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Home My WebLink About720564.tiff ,;11/1 75.E r . RESOLUTION RE: AGREEMENTS BETWEEN WELD COUNTY AND PACIFIC MUTUAL LIFE INSURANCE COMPANY. WHEREAS, Pacific Mutual Life Insurance Company has submitted proposals for group insurance, Policies No. GL-8864, GM-8864 and GR -8864, covering the employees of Weld County, Colorado, and WHEREAS, the Board of County Commissioners, Weld County, Colorado, believes it to be in the best interests of the County to accept the group insurance policies as proposed covering its county employees and to enter into such agreements on the bases recited therein. NOW, THEREFORE, BE IT RESOLVED, by the Board of County Commissioners, Weld County, Colorado, that the agreements submitted by Pacific Mutual Life Insurance Company, providing insurance coverage for county employees in accordance with Policies No. GL-8864, GM-8864 and GR-8864 as submitted, copies of which are attached hereto and made a part hereof by reference, be, and they hereby are approved. BE IT FURTHER RESOLVED that the Board be, and it hereby is authorized, to execute the agreements as submitted and to make same effective forthwith. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 4th day of October , 1972. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO /incee-c- /r'-,,61.,,. lf.0 ATTEST: �n-1�//�, W Clerk/of the Board By:re/.6vne: 72,,,L,rzyti Deputy County Clerk APPROVED AS TO FORM: fl/AcC N �I, ‘ - Cotinty ttorney (� 777 720564 An ' y9,2, r_J="aLl �{ isint Way-gal 1 r,157„�,.^lta'.!! Ia .. s LOS ANGELES, CALIFORNIA (Herein called the Company) APPLICATION is hereby made to the Insurance Company for Group Policy No.__GL-8864 by WELD COUNTY, COLORADO whose Main Office Address is Court House, Greeley, Colorado 80631 Said Group Policy is hereby approved and the terms thereof are hereby accepted. This Application is executed in duplicate, one counterpart being attached to said Group Policy and the other being returned to the Insurance Company. It is agreed that this Application supersedes any previous application for the said Group Policy. THE BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO (Full or Corporate Name of Applicant) Signed at Greeley Colorado "- 41i 1L C c —_/2 � �/ hairman (Signature and Title), On— October 4, 1972 Witness (To be signed by Resident Agent where required by law) This Copy is to Remain Attached to the Policy OR-51 (II/) 0� '•i • E .�*:%4'r74'... f j group imucp X30.' GL-8864 Pcscif is Mutual Life 4 Iszsures=zce Company 1,,,, (Herein Called the Insurance Company) 1 I, 'I' • This policy shall be construed in accordance with the laws of Colorado ,where it is delivered, - and is a contract between the Insurance Company and . , i;,.. WELD COUNTY, COLORADO (herein tolled the Policyholder). The Insurance Company HEREBY AGREES TO PAY the benefits hereinafter provided with respect to insured Individuals,subject to all of the terms appearing on this and the following pages, which are hereby made a parr of this Fag- The Policyholder may act for and on behalf of any and all persons to whom insurance under this policy relates, and every act done by,agreement made with, or notice given to the Policyholder shall be binding on all such persons. I , This policy is issued in consideration of the application of the Policyholder,a copy of which is attached to and made a part of this policy,and of the payment by the Policyholder of premiums in advance at the Home Office of the Insurance Company or to its authorized agent.The fast premium under this policy with respect to insured Individuals in any class which is an eligible class on the effective date of this policy shall be due and payable as of such effective date, to cover the period beginning on that date and ending on the day before the next ensuing premium-due date. The first premium with respect to insured Individuals in any class which subsequently becomes an eligible class shall be due and payable as of the date such class becomes an eligible class and shall cover the period beginning on that date and ending on the day before the next ensuing premium-due date. Premiums after the first premium shall be due and payable monthly on the first day of each calendar month. The period beginning oa the effective date of this policy and ending March 31, 1973 shall be considered the first policy year.Each policy year thereafter shall commence on the first day of April of each year and end on the thirty-first day of March next following. IN WITNESS WHEREOF, PACIFIC MUTUAL LIFE INSURANCE COMPANY has caused this policy to be executed at Los Angeles, California, as of the first day of April ,19 72 , its effective date. T 6-it/a-cc Ala e. SECRETARY PRESIDENT . 6411e451tailf REGISTRAR GROUP LIFE INSURANCE POLICY. e CD.7-'as ONE YEAR RENEWABLE TERM. PARTICIPATING.CD.� PAGE 1-B r. • , GENERAL PROVISIONS INDIVIDUALS' CERTIFICATES. The Insurance Company shall issue to the Policyholder, for delivery to each insured Individual, an individual certificate containing a statement as to the insurance protection to which the Individual is entitled and to whom it is payable, together with a statement of the "Conversion Privilege" of this policy. PREMIUM CALCULATIONS. At the beginning of each policy year the Insurance Company shall compute an aggregate monthly premium which shall be the sum of the.individual premiums for the Individuals then insured, calculated according to the table of pre- mium rates than in effect hereunder on the basis of the ages (nearest birthday) then attained by the insured Individuals and their re- spective amounts of insurance. From such computation an average premium rate shall be determined by dividing the aggregate premium by the aggregate amount of insurance then in fora,and such average premium rate shall remain in effect, and shall be used in calculat- ing all premiums under this policy, until a new one is determined. Each premium due during the policy year shall be calculated by mul- tiplying the amount of insurance in fore at the beginning of the premium-paying period by the average premium rate then in effect. Except as may be otherwise provided, any insurance becoming effective shall be char for from the first day of the policy month co- inciding with or next followmg the date the insurance takes effect. Premium charges for any insurance terminated shall cease as of the last day of the policy month coinciding with or next following the date the insurance terminates. If premiums are payable quarterly, semi-annually, or annually, premium charges or credits for a fraction of a premium-paying period required by the foregoing terms of this paragraph shall be made on a pro rata basis for the number of policy months between the date premium charges commence or cease and the end of the premium-paying period. Premium adjustments involving the return of uneimed premiums shall be limited to the period of twelve months immediately pre- ceding the date of receipt by the Insurance Company of evidence that such adjustments should be made. Instead of the method of calculation of premiums above provided,premiums may be calculated by any method which produces approx- imately the same total amount of praniums and is mutually agreeable to the Insurance Company and the Poliryholder. The followingg Table of Initial Premium Rates shall be used in calculating the initial premiums as above, and each subsequent premium shall be calculated at the premium rates in effect on the date such premium becomes due.The Insurance Company shall have the right to reduce or increase premium rates on any premium-due date and whenever a class of Individuals is trade eliphle or eliminated from eligibility for insurance under this policy. No increase in premium rates, other than an increase when a class of Individuals is made eligible or eliminated from eligibility for insurance under this policy shall become effective less than twelve months after the effective date of this policy or less than twelve months after the effective date of any previous increase in premium rates. Each reduc- tion or increase in any premium rate shall be made by written notification to the Policyholder by the Insurance Company. TABLE OF INITIAL PREMIUM RATES PER $1,000 OF INSURANCE Birthday thday Birthday Birth day Aardr ay on Binnhr thday da Vitt? to Nearest to gNeearest to Nearest m ofThena a Then of Thee[ Hof 7hena Carrevt Monthly Current Monthly Current Monthly Current Monthly Policy Year Ram Polio Year Rate Policy Year Rate Policy Year Ram 16 20 36 .34 56 1.80 76 9.24 17 21 37 .36 57 1.97 77 10.00 18 22 38 .38 58 2.14 78 10.86 19 23 39 Al. 59 2.32 79 1181 20 23 40 .45 60 2.51 80 1283 21 24 41 .49 61 2.72 81 13.93 22 24 42 .52 62 2.96 82 15.07 23 25 43 .58 63 3.21 83 1626 24 25 44 .63 64 3.48 84 17.50 25 25 45 .68 65 3.78 85 1880 26 .25 46 .74 66 4.11 86 20.16 27 26 47 81 67 4.48 87 21.60 28 .26 48 .89 68 489 88 23.13 29 26 49 .97 69 5.34 89 24.79 30 27 50 1.06 70 5.81 90 26.62 31 27 51 1.16 71 6.32 91 28.68 32 .28 52 1.26 72 6.84 92 31.03 33 29 53 1.38 73 7.38 93 33.75 34 .30 54 1.51 74 7.95 94 36.95 35 .32 55 1.65 75 8.56 95 40.98 In the event that the age and insurance distribution with respect to the employees insured under this policy on its efeettive date is such that the initial average premium determined by use of the foregoing table is less than the minimum permitted by law of the state in which this policy is delivered, such average premium is hereby changed to agree with the minimum average premium permitted by such law. GB.2oss - GENERAL PROVISIONS PAGE 2.0 CD.Y.et OA-SA-A Y GENERAL PROVISIONS (Continued) GRACE PERIOD-DISCONTINUANCE OF POLICY. A grace period of thirty-one days following the due date shall be allowed the Policyholder for the payment of each premium after the first. If any premium with respect to the insured Individuals in any class ! is not paid before the expiration of the grace period, this policy shall automatically discontinue with respect to all Individuals in such I class at the expiration of the grace period, except that if the Policyholder shall have given the Insurance Company written notice in advance of discontinuance at the commencement of or during the grace period, this polity shall discontinue with respect to all Indi- viduals in such class as of such earlier date. As to each class, the Policyholder shall be liable to the Insurance Company for all unpaid premiums with respect to the insured Individuals in such class for the period (including a pro rata premium for the grace period or fraction thereof) during which this policy was in force with respect to such insured Individuals. The Insurance Company reserves the right to discontinue this policy on any premium-due date (a) with respect to all classes of Individuals,when fewer than 25 Individuals are insured under this policy; or (b) with respect to any class of Individuals, when less than seventy-five per cent of the eligible Individuals in such class are insured hereunder; provided that the Insurance Company shall give the Policyholder at least thirty-one days' notice of its intent to discontinue. DIVIDENDS. This policy, at the end of each policy year of not less than twelve months throughout which it shall have been con- tinuously in effect and all premiums thereon paid, shall participate in any divisible surplus of the Insurance Company for such policy year as determined and apportioned by the Insurance Company. The divisible surplus, if any, apportioned to this policy for any policy year shall be credited to this policy as a dividend at the end of such policy year and shall be (1) paid to the Policyholder in cash, or at the option of the Policyholder, it may be (2) applied to the reduction of the premiums, or (3) left to accumulate to the credit of the Policyholder as long as this policy remains in effect, with compound interest at the rate determined from time to time by the Insurance Company. The Policyholder may withdraw dividend accumulations at any rime, and if this policy discontinues any dividend accumulations then remaining with the Insurance Company shall be thereupon paid to the Policyholder. The Insurance Company shall, however, have the right to defer the withdrawal or pay- ment of any dividend accumulations for as long as six months, but not exceeding the period permitted by law. In the event that Individuals are contributing toward the cost of the coverage under any group policy issued to the Policyholder and r the aggregate dividends under this policy and any other group policy or policies issued to the Policyholder should be in excess of the I4 Policyholder's share of the aggregate cost, such excess shall be applied by the Policyholder for the sole benefit of Individuals, but the Insurance Company shall not be obliged to see to the application of any such excess. Payment of any dividend to the Policyholder or application thereof toward any premium shall completely discharge the liability of the Insurance Company with respect to the dividend so paid or so applied. TRUSTEE POLICYHOLDER. If the Policyholder is a Trustee or Trustees of a trust fund, then (1) should there be more than one Trustee, the Insurance Company shall be entitled to rely upon the signature or signatures of such !. .., of the Trustees as are designated co the Insurance Company in writing by all the Trustees from time to rime as having been empowered to act in behalf of all the Trustees in any and all matters pertaining to this policy; and (2) the rights and obligations under this policy of all persons shall be determined by the terms of this policy without regard to the terms of any trust agreement or of any instrument amending or supplementing or replacing any such trust agreement. DATA REQUIRED—CLERICAL ERROR. The Policyholder shall furnish the Insurance Company with all information which the Insurance Company may reasonably require with regard to any matters pertaining to this policy. All documents furnished to the Policyholder in connection with the insurance, together with such records as may have a bearing on the insurance under this policy, shall be open for inspection by the Insurance Company at all reasonable times. Neither clerical error in keeping any records pertaining to the insurance under this policy, nor delays in making entries thereon, shall invalidate insurance otherwise validly in force or continue insurance otherwise validly terminated,but upon discovery of such error or delay an equitable adjustment of premiums shall be made. If any relevant facts pertaining to any person to whom insurance under this policy relates shall be found to have been incorrectly reported to the Policyholder or to the Insurance Company,an equitable adjustment of premiums shall be made,and if such misstatement affects the existence or the amount of insurance, the true facts shall be used in determining whether insurance is in force under the terms of this policy and in what amount. • THE CONTRACT—INCONTESTABILITY. This policy and the application of the Policyholder constitute the entire contract between the parties. All statements made by the Policyholder shall, in the absence of fraud,be deemed representations and not warranties, and no statement made by any insured Individual shall be used in any contest unless a copy of the instrument containing the statement is or has been furnished to such insured Individual or to his beneficiary. No agent has authority to change this policy or to waive any of its provisions. No change in this policy shall be valid unless approved by an executive officer of the Insurance Company and evidenced by endorsement hereon,or by amendment hereto signed by the Policy- holder and by an executive officer of the Insurance Company. The validity of this policy shall not be contested, except for non-payment of premiums,after it has been in force for two years from its effective date. No statement made by any insured Individual relating to his insurability shall be used in contesting the validity of the insurance with respect to which such statement was made after such insurance has been in force prior to the contest for a period of two years during such Individual's lifetime nor unless such statement is contained in a written instrument signed by him. This policy may be changed at any time or times by written agreement between the Insurance Company and the Policyholder, without the consent of any Individual or other person. Ga-205 ED. - 68 GENERAL PROVISIONS PAGE 9-C • . .. ...w .. ... . --.