reinstated.
LRS-6564.7 Ed. 2/63
5.0 900520
PREMIUMS
PREMIUM PAYMENT: All Premiums are to be paid by you to us, or to an authorized agent, on or before the due date.
The Premium Due Dates are stated on this Policy's face page.
PREMIUM RATE: The Premium due will be the rate per $100.00 of the entire amount of Covered Monthly Earnings then
in force. We will furnish to you the Premium Rate on this Policy's Effective Date and when it is changed. We have the
right to change the Premium Rate:
(1) when the extent of coverage is changed by amendment;
(2) on any Premium Due Date after the second Policy Anniversary; or
(3) on any Premium Due Date on or after the first Policy Anniversary if your entire group's Covered Monthly
Earnings changes by 25% or more from such group's Covered Monthly Earnings on this Policy's Effective
Date.
We will not change the Premium Rate due to (2) or (3) above more than once in any twelve (12) month period. We will
tell you in writing at least thirty-one (31) days before the date of a change due to (2) or (3) above.
GRACE PERIOD: You may pay the Premium up to 31 days after the date it is due. This Policy stays in force during this
time. If the Premium is not paid during the grace period, this Policy will terminate. You will still owe us the Premium up
to the date this Policy terminates.
WAIVER OF PREMIUM: No Premium is due us for an Insured while he/she is receiving Monthly Benefits from us. Once
Monthly Benefits cease due to the end of his/her Total Disability, Premium payments must begin again if insurance is to
continue. •
LRS-6564-8 Ed. 2/83 6.0 900520
BENEFIT PROVISIONS
INSURING CLAUSE: We will pay a Monthly Benefit if an Insured:
(1) is Totally Disabled as the result of a Sickness or Injury covered by this Policy;
(2) is under the regular care of a Physician;
(3) has completed the Elimination Period; and
(4) submits satisfactory proof of Total Disability to us.
BENEFIT AMOUNT: To figure the benefit amount payable:
(1) multiply an Insured's Covered Monthly Earnings by the benefit percentage(s), as shown on the Schedule of
Benefits page;
(2) take the lesser of the amount:
(a) of step (1) above; or
(b) the Maximum Monthly Benefit, as shown on the Schedule of Benefits page; and
(3) subtract Other Income Benefits, as shown below, from step (2) above.
We will pay at least the Minimum Monthly Benefit, if any, as shown on the Schedule of Benefits page.
OTHER INCOME BENEFITS: Other Income Benefits are benefits resulting from the same Total Disability for which a
Monthly Benefit is payable under this Policy, other than Retirement Benefits. These Other Income Benefits are:
(1) disability income benefits an Insured is eligible to receive under any group insurance plan(s);
(2) disability income benefits an Insured is eligible to receive under any governmental retirement systems, except
benefits payable under a federal government employee pension benefit;
(3) disability income benefits an Insured is eligible to receive under:
(a) Worker's Compensation Laws;
(b) occupational disease law;
(c) any other laws of like intent as (a) or (b) above; and
(d) any compulsory benefit law;
(4) any of the following that the Insured is entitled to receive from you:
(a) any formal salary continuance plan;
(b) wages, excluding the amount allowable under the Rehabilitation Provision; and
(c) commissions or monies, including vested renewal commissions, but, excluding commissions or monies
that the Insured earned prior to Total Disability which are paid after Total Disability has begun;
(5) that part of disability or Retirement Benefits paid for by you that an Insured is eligible to receive under a group
retirement plan. Disability and early Retirement Benefits will be offset only if such benefits are elected by the
Insured or do not reduce the amount of his/her accrued normal Retirement Benefits then funded; and
(6) disability or Retirement Benefits under the United States Social Security Act, the Canadian pension plans,
federal or provincial plans, or any similar law which:
(a) an Insured is eligible to receive because of his/her Total Disability or eligibility for Retirement Benefits;
and
(b) an Insured is eligible to receive for his/her spouse or children due to (a) above.