---- -- - - UntiIf11LITY. The word "Individual" as used in this policy shall mean anyone who is employed by the Policyholder, or is an elected official of the Policyholder. The classes of Individuals eligible for insurance under this policy shall be only those classes which are reported in writing to the Insurance Company by the Policyholder; provided, however, that Individuals, other than elected officials, who are part-time employees(but excepting Individuals who are full-time employees temporarily working on a part-time basis) and Individuals who are temporary employees shall not be eligible for insurance hereunder. As used herein, the term "part-time employees" shall mean employees who sre customarily employed by the Policyholder less than thirty boon per week, and the term "temporary employees" shall mean employees who are customarily employed by the Policyhol der on a full-time basis less than five months during a policy year. Upon written request from the Policyholder to the Insurance Company dist any class of Individuals-be eliminated from the classes of Individuals eligible for insurance hereunder, such class shall be eliminated as of the date stated in such re- quest, and upon such date this policy shall discontinue with respect to all Individuals in such class. Upon written request from the Policyholder to the Insurance Company, sad subject to writes acknowledgment of the Insur- ance Company, soy class of Individuals not eligible for insurance hereunder may be made eligible for insurance hereunder as of the date stated in such request. If the Policyholder or any eligible class is a proprietorship or partnership, die individual proprietor or partners thereof shall be deemed to be employees of the proprietorship or parmershp if and while devoting full-time service to the , proprietorship or partnership. An Individual in an eligible class of Individuals shalt become eligible for insurance under this policy as follows: (a) on the effective date of this policy provided the Individual's class b then an eligible class; othetwfse (b) on the first day of the policy month coinciding with or next following the date the Individual completes three month of continuous membership in an eligible clam. ` If an Individual's insurance terminates by reason of termination of employment and if the Individual returns to active work in an eligible clam within twelve months after such termination, such Individual shall again become eligible for insurance under the policy on the date he returns to active work in an eligible clam, anything hereinabove to the contrary notwithstanding. If m individual policy converted by an Individual from any previous group insurance under this policy remains in force at the time such Individual would otherwise become eligible for group luminance under this policy, such eligibility shall be deferred until such Individual shall famish, without expense to the Insurance Company, evidence of insurability sans- hcrory to the Insurance Company. INDIVIDUALS' CONTRIBUTIONS. Contributions from Individuals are required, but only for Supplemental Life Insurance. shall EFFECTIVE DATE OF AN INDIVIDUAL'S INSURANCE. The insurance hereunder for an eligible Individual become effective on the applicable date set forth below: I. If no contributions from Individuals are requited, the insurance shall become effective an the date the Individual becomes eligible for insurance. tied the Individual 2. If contributions from Individuals are required, the insurance shall become effective a sfoees to make the required makes written request for insurance on forms provided by due Insurance Company contributions: (a) When the date of written request is on or before the date the bndividual becomes eligible for insurance, the insurance shall become effective on the date the Individual becomes eligible for insurance. s after the Individual es(b) inen die ble for insurance,t a insute of ritten ance shahallgt is not later than become effective on the date off s such request provided a Individual is then in a class of Individuals eligible for insurance. insurance, (c) When the date of written request is more than thirty-one days after the Individual b yes elioble for the hanm or is after previous termination of insurance because of failure to make any required evidence of ce Company reserves the right to require of the Individual, without expense to the Insurance Company, insurability satisfactoryto the Insurance Company before he may become insured. If such evidence is required and submitted, the insurance shall become effective on the date the Insurance Company determines the evidence to be satisfactory, provided the Individual is then in a class of Individuals eligible for insurance. In e date be the eyffectivvee date oce in dors insurance shall an Individual ised feerred disabled until his return to working on a work in and s of Individuals become igible for insurance. GR•305 lNSURlNO PROVISIONS APPLICABLE TO INDIVIDUALS Page Row 3•YI INSURING PROVISIONS APPLICABLE TO INDIVIDUALS (Continued) ADJUSTMENTS OF AN INDIVIDUAL'S INSURANCE. If the amount of any insurance under this policy is contingent upon the classification of an Individual, and if at any time the Individual's classification warrants an amount of insurance greater or less than that for which he is then insured, the amount of his insurance shall be increased or reduced to that warranted by his new classification on the policy anniversary date coinciding with or next follarin{t the __—___..,_w date of change in the Individual's classification as determhne from the Policyholder's records; provided, however, that in any instance in which the Individual is both disabled and not working on the date his insurance would otherwise be increased, the effective date of the increase in the Individual's insurance shall be deferred until his return to active work. If an Individual's classification is contingent upon earnings and if a retroactive change in the Individual's rate of earn- ings warrants an increase or reduction in the amount of his insurance, such increase or reduction shall become effective a the policy anniversary date coinciding with or next following- the date the change in rate of earnings was actually determined by the Policyholder as shown in the Policyholder's records, anything in the preceding paragraph to the contrary notwithstanding; provided, however, that in any instance in which the Individual is both disabled and not working on the date his insurance would otherwise be increased, the effective date of the increase in the Individual's in- surance shall be deferred until his return to active work. TERMINATION OF AN INDIVIDUAL'S INSURANCE. An Individual's insurance under this policy shall, subject to the provisions of the section entlded "Extended Insurance", terminate at the earliest time indicated below: (a) in the event an Individual fails to make any required contribution for his insurance, for which a contribution it requhed and is not made shall terminate at the end of the period far which contribution has been matte. (b) If an Individual's insurance under this policy is contingent upon employment, the insurance of such Individual shall terminate on the last day of the policy month in which employment terminates. is r Cessation of active work shall be deemed termination of employment, except that while an Individual is absent on ac- count of sickness or injury, or is on pension or retirement, employment shall be deemed to continue until premium pay- ments for such Individual's insurance are discontinued. At the option of the Policyholder, the insurance of an Indi- vidual may be continued during a temporary lay-off but not beyond the end of the policy month following the policy month in which the lay-off starts, or may be continued during an authorized leave of absence granted by the Policy- holder for reasons other than sickness or injury but not beyond the period ending three months after such leave of absence starts. (c) The insurance of an Individual shall terminate on the date such Individual ceases to be a member of a cias of Individuahneligfbh foribatrance hammier. (d) The insurance of an Individual shall terminate on the date of discontinuance of this policy with respect to the class of Individuals of which he is a member. (e) The Supplemental Life Insurance of an Individual shall terminate on the date such Individual attain the age of 70 yean. GR-205 (8864) INSURING PROVISIONS APPLICABLE TO !MEI;DUALS PAGE s-A i , LIFE INSURANCE FOR INDIVIDUALS y The Insurance Company shall pay the applicable amount of life insurance determined from the Schedule of Benefits,immediately upon receipt of due proof of the death of any Individual while insured hereunder. BENEFICIARY. The amount payable by reason of the death of an Individual shall be paid to the beneficiary or beneficiaries desig- nated by the Individual. An Individual may designate a beneficiary, or change his designation of beneficiary, from tithe to time by written request filed with the Policyholder or at the Home Office of the Insurance Company. Such designation or change shall take effect as of the date of execution of such request,whether or not the Individual be living at the time of such filing,but without preju- dice to the Insurance Company on account of any payments made by it before receipt of such request at its Home Office. Except as may be otherwise specifically provided by the Individual, (a) if any designated beneficiary predeceases the Individual, the share which such beneficiary would have received if surviving the Individual shall be payable equally to the remaining designated beneficiary or beneficiaries, if any, who survive the Individual; and (b) if no designated beneficiary survives the Individual, or if no beneficiary has been designated, payment shall be made to the Individual's widow or widower,if surviving the Individual; if not surviving the Individual,in equal shares to the Individual's chil- dren who survive the Individual; if none survives the Individual,to the Individual's parents,equally,or to the survivor;if neither survives the Individual, in equal shares to the Individual's brothers and sisters who survive the Individual; or,if none survives the Individual,to the Individual's executors or administrators. OPTIONAL METHODS OF SETTLEMENT. The whole or'any part of any death benefit shall be paid in accordance with that one of the following methods (a) or.(b) that shall be elected by the Individual,or in accordance with such other method of settle- ment as shall be elected by the Individual and agreed to by the Insurance Company.An Individual may revoke any such election at any time before payments commence upon written notice filed at the Home Office of the Insurance Company.An Individual may change any such election at any time but only with the consent of the Insurance Company. In any case where the amount of any death benefit is payable in one sum, the beneficiary may, after the death of the Individual but before payment is made,elect that the whole or any part of any death benefit be payable in accordance with method (b) below, or in accordance with such other method of settlement as shall be elected by the beneficiary and agreed co by the Insurance Company. A beneficiary may change or revoke any such election, but only with the consent of the Insurance Company. (a) Payment in one sum This method shall be automatic if no other method is elected. (b) Payment in monthly instalments of any fixed amount specified in the election (which shall be not less than$5.00 per month per $1,000 so payable nor less than $10.00 per month regardless of the amount so payable),until the amount so payable with inter- est is exhausted. With respect to each such election, the rate of interest to be allowed on the unpaid balance shall be determined by the Insurance Company but shall in no case be less than the guaranteed rate of interest provided for with respect to optional methods of settlements under the individual policies of life insurance being issued by the Insurance Company on the date of such election. At the death of the payee to whom payment is being made under this method,the unpaid balance shall be paid in one sum to the executors or administrators of the payee,unless otherwise provided in the election. PAYEES WHO ARE MINORS OR INCAPABLE OF GIVING VALID RECEIPT. If any payee for any payment under this polity is a minor or,is,in the opinion of the Insurance Company,legally incapable of giving a valid receipt and discharge for such payment, the Insurance Company shall have the option, unless claim has been made by a duly appointed guardian or committee of such payee, of making such payment or any part thereof in monthly instalments of not over $100 the fast month and not over $50 a month thereafter to the person or persons who, in the opinion of the Insurance Company, are caring for and supporting such payee. . Payment so made shall be a complete discharge of the Insurance Company's obligations to the extent of such payment, and the Insur- ance Company shall not be obliged to see to the application of the money so paid. ASSIGNMENT-CLAIMS OF CREDITORS. Neither the Individuals nor their beneficiaries may assign the insurance or other benefits under this policy. Except so far as may be contrary to the taws of any state having jurisdiction in the premises, the insurance and other benefits under this policy shall be exempt from execution, attachment, garnishment, or other legal or equitable process, for the debts or liabilities of the Individuals or their beneficiaries. _ EXTENDED INSURANCE. If an Individual, while insured hereunder and while under age sixty, becomes totally disabled from bodily injury or disease which prevents engagement in any occupation for compensation or profit and if such disability continues after the discontinuance of premium payments for such Individual's insurance, the insurance will be extended, without payment of pre- miums,during the continuance of such total disability for a period of twelve months,or until prior receipt of the proof of permanent total disability referred to below. Permanent total disability, within the meaning of this section, is defined as disability resulting from bodily injury or disease which pre- vents engagement in any occupation for compensation or profit and which has existed continuously for a period of at least nine months. If,before the discontinuance of premium payments hereunder for any Individual or within twelve months thereafter, written proof is received at the Home Office of the Insurance Company that permanent total disability,as above defined,of such Individual began while such Individual was insured hereunder and was under age sixty,the insurance will be extended, without payment of premiums, during the further continuance of such permanent total disability for a period of one year from the receipt of such proof and for successive further periods of one year each during the continuance of such disability,provided proof of its continuance is submitted to the Home Office of the Insurance Company in writing within the three months preceding each such year. The amount of insurance which will be extended under the terms of this section will be the amount of insurance for which the Indi- vidual was insured in accordance with the terms of this policy on the date from which the Individual has been continuously and totally disabled. The Insurance Company shall have the right and opportunity to have the Individual examined when and as often as it may reasonably require during disability,but not more often than once a year after his insurance has been extended under this section for two full years. If the Individual ceases to be so disabled and is then eligible for insurance under this policy, insurance will be continued only if premium payments are resumed. If the Individual ceases to be so disabled and is not then eligible for insurance under this policy,or if this policy is discontinued with respect to the class of Individuals of which he was a member when he became so disabled,the insurance will auto- matically terminate thirty-one days thereafter, except that irrespective of the continuance of disability the insurance under this section will automatically terminate thirty-one days after the end of any year during which the Individual fails to furnish proof of the continu- ance of disability as hereinabove required or thirty-one days after refusal of the Individual to be examined as hereinabove provided. During the thirty-one day period (mentioned in this paragraph) preceding termination of insurance, the Individual shall be entitled to apply for a policy of life insurance in accordance with the "Conversion Privilege" of this policy as though employment had termi- nated at the beginning of such thirty-one days. io 10-'04 LIFE INSURANCE FOR INDIVIDUALS PAGE a LIFE INSURANCE FOR INDIVIDUALS (Continued) Written notice of the death of an Individual while covered under this section must be given to the Home Office of the Insurance Com- pany within twelve months after the date of death; if such notice is not given, the Insurance Company will not be liable for any payment on account of such death. No suit or action for the recovery of any claim for benefits under this section shall be sustainable in any court of law or equity unless commenced within two years after the date of the Individual's death; provided that where such limitation of time is prohibited by the laws governing the question of such limitation, then and fn that event no such suit or talon shall be sustainable unless commenced within the shortest limitation permitted by such laws. CONVERSION PRIVILEGE. If an Individual's insurance under this policy, or any portion of such insurance, ceases because of termination of employment or of membership in the class or classes of Individuals eligible for insurance under this policy, the Indi- vidual shall be entitled to have issued to him by the Insurance Company, without evidence of insurability, an individual policy of life insurance without disability or other supplementary benefin,provided written application for the individual policy shall be -made,and the fast premium thereon paid to the Insurance Company, within thirty-one days after such termination, and provided further that: (a) the individual policy shall be on any one of the forms,except arm insurance,that shall be selected by the Individual from among the forms that customarily issued by the Insurance Company at the age and for the amount applied for; (b) the individual policy shall be in an amount equal to or, at the option of the Individual, an amount less than the amount of the Individual's life insurance under this policy which ceases because of such termination; (c) the premiums payable under the individual policy shall be at the Insurance Company's then customary rate applicable to the form and amount of the individual policy, to the class of risk to which the individual then belongs and to his age attained on the effective date of the individual policy; and (d) any individual policy issued under the terms of this section shall take effect at the end of the thirty-one day period during which application for the individual policy may be made. If this policy discontinues, whether by its terms or by agreement between the Insurance Company and the Policyholder,and whether with respect to all Individuals or with respect to any class or classes of Individuals insured hereunder, any Individual insured here- under at the date of such discontinuance who has been continuously insured hereunder for at least five years prior to such dis- continuance, and whose insurance, or any portion of such insurance, terminates because of such discontinuance, shall be entitled to the conversion privilege as though his employment had terminated on the date of such discontinuance, except that the amount of the r., individual policy shall not exceed the smaller of (a) the amount of the Individual's life insurance under this policy which ceases be- cause of such discontinuance, less the amount of any life insurance for which he is or becomes eligible under any group policy issued or reinstated by the Insurance Company or by any other insurer within thirty-one days after such discontinuance, and (b) $2,000. If an Individual dies during the thirty-one day period within which he is entitled to have an individual policy issued to him in accord- ance with this section and before any such individual policy has became effective, the amount of life insurance which the Individual is entitled to have issued to him under such individual policy shall be payable as a claim under this policy, whether or not application for the individual policy or the payment of the first premium therefor has been evade. When an individual policy becomes effective under the conversion privilege, it shall be in exchange for all privileges and benefits under the group policy, except that if,after an individual policy has become effective under the conversion privilege, (1) proof is submitted within twelve months following termination of employment or of membership in the class or classes of Indi- viduals eligible for insurance under this policy, (a) that the insured Individual has died and that the insurance of such Individual would have been in force under the "Extended Insurance" section of this policy at the date of death if such individual policy had nor been issued,or (b) that the insured Individual is still living and that the insurance of such Individual would have been in force under the"Extended Insurance" section of this policy at the date of such proof if such individual policy had not been issued, and (2) such individual policy is surrendered to the Insurance Company without claim other than for the return of premiums paid thereon, then rights to the insurance under the "Extended Insurance" section of this policy will be restored to the same extent as though such individual policy had not been issued. If an Individual becomes entitled to have an individual policy issued to him in accordance with the terms of this section, and if such Individual is not given notice of the existence of such right at least fifteen days prior to the end of the thirty-one day period during which application for the individual policy may be made, then, in such event, the Individual shall have an additional period within which to exercise such right, but nothing contained herein shall be construed to continue any of the Individual's insurance under this policy beyond said thirty-one day period. This additional period shall expire fifteen days next following the date the Individual is given such notice,but in no event shall such additional period extend beyond sixty days next following the end of said thirty-one day period. Written notice presented to the Individual or mailed by the Policyholder to the last known address of the Individual or mailed by the Insurance Company to the last known address of the Individual as furnished by the Policyholder shall constitute notice for the purpose of this section. tee-sow(8864) ►was UPE INSURANCE FOR INDIVIDUALS LIFE INSURANCE FOR INDIVIDUALS (Continued) SCHEDULE OF BENEFITS BASIC LIFE INSURANCE Classification of Individuals Amount of Basic Life Insurance Class I Individuals who have been employed by the Policyholder for at kart five years $5,000 Class 2 Individuals who have been employed by the Policyholder for less than five years $2,500 Anything heteinabove to the contrary notwithstanding; A. The amount of basic insurance in force on the life of an Individual who is 65 years of age but under 70 yearn of age on the date he becomes instated under this policy or who attains the age of 65 years while insured hereunder shall not exceed $2.500. B. The amount of basic insurance in force on the life of an Individual who is 70 years of age or over on the date he becomes insured under this policy or who attains the age of 70 years while ionned hereunder shall not exceed $1,000. C. Any reduction in the amount of insurance in force on the life of an individual who attains age 65 or age 70 while insured hereunder shall become effective on the policy anniversary date coinciding with or next following the date the Individual attains said age. SUPPLEMENTAL LIFE INSURANCE Classification of Individuals Amount of Supplemental Life Immure F Class 1 Individuals whose basic monthly salary is $500 or over $5,000 Class 2 Individuals whose basic monthly salary is less than $500 $2,500 Anything hereinabove to die contrary notwithstanding; A. The amount of supplemental imurance in force on the life of an Individual who is 65 years of age but under 70 years of age on the date he becomes insured under this policy or who attains the age of 65 years while insured hereunder shall not exceed 5"of the amount of supplemental life imamate as determined frorn the above Schedule of Benefits. B. Any reduction in the amount of insurance in force on the life of an Individual who attains age 65 while insured hereunder shall become effective on the policy anniversary dace coinciding with or next following the date the Individual attains said age. GR-205(8864) LIFE INSURANCE FOR INDIVIDUALS Page 7-1 Buccific Mutual Life Insurccrace Company 529 WEST SIATH STREET • LOS ANGELES. CALIFORNIA • TELEPHONE ISIJI B23•lall MAILING ADDREO: PACIFIC MUTUAL BUILDING P. O. BOX BAOAO LOS ANGELES. CA 90044 Harry G.Bubb Senior Vice President August 10, 1972 Group Insurance Division Barton Buss-Chief Accounting Officer Weld County, Colorado Court House Greeley, Colorado 80631 Re: Special Conversion Privilege for People Insured Under Your Group Medical Expense Insurance Plan GM-8864 Dear Mr. Buss: It is a pleasure to inform you that Pacific Mutual life will currently issue an individual health insurance policy, without evidence of insurability, to employees whose coverage under your group medical plan terminates, with certain exceptions. An employee cannot convert to a Pacific Mutual Life individual health insurance policy if his coverage under your group plan ends because he has been paid the maximum amount he can become eligible for under the group plan or because the group plan terminates, or if he is a seasonal employee. Further, no person is eligible to convert if he is covered under a health insurance or service plan which provides hospital or surgical benefits, or eligible for health services or health insurance protection under a plan,other than Medicare,established by a governmental body. To be eligible for conversion an employee must have actually become ineligible under your group medical plan. He must apply for coverage, under the individual health insurance policy, of all his dependents who are covered under your group plan, unless the converted policy is to be the Senior Hospital Indemnity policy which supplements Medicare. He must apply for conversion, within 31 days after he terminates, on a form provided by Pacific Mutual Life. A sample of the form currently used is attached to this letter. Pacific Mutual Life must retain the right to change or withdraw this offer to adapt to changes which occur often in the field of health care. The right to withdraw this privilege of conversion, or one of the individual health plans described in the attached brochure, or to substitute a different individual health plan, or to change the conditions for exercising the conversion privilege,are reserved to Pacific Mutual Life.Although exercise of its right to change or withdraw all or part of this privilege is valid whether notice is given or not,please be assured that we will inform you of any change as soon as it is reasonably possible to do so. Very truly yours 43/4"fici—ISai40 Harry G. Bubb • • • • Pacific Ttautual Life Insurance Campar y LOS ANGELES, CALIFORNIA (Herein called the Company) APPLICATION is hereby made to the Company for Group Policy No. GM-8864 by .WELD COUNTY, COLORADO whose Main Office Address is Court House, Greeley, Colorado 80631 Said Group Policy is hereby approved and the terms thereof are hereby accepted. This Application is executed in duplicate, one counterpart being attached to said Group Policy and the other being returned to the Company. It is agreed that this Application supersedes any previous application for the said Group Policy. THE BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO (Full or Corporate Name of Applicant) ,J Signed at Greeley, Colorado By�f(/ ;�- l yj'7.{at/cc/a Chairman (Signature and Title) On October 4, 1972 Witness (To be signed by Resident Agent where required by law) This Copy is to be Returned to the Company Oa-al pq 451 , ruut,rttuEuttt'J COPY x ,; .. ......w.+.i.'$...c...,.w .y;` _ '`"s-'n.. _ ..as�6.a{..� 2 " 'i' I I -88• r /I 1 1 I�su= , .. _ .� pCEny (Herein Called 6e rnsurance Company) This policy shall be construed in accordance with the laws of Colorado ,where it is delivered, and is a contract between the Insurance Company and . WELD COUNTY, COLORADO (herein called the Policyholder). The Insurance Company HEREBY INSURES certain persons for the benefits hereinafter descdbed, subject to all of the CC. terms appeuMg on this and the following pages, which are hereby made a part of this policy. 0 The Policyholder may act for and on behalf of any and all persons to whom insurance under this policy relates, and every act done by,agreement made with,or notice given to the Policyholder shall be binding on all such persons. This policy is issued in consideration of the application of the Policyholder,a copy of which is attached to and made a part of this policy,and of the payment by the Policyholder of premiums in advance at the Home Office of the Insurance [I Company or to its authorized agent.The first premium under this policy with respect to insured Individuals in any class ti which is an eligible class on the effective date of this policy shall be due and payable as of such effective date, CO cover (i- • the period beginning on that date and ending on the day before the neat ensuing premium-due date. The first premium 'i1 with respect to insured Individuals in any class which subsequently becomes an eligible class shall be due and payable as il of the date such class becomes an eligible class and shall cover the period beginning on that date and ending on the day lj before the next ensuing premium-clue date. Premiums after the first premium shall be due and payable monthly on the first day of each calendar month. The period beginning on the effective date of this policy and ending March 31, 1973 shall be ,i considered the first polity year.Each policy year thereafter shall commence on the first day of April of each year and end on the thirty-first day of P March next following. l )1 ,• . �p IN WITNESS WHEREOF, PACIFIC MUTUAL LIFE INSURANCE COMPANY has caused this policy to be executed i at Los Angeles, California, as of the first day of April ,19 72 , its effective date. ,`0 )i•, idaa e. Atittees .,. 