Benefits above will be estimated if the benefits:
(1) have not been applied for; or
(2) have not been awarded; and
(3) have been denied and the denial is being appealed.
The Monthly Benefit will be reduced by the estimated amount. If benefits have been estimated, the Monthly Benefit will
be adjusted when we receive proof:
(1) of the amount awarded; or
(2) that benefits have been denied and the denial cannot be further appealed.
If we have underpaid the Monthly Benefit for any reason, we will make a lump sum payment. If we have overpaid the
Monthly Benefit for any reason, the overpayment must be repaid to us. At our option, we may reduce the Monthly Benefit
or ask for a lump sum refund. If we reduce the Monthly Benefit, the Minimum Monthly Benefit, if any, as shown on the
Schedule of Benefits page, would not apply.
900520
LRS-6564-9 Ed. 2/83 7.0
For each day of a period of Total Disability less than a full month, the amount payable will be 1/30th of the Monthly Ben-
efit.
COST OF LIVING FREEZE: After the initial deduction for any Other Income Benefits, the Monthly Benefit will not be
further reduced due to any cost of living increases payable under these Other Income Benefits.
LUMP SUM PAYMENTS: If Other Income Benefits are paid in a lump sum, the sum will be broken down to a monthly
amount for the period of time the sum is payable. If no period of time is given, the sum will be broken down to a monthly
amount for the period of time we expect the Insured to be disabled based on actuarial tables of disabled lives.
TERMINATION OF MONTHLY BENEFIT: The Monthly Benefit will stop on the earliest of:
(1) the date the Insured ceases to be Totally Disabled;
(2) the date the Insured dies;
(3) the Maximum Duration of Benefits, as shown on the Schedule of Benefits page, has ended; or
(4) the date the Insured fails to furnish the required proof of Total Disability.
REHABILITATION PROVISION: If, during a period of Total Disability for which a Monthly Benefit is payable, an Insured
accepts Rehabilitative Employment, we will continue to pay the Monthly Benefit less 50% of any of the money received
from this Rehabilitative Employment.
RECURRENT DISABILITY: If, after a period of Total.Disability for which benefits are payable, an Insured returns to Ac-
tive Work for at least six (6) consecutive months, any recurrent Total Disability for the same or related cause will be part
of a new period of Total Disability. A new Elimination Period must be completed before any further Monthly Benefits are
payable.
If an Insured returns to Active Work for less than six (6) months, a recurrent Total Disability for a same or related cause
will be part of the same Total Disability. A new Elimination Period is not required. Our liability for the entire period will be
subject to the terms of this Policy for the original period of Total Disability.
This Recurrent Disability section will not apply to an Insured who becomes eligible for insurance coverage under any other
group long term disability insurance plan.
LRS-6564-9 Ed. 2/83 7.1 q re
EXCLUSIONS
We will not pay a Monthly Benefit for any Total Disability caused by:
(1) an act of war, declared or undeclared;
(2) an intentionally self-inflicted Injury;
(3) the Insured committing a felony; or
(4) an Injury or Sickness that occurs while the Insured is confined in any penal or correctional institution.
•
900520
LRS-6564-10 Bd. 2/83 8.0
LIMITATIONS
MENTAL OR NERVOUS DISORDERS: Monthly Benefits for Total Disability due to mental or nervous disorders will not
be payable beyond twenty-four (24) months unless the Insured is in a Hospital or Institution at the end of the twenty-four
(24) month period. The Monthly Benefit will be payable while so confined, but not beyond the Maximum Duration of
Benefits.
If an Insured was confined in a Hospital or Institution and:
(1) Total Disability continues beyond discharge;
(2) the confinement was during a period of Total Disability; and
(3) the period of confinement was for at least fourteen (14) consecutive days;
then upon discharge, Monthly Benefits will be payable for the greater of:
(1) the unused portion of the twenty-four (24) month period; or
(2) ninety (90) days;
but in no event beyond the Maximum Duration of Benefits, as shown on the Schedule of Benefits page.