1----)0Lit4 _, re9)5C c:1 President Secretary ,/,, `I \�. REGISTRAR r� - Il ± GROUP COMPREHENSIVE MAJOR MEDICAL EXPENSE GR-23s1 INSURANCE POLICY n PIAnI ,-• • .. -r GENERAL PROVISIONS INDIVIDUALS' CERTIFICATES. The Insurance Company shall issue to the Policyholder, for delivery to each insured Individual, an individual certificate setting forth a summary of the essential features of the insurance coverage to which the Individual is entitled and staring to whom the benefits are payable. PREMIUM CALCULATIONS-EXPERIENCE RATING. This policy shall not be entitled to share in the surplus earnings of the Insurance Company. Each premium shall be calculated at the premium rate specified in the table below: TABLE OF PREMIUM RATES • MonthW • Rate per IIndividval Individual Insurance Under age 65 $20.30 Age 65 and over $ 6.00 Dependents Insurance Under age 65 $23.46 Age 65 and over $ 6.00 The Insurance Company shall have the right to make experience reductions or increases in premium rata on any premium-due date, and to reduce or increase premium rates whenever a class of Individuals is made eligible or eliminated from eligibility for insurance under this policy.No increase in premium rates,other than an increase when a class of Individuals is made eligible or eliminated from eligibility for insurance under this policy,shall become effective less than twelve months after the effective date of this policy or less than twelve months after the effective date of any previous increase in premium rata. Each reduction or increase in any prenuum rate shall be made by written notification to the Policyholder by the Insurance Company. Except as may be otherwise provided,any insurance becoming effettive shall be charged for from the first day of the policy month comciding with or next following the date the insurance takes effect. Premium charges for any insurance terminated shall cease as of the last day of the policy month coinciding with or next following the date the insurance terminates. If premiums are payable quar- terly, semi-annually, or annually,premium charges or credits for a fraction of a premium-paying period required by the foregoing terms of this paragraph shall be made on a pro-rata basis for the number of policy months between the date premium charges com- mence or cease and the end of the premium-paying Pam Premium adjustments involving the return of unearned premiums shall be limited to the period of twelve months immediately pre- ceding the date of receipt by the Insurance Company of evidence that such adjustments should be made. Instead of the method of calculation of premiums above provided,premiums may be calculated by any method which produces approx- imately the same total amount of premiums and is mutually agreeable to the Insurance Company and the Policyhokler. At the end of each policy year of not less than twelve months' duration throughout which this policy shall have been continuously in effect, the Insurance Company may allow to the Policyhokler an experience credit in such amount, if any, as shall be determined by an experience rating plan which the Insurance Company then has in effect. The amount of each such experience credit shall be paid in ash to the Policyholder, or upon request by the Policyholder, shall be applied against the payment of any premium or premiums. Ifat any time the aggregate of any Individual contributions theretofore made under this policy shall exceed the aggregate of premiums theretofore paid under this policy (after giving effect to any experience credits), such excess shall be applied by the Policyholder for the sole benefit of Individuals, but the Insurance Company shall not be obliged to see to the application of any such excess. • GRACE PERIOD-DISCONTINUANCE OF POLICY. A grace period of thirty-one days following the due date shall be allowed the Policyholder for the payment of each premium after the first. If any premium with respect to the insured Individuals in any class is not paid before the expiration of the grace period, this policy shall automatically discontinue with respect to all Individuals in such class at the expiration of the grace period, except that if the Policyholder shall have given the Insurance Company written notice in advance of discontinuance at the commencement of or during the grace period, this policy shall discontinue with respect to all Indi- viduals in such class as of such earlier date. As to each class, the Policyholder shall be liable to the Insurance Company for all unpaid premiums with respect to the insured Individuals in such class for the period (including a pro-rata premium for the grace period or fracdon thereof) during which this policy was in force with respect to such insured Individuals. The Insurance Company reserves the right to discontinue this policy on any premium-due date (a) with respect to all classes of Individuals, when fewer than 25 Individuals are insured under this policy; or one hundred (b) with respect to any t:dass of Individuals, when less than sevientyissze per cent of the eligible Individuals in such class are insured hereunder; provided that the Insurance Company shall give the Policyholder at least thirty-one days' notice of its intern to discontinue. GE-231 PAGE 2-B ID. 1-'59 GENERAL PROVISIONS (Continued) TRUSTEE POLICYHOLDER. If the Policyholder is a Trustee or Trustees of a crust fund, then (1) should there be more than one Trustee, the Insurance Company shall be entitled to rely upon the signature or signatures of such of the Trustees as are designated to the Insurance Company in writing by all the Trustees from time to time as having been em- powered to act in behalf of all the Trustees in any and all matters pertaining to this policy; and (2) the rights and obligations under this policy of all persons shall be determined by the terms of this policy without regard to the terms of any trust agreement or of any instrument amending or supplementing or replacing any such trust agreement. DATA REQUIRED-CLERICAL ERROR. The Policyholder shall furnish the Insurance Company with all information which thr Insurance Company may reasonably requite with regard to any matters pertaining to this policy. All documents furnished to the Policyholder in connection with the insurance,together with such records as may have a bearing on the insurance under this policy, shall be open for inspection by the Insurance Company at all reasonable times. Neither clerical error in keeping any records pertaining to the insurance under this policy, nor delays in making entries thereon, shall invalidate insurance otherwise validly in force or continue insurance otherwise validly terminated,but upon discovery of such error or delay an equitable adjustment of premiums shall be made. If any relevant facts pertaining to any person to whom insurance under this policy relates shall be found to have been incorrectly reported to the Policyholder or to the Insurance Company, an equitable adjustment of premiums shall be made, and if such misstate- ment affects the existence or the amount of insurance, the true facts shall,be used in determining whether insurance is in force under the terms of this policy and in what amount. t OR-231 PAGE 3-III Ed. 1-'68 • STANDARD PROVISIONS THE CONTRACT.This polity sad the applicatins of the Policyholder eonsiiaee the acetate contract batmen een the pieties Au statements made by the Policyholder shall, in the absence of fraud, be deemed representations and not warranties sad no such statement shall be used in defence to a shim hemonda unless it is contained unwritten application. No agent has authority to&sage the policy or to waive any of is protiaims.No crane in this policy shall be valid makes by an executive officer of the Influence Company end evidenced by endowment hereon,or by ameidmmt hereto signed by the •7 des and by an executive officer of the Insurance Campaay NOTICE AND PROOF OF CLAIM. Written notice of injury or of sickness upon which claim may be bred must be given:to the Insurance Company widen twenty days of the Ake of the commencement of the first loss for which Sides arising oat of oath sorb injury or sickness may be claimed Notice given by of in behsif of the daises to die Issuance Company at in Home Office or to soy rtthodaed anent of the!stoniest Company,with partial=sufficient to identify the issued Wielded,shell be deemed to be notice to the lem snot Compaq.Failure to furnish notice within the time podded in thus policy Ws g not invades,say dual if it shall be dawn not to have been rmwnably possible to Emile such notice and the such notice eras famished es sum as sum reresnbiy passible. The Insurance ,upon reatpt of the notice required by this policy,will furnish o rm• the claimant each fosrareusmdy famished by it for filing of loss If such font ate not m furnished within fifteen days steer the Insurance Coospeq receives sods notice,die claimant shallbe deemed to have complied with the ngsisemenss of this polity m to pmaf of loos upon subii ds&within the time filed in this policy for Hiog pooh of lace,writes pwnf anew die odxnerenoq dancer sod eases of the Ism for whits rein is not da Af s mati a proof of loss of time an .emus of hospital confinement for whirs dais is made saes be fimithd to the Wow Compaq within ninety days these the termination of the period for whid► dais is made. Affirmative pad of say other lots an which Haim may be bred must be furnidhed to the Insurance Company not firer then ninety days liter the dose of and loss. .. EXAMINATION.The Insurance Company shell have the eight end oppotaie' a maim the pawn of the anted leakiest when and so often as h msy ressonibly requite doe*pendency of dem hereunder,end nib the right and owned"o swam se snoopy in case of death where flax ant by law. PAYMENT OF CLAIM. Upon request of the insured Idividuel and subject to due proof of lees dos 'caned doily hospital bawfits will be paid to the insured I dividuel each week dns' any period for which due sosussuse Compaq is lisle,sod any bounce remaining unpaid at the anniaatca of sdi paid will be Mandate*upon receipt of due p oof. All tithe banks provided in this policy will be paid immedistely afar receipt of due . All payments under the policy shall be in accordance with the above pcovufon. except that in case of the death of die imbed In- dividual before all amouno payable under the policy have been paid, tin Insurance Company may pay any such amount up to an aggregate not in excess of $260.00 to any person or institution determined by the Insurance Compaq to be equitable entitled thereto. Any payment In accordance with thb potion shall discharge the obligation of the Imaaaoe Compaq bast s&to the extent of such payment. LEGAL PROCEEDINGS. No action at few or in equity shell be brought o recover oh dtis polity pion o the aphides of deny days afar proof of loss has been find in accords=vied* of this poles. nor shall such taint be bleu*et ell unless brought within two yeses from the expiration of the dmew�p000f of kw is required by this polity. TIME LAMTATION.It any time limitation of dtt policy with respect to giving notice of dais or fusaishkag proof of less or the bringing of sn action a law or in equity is las than dui permitted by the few of the state in width this pokey is delivered, such limitation is hereby ateteded to epee with the minimum period permitted by such kw. WORKMAN'S COMPENSATION NOT AlACI`D.Ibis policy is not in lien of and dm not effect any requiems feraorasp by workmen's composite lnerance. alit(8864) PAGE 4 (Colo) INSURING PROVIS10Ns DEFINITIONS. For the purposes of this policy. the following terms stall have the meanings set forth below; 1. The term Indh•Idual" shall mean airing who b employed by nisi Policyholder, or is an elected official of the Policy- holder. _. i'IM• norm "qualified dependent' shall mean only the unmarried child of an Individual or the notes of an Individual. excluding in any case; (•t) any child nineteen or more yam of age, unless such child b under twenty-three yens at age, attends an aaredited college. tniveniry. or comparable educational inn login as a full course daytime etudes; is dependent upon the Individual for support and maintenance and hu been reported to the Polloybolda for the Insurance pier to the date he Rot incurs any charges with respect to which claim is trade hereunder: 04 a legally separated spouse , (c) any spouse or child while such person h on active duty in any military. naval or air force of any country: (d) any noun or child who is insured unda this Policy as an Individual: and (a) any stepchili. legally adopted child, a foster chill. unless such child is dependent upon the ldlvnual for anon aad maintenance and has been reported to die Policyholder for the insurance prior to the date he first incur any charges with respect to which claim is made hereunder. While both a husband and his wife are insured wrier this policy as individuals die wife dull set be considered to have any quallficd dependents. 3. The taint "illness" shall mem a bodily dhorder. mental Infirmity or bodily Inlay. All bodily Unties sustained in any one accident shall be considered one illness. and all bodily disorders eaisdng simultaneously which are due to the ,ame or related causes shall be considered one: illness. If an illness is due to causes which an the same as a related to the causes of a prier illness and there has been no recovery from the prior illness, the Went than be camidered a continuation of the prior illness and not a separate illness. The tam "illnesses" dull mean more dun one illness. n. The term -individual insurance" shell mein Insurance under this policy portaining to an Individual's own Illness. 5. The term "dependents insurance" than mean insurance under this policy pertaining to illness of depandens. u. The term "covered person" dun mean an Individual who is insured for tndivldual insurance or a qualified dependent with respect to whom an individual h insured for dependents insurance. 7. The term "phydolan" dull mean a person who le lcened to practice s either a Doctor of Medicine a a Doctor at Osoeopadry. To the assn that benefits are provided, the term dull also include a psswn who is leased to Faction and who M p policing wilts the scope of hit Reese as• twist, podiatrist. chiropractor. or payehologlet. 9. The tam"hospital" dun mean only an is8tutiae which meets fully an of the following terse: (I) ft b engaged primar- ily in providing medical care and treatment of dck and injured person on an in-patient badst(lb it maintains facilities ford pods of illnesses and for treatment by a tinder the aupetvblon of a staff of physic!**(lit) u continuously pro- vides 9.4-hour a day meting service by regbared profsdotal nasal(Iv) it maintains organised faeiUties far maker sue- gay, except In the ere of a hospital pehnattny concerted with the treatment of chronic dissent and(v) ft b not, other than Incidentally, a place far rot. a place fa custodial can, a place fa the aged, a plate for drug addicts. a place fot alcoholics, apace fa the can of the mentally RI er pawn with nervous Maeda a piece fa the can of senile a mentally deficient pram, •mains home, a hotel, a e shdlar inatotian. ! IL The term"convalescent hospital" shall moan only as institution which meets fully all of the following tans (p It b regulorly engaged in providing skilled meslag care fa sick and inbred palm under S4-hour a day supervision of a physician a•gnduas repaired mese(R Nth ((f) it has available at all!Imes the services of a physician who at• staff member of a general kapltah(Res It has au duty 24 hots a day a registered men(R.N.). Licensed Vocational Nurse(4 V.N.). a skilled praedoal name, and has a registered as (R IL) on duty at lest eight bas per days(its It masNn a daily medical mead fa itch pales, (v) it complies with an licensing and other legal requhemea and(ere it is not, caber than beldenally, apiece for rat, • place for asocial care, apiece for the aged, apiece for drug addicts, spleen for aleabolies, a pane fist training the phydeally or mentally bandloapped, •hoal, a ■ similar inebsden. nears 038641 _ PACs 6 INSURING PROVISIONS(Continued) 10. The term "intensive care unit" shall mean a separate, clearly designated service area which b maintained within a hospital solely far the care and treatment of patients who are critically 111(or to the case of surgery, require medical attention because of their critical condition beyond fie usual post-operative period) and with respect to which every one of the following tests is fully net: (i) there is provided within such area special nursing care and observation of a continuous and constant mature that are not available hi the regular rooms and wards of the hospital;(ii) there h within such area a concentration of special life saving equipment which b immediately available at all times for the treat- ment of Pads=confined within such area;(Iii) such area contains at least two beds fur the accommodation of criti- cally 111 patients; and(iv) there b at least one registered me(R li ) In continuous and constant attendance on the patients confined in such area, 24 bow a day. EUGRIILITY. The classes of Idlviduah eligible for individual insurance under this policy full be only those classes which are reported in writing to the Insurance Company by the Policyholder; provided, however. that Individuals, other than elected "? officials, who are part-time employees(but excepting Individuals who are full-time employees temporarily working on a part- time basis) and Individuals who are temporary employees shall not be eligible for insurance hereunder. As used herein, the term "part-time employees" shall mean employees who are customarily employed by the Policyholder leas than till"haw par week, and the tern "temporary employers"shall mean employees who are customarily employed by the Policyholder on a full-time basis kiss than five months during a policy year. All claws of individuals eligible he imdtvkind Insurance shall be qualified fied for dependence Isuroee. Upon written request from die Policyholder to the Insurance Company that any class of Individuals be eliminated from the classes of Idividuab eligible for individual insurance, such class shall be eliminated as of the date stated in such request. and upon such date this policy full discontinue with respect to all Individuals in such class. Upon written requeu from the Policyholder to the Insurance Company that any class of Individuals be eliminated from the classes of Individuals qualified for dependenu insurance, such class shall be eliminated as of the date stated in such request, and upon such date dependents insurance shall discontinue with respect to all lodividuah in such class. i; 1 t h 1 i Gib431 8864 8"1 ( ) h • • r INSURING PROVISIONS (Continued) Upon written request from the Policyholder to the Insurance Company,and subject to written acknowledgment of the Insurance Com- pany, any class of Individuals not eligible for individual insurance or any class of Individuals eligible for individual insurance but not eligible fur dependents insurance may be made eligible for individual insurance or dependents insurance,as the case may be,as of the date stated in such request. At the option of the Insurance Company on any premium-due date- if less than sevenry-five per cent of the Individuals in a class of Individuals qualified for dependents insurance are insured therefor,such class shall be eliminated from the classes of Individuals qual- ified for dependents insurance as of such date; provided that the Insurance Company shall give the Policyholder at least thirty-one days' notice of its intent to exercise such option. i If the Policyholder or any eligible clus is a proprietorship or partnership, the individual proprietor or partners thereof shall be deemed to be employees of the proprietorship or partnership if and while devoting fall-time service to the proprietorship or partnership. An Individual in an eligible class of Individuals shall become eligible for individual insurance under this policy as follows: (a) on the effective date of this policy provided the Individual's class is then an eligible class; otherwise (b) on the first day of the policy month coinciding with or next following the date the Individual completes three months of continuota membership in an eligible class. If an Individual's insurance terminates by reason of termination of employment and if the Individual returns to active work in an eligible class within twelve months after such termination, such Individual shall again become eligible for instance under this policy on the date he returns to active work in an eligible class, anything hereinabove to the contrary notwithstanding, An Individual in a class of Individuals qualified for dependents insurance shall become eligible, as an Individual, for dependents in- surance on the latest of the following dares: (a)) on the date the class of Individuals of which the Individual is a member becomes qualified for dependents insurance; or (b) on the date the Individual becomes eligible for individual insurance; or (c) on the date the Individual first acquires a qualified dependent. INDIVIDUALS' CONTRIBUTIONS. Contributions from Individuals are not required for individual insurance and contributions are required fcc dependents instance, EFFECTIVE DATE OF INSURANCE WITH RESPECT TO AN INDIVIDUAL. The individual insurance hereunder for an eligible Individual shall become effective on the applicable date set forth below: I. If no contributions from Individuals are required, the insurance shall become effective on the date the Individual becomes eligible for insurance. ?. If contributions from Individuals are required, the insurance shall become effective as follows,provided the Individual mattes writ- ten request for insurance on forms provided by the Insurance Company and agrees to make the required contributions: (a) When the date of written request is on or before the date the Individual becomes eligible for insurance, the insurance shall become effective on the date the Individual becomes eligible for insurance. (b) When the dare of written request is not later than thirty-one days after the Individual becomes eligible for insurance,the in- surance shall become effective on the date of such request,provided the Individual is then in a class of Individuals eligible for insurance. (c) When the date of written request is more than thirty-one days after the Individual becomes eligible for insurance,or is after previous termination of insurance because of failure to make any required contubution, the Insurance Company reserves the right to require of the Individual,without expense to the Insurance Company,evidence of insurability satisfactory to the Insur- ance Company before he may become insured. If such evidence is required and submitted,the insurance shall become effective on the date the Insurance Company determines the evidence to be satisfactory, provided the Individual is then in a class of Individuals eligible for insurance. In any instance in which an Individual is both disabled and not working on the date he would otherwise become insured, the effec- tive date of his insurance shall be deferred until his return to active full-time work in a class of Individuals eligible for insurance. If the individual insurance of an Individual terminates because benefits to the extent of the Maximum Amount beaune payable, the Individual must furnish, without expense to the Insurance Company,evidence of insurability satisfactory to the Insurance Company before he may again become insured for individual insurance GR-73t PAGE 6 tto.11.17 • • • INSURING PROVISIONS (Continued) • EFFECTIVE DATE OF AN INDIVIDUAL'S DEPENDENTS INSURANCE. Written request to the Policyholder for depend- ents insurance shall be required of any Individual who becomes insured therefor,and such request must be made with respect to all eli- gible dependents which the Individual has at the dare of such request. Written request to the Policyholder shall be required also of any Individual each time the premium for his dependents insurance is to be increased because of the addition of one or more dependents. An Individual who is eligible for dependents insurance shall become insured with respect to each of his qualified dependents on the latest of the following dates, provided he makes any required written request therefor to the Policyholder and agrees to rnake any required contributions: (a) on the effective date of the individual insurance of the Individual;or (b) on the dare the Individual becomes eligible for dependents insurance;or (c) on the date the Individual makes any required written request to the Policyholder for dependents insurance with respect to such dependent; or (d) on the date the dependem becomes a qualified dependent as defined in this policy. Anything hereinabove to the contrary notwithstanding: • (1) if an Individual makes written request to the Policyholder for dependents insurance more than thirty-one days afar the date the Individual first becomes eligible therefor, or after previous termination of dependents insurance because of failure to make any required contribution, the Insurance Company shall have the right to require evidence of insurability (without expense to the Insurance Company) of each of such Individual's qualified dependents existing on the date of such written request; (2) if the premium required for any dependents insurance of an Individual is to be increased because of the addition of oae or more qualified dependents and if the Individual makes written request to the Policyholder for insurance with respect to such dependent or dependents more than thirty-one days after the Individual becomes eligible therefor, the Insurance Company shall have the right to require evidence of insurability (without expense to the Insurance Company) of each of such Individ- ual's qualified dependents not covered for dependents insurance on the date of such written request; (3) insurance shall not become effective with respect to a qualified dependent as to whom evidence of insurability is required until the date the Insurance Company determines the evidence to be satisfactory; (4) if, on the date the dependents insurance would become effective with respect to a qualified dependent, such dependent is con- fined in any institution for care or treatment of bodily disorder, mental infirmity or bodily injury, the effective date of such insurance shall be deferred until the date the dependent is discharged from the institution, unless the qualified dependent has been continuously confined in such institution since bitth. If an Individual's dependents insurance with respect to a qualified dependent terminates because benefits to the extent of the Mad- mum Amount became payable,evidence satisfactory to the Insurance Company of the insurability of such dependent mutt be furnished by the Individual, without expense to the Insurance Company, before he may again become insured for dependents insurance with respect to such dependent. ADJUSTMENTS OF INSURANCE. If the amount of any insurance with respect to an Individual or his qualified depeadmn is contingent upon the classification of such Individual, and if at any time the Individual's classification warrants an amount of insurance greater or less than that for which he is then insured, the amount of such insurance with respect to the Individual or his qualified dependents, as the case may be, shall be increased or reduced to that warranted by his new dassification on the policy anniversary date coinciding with or next following the date of change in the Individual's classification, as determined from the Policyholder's records; provided, however, that no increase in any insurance with respect to an Individual's qualified dependents shall become effective unless and until the insurance hereunder with respect to the Individual conforms to that warranted by his proper classification. • In any instance in which an Individual is both disabled and not working on the date the amount of any insurance hereunder with respect to him would otherwise be increased, the effective date of the increase in such insurance shall be deferred until his return to active full•rime work. In any instance in which a qualified dependent is confined in any institution for care or treatment of bodily disorder, mental infirmity or bodily injury on the date the amount of any insurance hereunder with respect to such dependent would otherwise be increased,the effective dare of the increase in such insurance shall be deferred until the date the dependent is discharged from such institution. TERMINATION OF INSURANCE. The insurance with respect to an Individual and his qualified dependents shall terminate as provided below: (1) The dependents insurance with respect to a qualified dependent shall automatically terminate when such dependent ceases to be a qualified dependent. (2) In the event an Individual fails to make any required contribution for his individual insurance, all insurance hereunder with re- spect to the Individual and his qualified dependents shall terminate ar the end of the period for which contribution has been made. (3) In r^; event an Individual fails to make any required contribution for'his dependents insurance, the Individual's insurance with respect to his qualified dependents shall terminate at the end of the period for which contribution has been made. (4) If benefits CO the extent of the Maximum Amount have become payable under this policy with respect to illnesses of an Individual or qualified dependent, the individual insurance of the Individual or the dependents insurance with respect to the qualified de- pendent, as the case may be, shall automatically terminate. • GR-231 PAGE 7 ID.a••st a an _ INSURING PROVISIONS (Continued) (S) If :sae Individual s insurance under this poky is contingent on employment,all insurance hereunder with respect to an iudividuai and ha qualified dependents shall autonutically terminate on the last day of the policy month in which the Individual's employ- me^.t terminates (except as provided in the last paragraph of this section). Termination of employment shat, for all purposes of this policy, be deemed to occur when an Individual ceases to he actively engaged in work on a full-time basis with the Policyholder for any reason (including retirement). However, an Individual who is disabled, granted a leave of absence, temporarily laid off,or placed on a pan-time employment basis will never- theless be considered as still employed on a full-time basis until the Policyholder, acting on a basis precluding individual selec- tion, terminates the insurance by notifying the Ittsurante Company to that effect or by discontinuing premium payments for the insurance, but in no event shall the Individual be considered employed on a full-time basis with the Policyholder beyond any limit specified for his sates as follows: Status of Iasa(wiafasaf Limit referred to ohne An Individual who is on leave of absence or part-time employment for reasons other than disability Three months . An Individual who is on temporary layoff for reasons other End of the policy month following policy month during than disability which layoff commences An Individual who is disabled (indudiog ass Individual on Two years,but in no event after the Individual commences pan-time employment beause of disability) any work for remuneration or profit with any employer other than the Policyholder or after he has been continuously disabled far thin months subsequent to his attaining the age of 86 years. (6) All insurance under this policy with respect to an Individual end his qualified dependents shall automatically terminate if the Individual ceases to be a member of the dimes of Individuab eligible for insurance under this policy, or if this policy discon- tinues with respect to the tins of Individuals of which he is a member. In the case of Individuals who are insured hereunder for dependents insurance and who are on leave of absence lot military service, the Policyholder may, at its option,permit, for such period or periods as may be established by the Policyholder from time to time, ddeeppeen�dents insurance of all such Individuals,or all of any class or classes thereof determined by the Policyholder on a basis precluding individual selection,to be continued beyond the date individual insurance of such Individuals is terminated pursuant m the foregoing provisions hereof, subject to the other provisions of this policy. EXTENSION OF COVERAGE. If the insurance under this policy with respect to an Individual or any of his qualified dependents terminates for any reason except when termination tccun because benefits to the extent of the Maximum Amount became payable, coverage for the person (Individual or qualified dependent) whose insurance terminated shall he extended under the circumstances and to the extent stated below: 1. In the event that the person whose itsurance terminated is totally disabled and under the care of a physician, for reasons other than pregnancy, at the time of such termination of insurance,coverage for such person pertaining solely to the illness which caused the total disability shall be extended during such toad disability while under such care. but not beyond the end of the calendar year next following the calendar year in which such termination of insurance occurs if such person has been insured hereunder for twelve months or more immediately prior to such termination, otherwise not beyond the end of a period of time equal to the number of full months for which such person has been insured hereunder immediately prior to such termination. 