PRE-EXISTING CONDITIONS: Benefits will not be paid for a Total Disability:
(1) caused by;
(2) contributed to by; or
(3) resulting from;
a Pre-existing Condition unless the Insured has been Actively at Work for one (1) full day following the end of:
(1) 3 consecutive months during which the Insured has not had:
(a) consultation with a Physician; or
(b) received medical care, treatment or services, including diagnostic procedures or took prescribed drugs
or medicines, for such condition; or
(2) 12 consecutive months from the date he/she became an Insured.
•
}s P r x 900520
LRS-6564-11 Ed. 2/83 9.0
SPECIFIC INDEMNITY BENEFIT
If the Insured suffers any one of the Losses listed below from an accident resulting in an Injury, we will pay:a guaranteed
minimum number of Monthly Benefit payments, as shown below. However:
(1) the Loss must occur within one hundred and eighty (180) days; and
(2) the Insured must live past the Elimination Period.
For Loss of: Number of Monthly Benefit Payments:
Both Hands 46 months
Both Feet 46 months
Entire Sight in Both Eyes 46 months
Hearing in Both Ears 46 months
Speech 46 months
One Hand and One Foot 46 months
One Hand and Entire Sight in One Eye 46 months
One Foot and Entire Sight in One Eye 46 months
One Arm 35 months
One Leg 35 months
One Hand 23 months
One Foot 23 months
Entire Sight in One Eye 15 months
Hearing in One Ear 15 months
"Loss(es)" with respect to:
(1) hand or foot, means the complete severance through or above the wrist or ankle joint;
(2) arm or leg, means the complete severance through or above the elbow or knee joint; or
(3) sight, speech or hearing, means total and irrecoverable Loss thereof.
If more than one (1) Loss results from any one accident, payment will be made for the Loss for which the greatest number
of Monthly Benefit payments is provided.
The amount payable is the Monthly Benefit, as shown on the Schedule of Benefits page, with no reduction from Other
Income Benefits. The number of Monthly Benefit payments will not cease if the Insured returns to Active Work.
If death occurs after we begin paying Monthly Benefits, but before the Specific Indemnity Benefit has been paid according
to the above schedule, the balance remaining at time of death will be paid to the Insured's estate, unless a beneficiary is
on record with us under this Policy.
Benefits may be payable longer than shown above as long as the Insured is still Totally Disabled, subject to the Maximum
Duration of Benefits, as shown on the Schedule of Benefits page.
900520
LRS-6564-13 Ed. 2/83 10.0
COST OF LIVING BENEFIT
If the Consumer Price Index (CPI-W) published by the United States Department of Labor increases while an Insured is
receiving Monthly Benefits from us, an additional benefit will be payable. The Cost of Living Benefit will be payable during
any of the first ten (10) years, following satisfaction of the Elimination Period, in which the Consumer Price Index in-
creases.
Percentage increases in the Consumer Price Index will be calculated by us each year. The increase will be based on a
comparison of published annual Consumer Price Index statistics in October of each year. If the Consumer Price Index is
changed or no longer published, the most comparable index (in our opinion) then published will be used for these pur-
poses.
This amount payable will be the lesser of the following, multiplied by the Monthly Benefit, after any applicable reduction
according to the section entitled Benefit Amount:
(1) 3-1/2%; or
(2) the most recently determined annual percentage increase in the Consumer Price Index;
excluding any prior Cost of Living Benefit payments. This benefit will be payable while the Insured continues to be entitled
to Monthly Benefits.
The first Cost of Living Benefit increase will become effective on:
(1) the January 1st of the first year following the year in which the Elimination Period was satisfied; or
(2) the date the Consumer Price Index is first determined to have increased.
Effective ll/1 /90
Arovision a.,,o, Cost of
Living_Benetitradc er
LRS-6564-15 Ed. 2/83 11.0 900520
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