2. in the event that the person whose insurance is terminated is a female Individual or the wife of an Individual, coverage in con- nection with apregnancy of such person which existed at the time of such termination of insurance shall, to the extent that such coverage would be provided had such insurance not terminated, be extended for such person for the duration of the pregnancy and, if such person is confined in a hospital at termination of the pregnancy, for the further period that such person is continu- ously confined on account of the pregnancy; provided, however, that no benefits shall be payable with respect to charges incurred in connection with a pregnancy after the discontinuance of this policy. Termination of insurance under this policy with respect to all Individuals who are employees of an affiliate of the Policyholder and who are insured under this policy shall be deemed to be discontinuance of this policy with respect to such Individuals. No premium charges shall be made for the foregoing extension of coverage after termination of insurance. GR-231(8864) PAGE 8-1 r", • �. COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS CASH DEDUCTIBLE, The cash deductible applicable to a covered person for each calendu year shall consist of eligible charges incurred in connection with an illness, in an amount determined as hereinafter provided, incurred during a period of twelve consecutive months, or less, in such calendar year in connection with the illnesses of such person: provided, however, that no cash deductible shall apply with respect to any hospital charges incurred for treatment of an illness on an out-patient basis, or with respect to any eligible charges Incurred for treatment of bodily injuries sustained in an accident. All eligible charges which are used in detamirdng benefits under this policy may be applied toward satisfaction of the cash de- ductible, except as otherwise provided in the next sentence. If any benefit section of this policy shall contain a statement indi- cating that the eligible charges which are used in detamining benefits under such benefit section are not subject to the cash de- ductible hereunder, then no eligible charges which are used in determining benefits under such benefit section may be applied toward satisfaction of the cash deductible haeutder. The cash deductible applicable to a covered person for a calendar year stall be$100; provided, however, that if insurance here- under with respect to a covered person became effective on the effective dace of this policy, the cash deductible applicable to such person solely for die calendar year in which this policy became effective shall be reduced to an amount equal to 80%of the full cash deductible. • The cash deductible applicable to a covered person for a calendar year shall, subject to the provisions of the second paragraph of this section,be satisfied at the time as of which eligible charges, in an amours at least equal to the cash deductible applica- ble to such person for the calendar year, have been incurred during a period of twelve consecutive months, a less, in such cal- endar year in connection with the illnesses of such person. The cash deductible applies separately to die amount of eligible charges incurred during each calendar year by each covered person; provided, however, that if three "covered family members" uncle eligible charges in excess of their cash deductible 4 during elirek calendar year, then, during such calendar year, on a after the date the third "coveted faintly member" inctrs cured byany escovered family memin excess of the ber licable cash deductible no additional cash deductible will be applied o eligible charges LM The tam "covered family member" means an Individual and each of his qualified dependents inured under the policy, CARRY-OVER OF DEDUCTMIF, If the cash deductible applicable to a covered person h satisfied by the application of eligible charges wholly incurred during the last three months of a calendar year, then(a) the cash deductible applicable to such person for the next ensuing calendar year shall also be considered as having been satisfied as of January 1 of such ensuing calendar year. provided that the eligible charges so applied in the previous calendar year are equal to the cash deductible applicable to such shall be reduced dn for such e ar of January 1 alendar year,such yotherwise ye(b) the cash deductible the amount off eligible charges col applied in to such th on ev such ensuing ous calendar yer.calendar year Further- more. if the cash deductible h not satisfied for a calendar year but eliglbk charges are incurred tiring the last three months of such calendar year, or if the cash deductible is satsfied for a calendar year partially by the application of eligible charges incur-red during ear, then the cash deductible, fled in party eligible charges harges incurred dieing last three months of such the last three months of the pekecakM the u yearn ith respect to calendar which nar o be satis- benefits were payable during such year. MAXIMUM AMOUNT. Not more than$20,000 of benefits in the aggregate(herein called the Maximum Amotmd shall be i payable by the Insurance Company under the provhtons of thh policy with respect to the entire duration of coverage of any one person, whether or not such coverage was interrupted by a previous termination of the person's insurance hereunder for any reason, except as provided by the section entitled "Maximum Amount Reapplied In the even that benefits to the extent of the Max- imum Amount become payable, the imtrance under this policy as to the Individual ar qualified dependent with respect to whom the maximum becomes operative shall automatically terminate as provided by the section entitled "Termination of Insurance". • MAXIMUM AMOUNT REAPPLIED, If benefits to the extent of 21,000.00 or more became payable with respect to illnesses of the expense Individual or a the qualifiednsixance dependent, the Maximum Amount may be reapplied to such person by the Individual funtshing, without Company, evidence satisfactory to the Insurance Company of the insurability of the person with respect to whom dte Maximum Amount h being reapplied. If such evidence b furnished, the Maximum Amont shall be reapplied to such person, effective on the date the Insurance Company determines the evidence to be satisfactory except that in the event such per- son is an employee who b not then actively at work on full time, the reapplication shall be deferred tmtil his return to active work on full time. If the conditions to have the Maximum Amount reapplied to such person are satisfied, the Maximum Amount shall be applied to such person as though no benefits became payable tmda this policy with respect to illnesses of such person prior to the date such reapplication is effected. If any benefits became payable with respect to the illnesses of the Individual or a qualified dependent and the Maximum Amount applicable to such person has not been fully reapplied to such penon at the end of any calendar year, a portion of the Maximum Amount equal to the lesser of 21,000.00 and the entire potion of the Maximum Amount which has not been reapplied shall auto- matically be reapplied to such person on the first day of the next ensuing calendar year, WHEN CHARGES DEEMED INCURRED, For the purposes of this policy, a charge shall be deemed to be incited as of the date of the service, treatment or purchase of the supply giving rise to the charge, GR-231 REV. 3-'71 PAGE 9A-1-f l (CARRY-OVER DED.) . ,.•-•-„. I- CObCPRIEHENSIVE iwyoal MEDICAL i0CPEhls: BINEPITS (Cosdna.d) EXCEPT!. OM. P. Par the pops of this policy, earthing Selo to the meal aohddrdiag,ue dlrbis thee eball (a as rat admit: (i) charges incurred in coanetsiae with a bodily Wary nideg out of, or la the comae of. say employment far wags a peat or I dam se covered by a waden's comp eadon set or Wass lagYhtiioa ce the madame &odes of mWoteseca, wage sad ors; (ii) angel for or is manmtlee wilt ray in einthimr rs as.bossy ddq or the lam of sq rmesii (rill charges tat:mred far cosmetic surgery odes enoe sty fa repair at alleviation at damage msaltbs from ea academe *cawing while a coveted puma; • (1e) charges incurred for any dermal services and supplies for treatment of(a) the teeth, (b)the gums other than for tumors. i' and (c) other amocWsd annum primarily in connection with t s treatment or replacement d teeth, miles the charges are neoesseli fns repair a alleviation of damage to mad anal tooth nth%from an solids ooenshtg while a fcovered person; M chastise inenred for callus or com paring, toenail trimming, or foot massage; j is (vi) charges for or in connection yids trod or feraapmtaacq whether by embolism or ad ro* °opt dme chew for peel's- seen! embdm service and is trseepoet die avast pans dimedy to mid Isom a hospital where treatment is given for an hirers will not be eshadad by this Ympara; (vii) charges with lespect to confinement Ma baled ironed or eperaad by the 1Lmd Stab GaameasR, or with tepee es my i` surgical,medical,r other tisement moAvd is art a bespital,r with spat to a hospital anis e at say sapid,or ether traemmn for which so cheep is mode that rte bididdmil et jellied demos is se med to psy: (vuo dirges inclined during eonfiserat in a hospital cooed or ope eml by a See,Palace et phial seHidWes oda there is an maosdieiaenl segairement is pet end•air Wale word to toy Writ sty S ISM ird r'Solei l; (ix) cftarges for medical examinations of any covered person for "check-up" purposes when not incident and necessary to the treatment of an illness, except that this item(ix) dull not apply with respect to(a) the first$90 of such charges incurred, 1 other than for routine immunizatiom, during each calendar year an behalf of a qualified dependent who is less than two Iyears of age, and(b) an additional amount consisting of the first$95 of such charges incurred for routine immunizations 1 of a qualified dependent who b leas than two years of age; • (x) charges for or in connection with any illness caused by any act of war, whether declared or uedeclared, or by any atomic explosion or other release of nuclear energy(except only when being used solely for medical treatment of an illness of a covered person); (xi) charges incurred for treatment of mental infirmity(a) while confined to an institution which b primarily for treatment of the mentally ill, or(b) all other such charges incurred while not confined to a hospital, which(1) exceed B0*of the amount determined by multiplying the applicable member of Relative Value Units specified in the "Psychiatric Services" section of the Relative Value Schedule of Medical Services by the Dollar Unit Value specified in the Schedule of Benefit az page 11D for all treatment of mental infirmity during each of the first 10 calendar days of such treatment in a calendar year, or(2) exceed 5o% of such amount for all such treatments during each of the next 16 calendar days of such treatment in such calendar year. or(3) are lactated doing dte portion of a claendar year which follows the 26th(reduced in the fiat year a person b insured hereunder by multiplying 26 by tke ratio of 12 to the number of months between dm date he became Rotted hereunder and the end of such calends year) calendar day in which such charges are incurred during such calendar year; (xil) charges incurred for or in connection with the treatment of alcoholism or narcotism; (xiii) charges for any services or supplies other than those which are certified by a physician who b attending die individual or qualified dependent as being required fa the treatment of the noes; (xiv) charges incurred for any services rendered for pregnancy or for resulting childbirth or for prenatal or postnatal taro, except that in the case of Caesarean section, abortion, miscarriage, or severe medical or surgical complications of a pregnancy, no charges shall be excluded if they otherwise qualify as eligible charges; Gitet1S1(8864) Pogo 10A • COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued) (xv) charges incurred in connection with any illness contracted or sustained by a covered person before the effective date of the insurance under this policy with respect to such person; but this exception shall not apply as to (a) chugs not in excess of$5,000..00 incurredduring the fins policy year by or on behalf of a covered person with respect to whom insurance hereunder because effective on the effective date of this policy: (b) charges not in excess of$1,000.00 incurred, during the first twelve months of coverage, by or on behalf of a covered person with respect to whom insurance hereunder becomes effective after the effective date of this policy: or (c) charges incurred by or on behalf of any covered person after the end of any ninety-day period ending subsonic*to the effective date of the insurance hereunder with respect to such person, during which period suds person receives for or in connection with such illness neither medial, surgical, hospital, or nursing treatment or services of any kind, nos any drugs or medicines lawful?! obtainable only upon prescription of a physician; or (d) charges incurred by or on behalf of any covered person more than one year after the effective date of the insurance hereunder with respect to such person. In no event shall the eligible charges indude charges for services, treatments or supplies which are not reasonably necessary for the care and treatment of the illness, nor shall charges for any services, treatments or supplies which are unreasonably priced be included in excess of reasonable charges therefor. • COORDINATION OF BENEFITS. All benefits nada this policy payable for charges incurred or as a credit towatd any applicable cash deductible are subject to this provision. The tenn "allowable expense" means any necessary, reasonable, and customary item of expense at least a portion of which is covered under at least one of the plans covering the person for whom claim is made. The term "plan" includes the heaths payable under dds policy and any other hospital, surgical, medical or major medial bane- fits provided by(i) group, blanket or franchise lmuunce coverage, (ii) group Blue Cross, group Blue Shield, group pmedoe, and other prepayment group coverage, (iii) any coverage under labor-management trusteed plans. union welfare plans, employer organizadon plans, or employee benefit organizadon plans, and(iv) any coverage under governmental programs, and any cover- age required or provided by any statute. The term "plan" shall be construed separately with respect to each pulley, contract, or other arrangement for benefits or services and separately with respect to that portion of any such policy, contract or otter arrangement which reserves the right to take the benefits or services of other plans into consideration in determining its benefits and that portion which does not Benefits under this policy will be reduced if, with respect to any calendar year, the benefits that would be payable under all plans its the absence of this provision and similar provisions in other plans would exceed the total allowable*sperms. Notwithstanding any other provisions of this policy, if this provision applies, the benefits payable under this policy with respect to a covered person will be reduced so that the total paymenu provided or available to or for the benefit of such person, under all pians as defined above, do not exceed 100%of the allowable.expense. Whenever payments which should have been made under this policy in accordance with this provision have been made under any other plan, the Insurance Company shall have the right, exercisable alone in its sole discretion, to pay over to any organizations makeing such other payment any amounts it shall determine to be warranted in order to satisfy the intent of this provision, and amounts so paid shall be deemed to be benefits paid under this policy and, to the extent of such payments, the Insurance Com- pany shall be full discharged from liability under this policy. Whenever payments have been made by the Insurance Company with respect to allowable expenses in a total amount, at any time, in excess of the maximum amount of payment necessary at that time to satisfy the intent of this provision, the Insurance Company shall have the right to recover such payments, to the extent of such excess, from among one or more of the following as the'InsuranceCompany shall determine: (a) any persons to, or for, or with respect to whom such payments were made; (b) any other insurance companies: or (c) any otherorganizatlom. c N.aau (8864) PAGE 10A•2-I • n -•. ,‘utaistf alVE MAP.* MEDICAL EXPENSE BIIEIITs• tCorttned) '•' rpf At Atiff e.•NVA I Ve. t•VT tnKPETAL EXPENSE BENEFITS. Fa the ptrprses of thb section, t p cif obit ctssr.;es shall he the charges which are used in determining benefits under this section, except to the titers m,.11fictl under this section and the section entitled "Exceptions-; and (II) successive periods of confinement in a hospital or convalescent hospital shall be comidered one period of confinement unless the subsequent confinement commences after complete recovery from the illness causing the previous confine- ment. or units, the subsequent confinement is due to came: entirely unrelated to the causes of the previous confine- ment or. In the case of an Individual, unless the subsequent confinement commences after the Individual has returned to active work on full-time and completes two weeks of continuous active service or, in the case of a qualified dependent unless the subsequent confinement is separated from the previous confinement by a period of at least three months: and ` (ill) a charge made by an outside agency far professional ambulance service when used to transport the covered paste to and from a local hospital where treatment ft given for an illness, or for laboratory examinants, x-ray examinatlors, whole blood or blood plasma, anesthetics(but not for the administration thereof). and drug or serums for use daring a period of confinement with respect to which benefits are payable under this section, shall be deemed to be a charge made by the hospital or convalescent hospital if in comnecdon with treatment while the covered pesos is confined in the hospital a convalescent hospital: and (iv) when treatment for an accidental bodily injury is performed outside a hospital, charges such as those for bandages, dressings, splints, casts, tetanus anti-toxin injections, etc. , which would have been incurred if the treatment had been performed in a hospital shall be deemed to be charges made by a hospital; and (v) a charge made for a surgical tray need during a stgical procedure performed in a clinic or in a physician's office shall be deemed to be a charge made by a hospital, but the amount of such charge which shall be deemed to be an eligible charge shall not exceed dm amount determined by multiplying the applicable Dollar Unit Value specified in the Schedule of Benefits on page 11C-1-cby 1.5. If an Individual or qualified dependent, while a covered person, becomes confined in a hospital or convalescent hospital for treatment of an illness, the Insurance Company shalt subject to the terms of this policy, pay a benefit in an amount equal to the eligible charges actually made by the hospital or convalescent hospital. comhtem wadi is rata then in effect, to the Individual or qualified dependent wadi respect to such confinement, but not exceeding the following amounts: (a) for daily service charges, including airy flat daily charges for routine services, an aslant equal to the applicable maximum eligible charges for Dally Service Charges shown in the Schedule of Benefits far each day of such confine- ment: and • ' (b) for all charges by fie hospital as convalescent hospital. including daily service charges, an amount equal to the ap• placable maximum eligible charges far All Hospital Charges shown in the Schedule of Benefits: less, in the event such charges are subject to the cash deductble, as determined from the Schedule of Benefit', and the cash deductible applicable to such covered person has not been satisfied, an amount equal to the part(or all) of such cash deduc- tible that has not been satbfled: provided, however, that (1) no benefits shall be payable for charges for confinement in a convalesces hospital unless(a) a physician certifies that such confinement b necessary for the continued treatment by the physician of an thuss, (b) such confinement follows at least five days of hospital confinement as an in-patient, and(e) such confinement begins within seven days after tetminatdoe of hospital confinement: (2) no benefits shall be payable with respect to any charges for private duty nursing, professional surgical or medical Caro; a personal services such as radio, telephone, newspapers and the like: or for equipment ce supplies far use other than twang a period of confinement with respect to which benefits are payable under tab section: and (3) no benefits shall be payable unless the covered person b confuted as a registered bed patient and the hospital or convalescent hospital makes a charge for board and room in accordance with its regular and customary practice, except when the only charge is for(a) treatment of a non-occupational bodily injury, (b) treatment in connection with stugery, or(c) treatment of a disease, except that no benefits shall be payable in connection with any treat- ment for which benefits are payable under(a) or(b) above, provided. however, that if the htspatal makes no charge for board and room benefits shall not be payable for any of tie following: (I) take-home drugs. or (ill occupational therapy. CC (ill) physical therapy received were than 90 days after dbdharge from confinement in a hospital. at (iv) physical therapy which dos not follow a confinement of at least three days as a reg stasrd patient to a hos- pital, at (v) physical therapy which is not recommended by a legally qualified physicbo sod wpm within two weds of discharge from confinement in a haspbat The requirement that a covered person must be confined in a hospital for treatment of an illness in order for the charges for such confinement to qualify as eligible charges shall not apply with respect to hospital charges for routine nursery care of a qualified dependent who is born as a result oT a pregnancy for which benefits are payable under this policy. The Schedule of Benefits is set forth on the next page, ao-9at /ARRAN _.... Inge 12-3-c(1) COMe4ENCSNE MAJOR MEDICAL EXPENSE BENEPiTS(Continued) SCHEDULE OF BENEFITS Classification of Individuab One ilea applicable to all • Hospital Expense Benefits Daily Service Charges maximum eligible charges for each day in which the cowed pawn occupies: (a)beapital accommodations other than an intendve can nat the hospital's charge for semi- prbrate accommodations not to . exceed$44 (b) an insea ease met of charges specified in a above for the first ten days i (naming 25g coronary. special. and respiratory rare) o a � n ) such emit and 100*thereafter (e) aceamroodadan in a earvabscent hospital 50}of charges specified in(a) above All Hospital Charges(including daily savior charges) • maxima eLgble charges during any period of confinement 1007►of the flat$2.000 of such charges pins 80*of the balsam of sad thaws The eligible charges wed in detamlting beau under thb section are subject to the cash deductible described In the section entitled'Cash Deductible", except eligible charges tattered fa treatment of an illness on an out-patient basis or• for treatment of bodily injuries sustained in an accident. • DR-431 01864) Pages 111"3-c(2) ap.1PRE11ENSIVE MAJOR IdFISICAI. EXPENSE IILNEllts (Counnued) rs-tiNt.lt'Al rsPCNSE BENEFITS. For the purposes of this section, eligible charge. shall he sic charges which are used in detemlour.; benefits under this section, except to the extent modified under this section and the section entitled "Exceptions". Il an Individual or a isualified dependent, while a covered person, utde goes a surgical or radiotherapy procedure enumerated in the Relative Value Schedule of Surgical and Radiotherapy Procedures fa the treatment of all tibias, die Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal to one htmd ed percent of the eligible charges actually made to the Individual or qualified dependent for c (a) the surgical procedues. if such protmdus t b pedonned by a physician: and (b) services rendered by a physician asasadng with such surgical proceduse:and (c) anesthesia services rendered by a physician or prefesdoal anesthetist for die administration_ of an anesdtede in connection with such surgical procedure; and (d) the radiotherapy procedure, if such procedure is performed by a physician a professional radio-therapist; but not exceeding an amount equal to one hundred percent of the applicable Dollar Unit Valise for Surgical Expense Bene- fits shown in t e schedule of Benefits multiplied by the Relative Value specified far such procedure a services, as die case may be. in die Relative Value Schedule of Surgical and Radiotherapy procedures. leas, in the event the cash deductible applicable to such covered person for die then current calendar year has not been saddled, an amount equal to the part(a an) of stab rah deductible that has not been tabbed. If two or more surgical or radfodheapy peacetimes are performed, payment shall be made fa each precedes*is accordance with the terms of the foregoing paragraph. provided diets (1) if multiple or bilateral statical procedures, which add significant time or complexity to patient care, are pertained at die same operadve 104011, the total Optative Value tot such procedures shall not, unless otherwise specified in the Relative Value Schedule of Surgical and Radiotherapy Procedures, exceed the Raidve Value of the major procedure i plus 500/4 of the Relative Value of each die lesser Z procedure as specified in said Relative Value Schedule;and (2) if an incidental surgical procedure(such as incidental appendectomy, lysb of adhesions, excision of prevlats scar, ! puncture of ovarian cyst, etc.) is performed trough due seine incision, payment shall be made only fa diet our pro- cedure for which the largest Relative Valise is specified in said Relative Value Schedule. 3 c SCHEDULE OF BENEFITS Classifications of Individuals One claw applicable to all F Surgical Expense Benefice Dollar Unit Value for Surgical Expense Benefits: 56.70, except that the Dollar Unit Value applicable to a surgical procedure performed in a physician's office or in a clinic shall be $7.701 The eligible charges used in determining benefits under this section are not subject to the cash deductible described in the k section entitled "Cash Deductible". G t it G GR-231(8864) Pan 1.1C-1-e COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued) MEDICAL CARE EXPENSE BENEFITS. For the purposes of this section, eligible charges shall be the charges which are used in determining benefits under this section, except to the extent modified under this section and the section entitled "Exceptions", If an Individual or qualified dependent, while a covered person, receives any necessary medical service enumerated in the Schedule of Medical Services in connection with the therapeutic treatment of an illness, rite Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal to one hundren percent of the eligible charges actually made to the Individual or qualified dependent for such service, but not exceeding an amount equal to one hundren percent of the applicable Dollar Unit Value for Medical Care Expense Benefits shown in the Schedule of Benefits multiplied by the Relative Value specified in the Schedule of Medical Services for such service, less, in the event the cash deductible applicable to such covered person for the then current calendar year has not been satisfied, an amount ew e! to the put (or ail)of such cash deducdble that has not been satisfied; provided, however, that r (1) no benefits shall be payable with respect to charges which are related to the performance of any surgical operation or to any postoperative care. except charges insured after the applicable number of days of follow-up care indicated in the Schedule of Sutgical and Radiotherapy Procedures for services which are reasonably necessary for the therapeutic treatment of an illness; and (2) no benefits shat) be payable with respect to any charges for x-ray examinations, drugs, medicines a supplies, except as may be provided under other sectionsref this policy; and (3) the requirement that medical services must be received in cotmection with the therapeutic treatment of an illness in order for the charges for such services to qualify as eligible charges shall not apply with respect to(a) the first $90 of such charges incurred, other than for routine immunizations, during each calendar year on behalf of a qualified dependent who is less than two years of age, and(b) an additional amount consisting of the first$35 of such charges incurred for routine immunizations of a qualified dependent who U less than two years of age. SCHEDULE OF BENEFITS Classifications of individuals One class applicable to all Medical Care Expense Benefits Dollar Unit Value for Medical Care Expense Benefits: $2.70 The eligible charges used in determining benefits under this section are subject to the cash deductible descdbed in the section entitled "Cash Deductible". COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Condoned) DIAGNOSTIC LABCRATCRY AND X-RAY EXPENSE %NMI'S. For the purposes of this section. efigibh cbarges dial be the charges which are used in detemdMng benefits under this section. except to the extent modified nada this section and the section emitted "Excepdas". If an Individual or qualified dependent. while a coveted person. incur eligible charges far a necessary laboratory a x-ray precedent enumerated in the Schedule of Diagnostic laboratory and X-Ray Preceding*for diagnostic purposes in connection with the dimmed( treatment of an illness, and if such pecan b not emitted to other benefits of any hind under dab policy by reason of such procedure. the Insurance Company shall, sub(ect to the terns of this policy. pay a benefit in an amount equal to one hundred percent of the eligible charges actually made to the Individual or qualified dependent for such potted=coudaent with the usual charges made fat such procedure, but not exceeding an amount equal to one hundred percent of the Dollar Unit Value for Diagncedc laboratory and X-Ray Expense Benefits shown in the Schedule of Benefits multiplied by the Relative Value specified for such procedure in the Schedule of Diagnostic Laboratory and X-Ray Proaedues. lea in the event the cash deductible applicable to such coveted person for the then=nut calendar year has not been satisfied, an amount equal to the part(or all)of such cash deductible that has not been satisfied. SCHEDULE OF BENEFITS Cindfitntios of Individuals One clam applicable to all Diagnostic Lboatary and X-Ray Expense Benefits Dollar Unit Value for Diagnostic Labatt*??and X-Ray Expense Beneath 16.70 The eligible cheeses geed in detemdnieg benefits under this section am subfect to the cute deductible desedbed in the section entitled"Cash Deductible'. GR-2J1 (rt,(1 PAGE 116 • .. • COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued) PRESCRIPTION, APPLIANCE AND NURSING EXPENSE BENEFITS. If an Individual or qualified dependent,while a cov- ered pence, incurs eligible charges, as defined below, for the thaapentic treatment of an illness, the Iamtance Company shall,subject to the tams of this policy,pay benefits in an amount equal to eighty percent of the following: the total digibk charges, as defined in this section, incurred by such covered person, less, in the event the ash deductible applirahly to such covered person for the then as- cent calendar year has not been satisfied,an amount equal to the part (or alt) of such ash deductible that hus not been giddied. For the purposes of this section, eligible ages shall be the following charges actually made to Individuals and qualified dependents on account of their illnesses,except to the event modified under the section enticed "Exceptions": (1) charges msde by a registh and graduate nurse other than one who ordinarily resides in the Individual's (or the wife's or husband's) - home or who is a member of the immediate family (comprising the Individual, the Individusl's wife or husband, and the chil- dren,brothers,sisters,and parents of either the Individual or the Individual's wife or husband) for professional nursing services; and (2) cartes made by a licensed physiotherapist other than one who ordinarily resides in the Individual's (or the wife's or husband's) home or who is a member of the immediate family (comprising the Individual,the Individual's wife or husband,and the children, brothers, sisters, and patents of either the Individual or the Individual's wife or husband) for professions! phyaiatbmpy; and (3) charges made for any of the following services and supplies to the extent such charges do not duplicate charges included under other sections of this policy: (a) drugs and medicines Lwfully obtainable only upon the presaiptiaa of a physician; (b) rental of a wheel chair,hospital bad, iron lung,and such other equipment as is necessary for the t,eahpeatc hestmast of the covered person; (c) artificial limbs and artificial eyes;snd (d) casts,splints,and=pod dressings. The eligible charges used in determining benefit under this section are subject to the ash deductible described in the median endded "Cash Deductible". E� • E u �. • • IllDills.."---: _ COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS(Continued) PREGNANCY EXPENSE BENE6ITS. For the purposes of this section, eligible charges shall be the charges which are used in determining benefits under this section, except to the extent modified under this section and the section of the policy entitled "Exception". . i If a female Individual, or the wife of an Udividual, while she is a covered Pelson. or within nine months afta termination of in- surance as to such person coda this policy other dun by discontinuance of this policy, incurs any of the charges described in(a) and(b) below in connection with a pregnancy resulting in childbirth(other than delivery by Caesarean s chon). the Insurance Company shall, upon receipt of notice and proof of claim, and subject to the further provisions hereof, pay to the Individual the amomt of sud i charges factored fa such pregnancy on or after die effective date of this policy up to the maximum payment for any one pregnancy thaw! in the Schedule of Benefits: (a) the amount of the eligible charges actually made by a physician for an obstetrical procedure: and (b) .the amount of the following charges which ate incu mrd in comectim with a hospital continenmt for which a room and board charge k made by the hospital: M the amount of the eligible charges actually made by the hospital for such person's roam and baud(including all regular daily services)and all other services for medical care and treatment, exclusive of profesdonal services; and (u) the amomt of any eligible charges actually made by a physician for the cost and administration of an • anesthetic given w such person in the hospital: and (ill) the amount of any eligible charges actually made for profesdonal ambulance service when used to transport such person to and from thehopital. • Payment under till'section dull be conditioned upon the pregnancy on which claim is based having its inception while the female Individual, or the wife of the Individual, as the ease may be, k a covered person. SCHEDULE OF BEFITS . Classifications of Indlvlduah Otte class applicable to all • Pregnancy Expense Benefits Maximum payment for any one pregnancy $500 • The eligible charges used in determining benefits under this section are not subject to the cash deductible described in the section sodded 'Cash Deductible'. is I CE-231 (8864) Page 11G-3-a (Taniedoe-!rasa.Deiiv ., • RADIOTHERAPY Values for treatment include all technical expense, professional radiological service and professional admin- istrative services, where applicable, including professional nuclear physicist service. • Procedure Relative No. Schedule Valve 7628 Benign lesions, per treatment 2.0 7620 Malignant lesions, size 0-1 cm, per course 9.0 • NUCLEAR MEDICINE Values for treatment include all technical expense including radioactive materials, professional physician services aad professianal administrative service, where applicable, including professional nuclear physicist service. Per Course Schedule _. Procedure No. • 10710 Metastatic cancer to base 18.0 10716 Hyperthyroidism 18.0 ASSISTANTS • Where the procedure number is preceded by a cross (e), a surgical assistant will be allowed. Assist at surgery, 10% of listed Relative Value of the surgical procedure plus 2 units, and after 3 hours, 1 nit for each additional bah hour, or fraction thereof — minimm allowance 6.0 For surgical or radiotherapy procedures not shown on this Schedule, and which are not expressly excluded by the terms of this policy, the Insurance Company will determine the Relative Value for the procedure and for any . anesthesia service in connection therewith. A procedure of equal gravity and ity will be used as a basis for such determination. The Relative Values for all surgical procedures include the surgery and the follow-up care for the period indi- cated in days in the column headed "Follow-up Days Included". When a surgical procedure or procedures are carried out within the listed period of follow-up care for a previous surgery, the follow-up periods will continue concurrently to their normal terminations. • Benefits shall not be payable for the attendance of two physicians on the same case at the same time except where it is warranted by the necessity of supplementary skills. ANESTHESIA 1. The total values for anesthesia services include pre- and post-operative visits, administration of the anesthetic and the administration of fluids and/or blood incident to the anesthesia or surgery. 2. When hypothermia and/or a pump oxygenator are employed in conjunction with an anesthetic, the anesthetic "base" value will be 20 units. 3. la procedures where no value is listed, the basic portion of the calculated value will be the same as listed for a comparable procedure. 4. Where unusual detention with the patient is essential for the safety and welfare of such patient, the neces- sary time will be valued on the same basis as indicated below for anesthesia time. 5. No fee will be allowed for local infiltration anesthesia administered by the operating surgeon. Calculation of Total Anesthesia Values .i BASIC VALUE is listed for most procedures. This includes the value of all anesthetic services except the • value of the actual time spent administering the anesthesia or in unusual detention with the patient. TIME UNITS are computed by allowing 1 unit for each 15 minutes of anesthesia time.. Anesthesia time starts with the beginning of the administration of the anesthetic agents and ends when the ane sthesiologistis no longer in personal attendance(when the patient may be safely placed under customary postoperative supervision). Basic Value ♦Time Units TOTAL ANESTHESIA VALUE , rwne RELATIVE VALUE SCHEDULE OF SURGICAL AND RADIOTHERAPY PROCEDURES Relative Vine Follow-up Pr.ad.. Relative Value Polito Procedure Days Dai pee Surgery Anesthesia Included Ma, Surgery AnestMsta Indus si nimm sincC1.UStELkTft. stsmi •3261 1ppeadectomy 15.0 4.0•T 1: A.Eon C•11 bidder, removal al '0.0 5.0•T 4: 'tom• •3114 Lavetertomy, total . . 110 0 604.1 90 •1'b: 1 n .4e...s► •son q u 1,14•11 •. •3::1 l.•p•wramy. e•plat•raee ISO 1-0 One 10 •te I,•rt. w 1%0 10•r 4 •1551 Pear reeler roily. fecal 6 p.n.s. •C ' 1 e• 'Sing* r.b.• ••4 tibiae n.0 1.0•r 9 or •ubloral 80.0 CO•T 90 ♦1602 I.e. ear 10,0 1.0•l 4 BREAST p.aarrtea• ♦ 457 Amputation — simple 30.0 3.0+T 45 Radius and ulna, wimple ♦ 470 radical 80.0 3.0+T 60 444 Excision of cyst — unilateral 15.0 3.0+T 30 closed reduction 445 bilateral 20.0 3.0•T 30 820 underage IS 10.0 3.0+T 1. 821 age 15 or over 15.0 3.0+T 12 CHEST simple or compound + 825 open reduction 50.0 3.0+T 15 2111 Bronchosco di merit 15.0 4.0+T 30 py� Tibia and fibula, simple +2191 Lung, total removal of 100.0 I1.O.+T 90 closed reduction +2196 Pulmonary resection with 90 925a under age 15 20.0 3.0+T 9 concomitant thorocoptesty. . . 150.0 11.O+T 180 925 age 15 or over 25.0 3.0+T 18 +2301 Cardiotomy, exploratory 100.0 15.0+T 90 ♦ 928 simple or °outpaced +2350 Myocardial Aneurysm 120.0 15.0+T 90 open redaction 60.0 3.0+T 18 +2317 Excision of cardiac tumor 100.0 15.0 ST 90 851 Finger,simple,closed redaction 4.0 3.0+T 4 EAR, NOSE i THROAT 980 Toe,simple,closed reiamion . . 3.0 3.0+T 6 . 600O Fenestration 100.0 4.0+T 90 Arthreplasty 5972 Mastofdectomy, simple 50.0 4.0+T 180 (plastic or reconstructive operation) 5998 Stapes mobilisation 70.0 4.0+T 90 +1141 Shoulder 80.0 3.0+T 12 1991 Sphenoidsinamtomy 30.0 3.0+T 30 ♦1142 Elbow 80.0 3.0+T 12' Radical♦atrotomy (Caldwell-Lac) +1152 Ankle 75.0 3.0+T 1!1 1988 unilateral 50.0 3.0+T 90 +1151 Knee 100.0 3.0+T 271 1990 .bilateral 65.0 3.0+T 90 Tonsillectomy with or without Renoir of tendons adenoidectomy- 2992 under age 15 15.0 3.0+T 30 +1573 Fasciectomy, for Demesne 2993 age 15 or over 20.0 3.0+T 30 contracture 40.0 3.0+T 121 3044 Esophagectomy 100.0 12.0+T 90 ♦1585 Lengthening or shortening of Achilles tendon 35.0 3.0+T 9t EYE +1621 Transpiatation of tendon 37.5 3.0+T 91 Cataract, operation for intro- RECTUM capsular, extracapsular, or +5611 linear, unilateral 70.0 8.0+T 90 Fissurcrtomy or ulceretomy +5421 Enucleation of eyeball 35.0 4.0+T 30 3371 with sphincterotomy 15.0 3.0+T 9( +5541 Excision of lesion of iris 50.0 4.0+T 45 Hemorrhoidectomy, 3375 internal and external 32 0 3.0♦T 9( GENITO-URINARY TRACT +4634 Cervix amputation 20.0 4.0•T 45 SKULL 3931• Cystoscopy, initial, office 6.0 3.0+T 7 Elevation of depressed skull hospital 8.0 3.O+T 7 +5018 fracture, simple 50.0 9.0+T 6( 4650 Dilation and curettage of uterus Osteoplatsic craniotomy for (non-puerperal) 15.0 3.0+T 15 excision of brain tumor, +4617 Hysterectomy, total 70.0 4.0+T 45 ♦5130 abscess, or cyst supratentorial 125.0 9.0•T 9( +4621 subtotal 40.0 4.0+T 45 +5140 Craniotomy for pallidectomy . . . 100.0 9.0 4•T 9( +4627 radical for cancer 100.0 6.0+T 90 Osteoplastic craniotomy for +3835 Kidney - fixation of 35.0 5.0+T 90 +5136 obliteration of aneurysm 140.0 11.0+T 9( +3821 removal of 75.0 5.0+T 90 Burr holes with vemricalo a hY Bladder tailor- +5152 not followed by surgery 30.0 30.0 7.0+T 3( 3924 transurethral resection . . . . . 50.0 5.0+T 90 +5153 followed b surgery 20.0 7.0+T Prostatectrmy, perinea', by R Y 3( +4311 subtotal 75.0 6.0•T 90 4321 transurethral electroresectioa • SPINE AND SPINAL CORD of prostate 75.0 5.0+T 90 +4481 Cystocele -repair of 35.0 3.0+T 60 Laminectomy for removal of inter- +4484 Rectocele - repair of 30.0 3.0+T 60 +5208 vertebral discs, cervical . . . . 90.0 8.0+T 9 •4485 Cystocele and rectocele- +5192 Cordotomy, cervico-dorsal. . . . 80.0 8.0+T 9 repair of 50.0 3.0+T 60 5214 Myelography 10.0 3.0+T GOITRE +4917 Thyroidectomy, subtotal VEINS AND ARTERIES or partial 65.0 5.0+T 30 +2522 Ligation of carotid artery 40.0 4.0+T N +4914 total or complete 80.0 5.0+T 30 Ligation and division of +4911 Local excision of small cyst long saphenous vein at or adenoma of thyroid 35.0 5.0+T 30 saphenofemoral junction HERNIA 2558 unilateral 20.0 3.0+T 31 2560 bilateral 28.0 3.0+T V +36131 inguinal, unilateral 35.0 3.0+T 45 Ligation and division and +3661 Ventral. incisioual 55.0 3.0+T 45 complete stripping of - . Umbilical long saphenous vein +3665 under age 5 25.0 3.0+T 30 +2561a unilateral 30.0 3.0+T 3( +3666 age 5 or over 35.0 3.0+T 30 +2562 bilateral 42.0 3.0+T 3( long and short saphenous veins MATERNITY ♦2563 unilateral_ 40.0 3.0+T 3( ♦4801 Classic Caesarean section. . . . 40.0 5.0+T 45 +2564 bilateral 55.0 3.0+T 3( +4811 Ectopic pregnancy, by laparotomy 50.0 5.0+T 60 GR-231 (CONTINUED ON REVERSE SIDE) Page12 (RVS-COLO) I . Relative Detention Value +9071 Detention - prolonged detmtlm with patient in critical condition, requiring constant a mention beyond usual service, pa hoer . 15.0 Psychiatric Services 9050 Psychotherapy, pa hour, any type, office, home, or hospital 15.0 9054 Group psychotherapy, 11/2 bouts, pet person 7.5 9055 Electroshock Therapy, pa vestment 12.0 Cardiovascular 9101 Elecaotardiogtam with interpretation and report 7.5 e._ 9104 Hisovocan togtam with enecise(Mashes Tac) 12.5 < Non-Sheglatl Operating Roam Services s" 9195 Operation of pomp with oxygenator or heart exchanges, per boa of pump time 15.0 Pulmonary 9201 8pkamevy. colic rte(Send-Webs or similar immanent) including two efforts on each test, graphic acceding and mince report(total and timed vital capacity and maximal breathing o nen 9215 WW1 Capialty, oral ad tined(Vitale or similar immerhat). . . 2.5 9120 Maraud huathieg.tepidly 5.0 Allergy Testing 9300 Saatch or puncture rasa, op to 90 rase, per 10 tests(minimum 2.5 Colorado units) 2.5 9902 'mistreat tests, tap to total aide tie, par 10 tests(minimum 2.b Colorado mtrs) 3.75 9304 Pitch tams, nth(mWm=2.5 Colorado units) 0.5 Misonilaneota • 9330 Blow-eoespbalog am, awake, asleep(nattaal or induced)and activation 17 5 Illeraranyagardry. oM ssuamig 12.5 2SSD Duodenal drain, 12.5 Moo Phlebotomy, theapatnio, independent procedure 5.0 9404 IUMmhiteset yeshiva WS,wear tent, initial or subsequent 1.5 Physical Medidp The following relative value applies only when these services are under the supervision of a physician and are carried out by the physician or by a licensed phydoal therapist efisployed or supervised by him. Additional charges for office visits are allowed when manilla additional services warrant such extra charges, e.g.. tarot dressing. special examine Aden, eta Moo One of the followingmodalities to one area 2.5 a. Diathermy e. Ultraviolet i. Contrast baths b. *Mahound. f. Microwave J. Whirlpool C Amt or cold pads g. Moistaire 1. Tilt table d. Inks-red .h. Medcasonlata L atrh measurement and initial instruction For medical services not shown on thh Schedule, and which are not expressly excluded by the terms of this policy, the Insurance Company will determine the Relative Value of die service. A service comparable to die enumerated service of aloseat similarity will be used as a basis for suet detemninatioo. egmlit ._ RELATIVE VALUE SCHEDULE OF MEDICAL SERVICE Relative I Office Visits Value 9000 Initial office visits, routine, newpatient or new Illness, history examination examinau 5.0 i +9001 initial(a subsequent) office visit, complete diagnostic history and physical (mamma[ton, taut,- bibbed patient or minor chronic Uhler, including Initiation of diagnostic and treatment pro- x grams 10.0 +9002 Initial(a subagnest) office visit, oamprehruive diagnostic history and physical examination, new patient or make illoer, including initiation of dissuade sod treatment programs, and i requiring at least are hoer of time 17.5 . 9003 Follow-up office visit, brief[ e.g,, routine takection, minimal dressing, etc 2.0 Y 9004 Follow-up office visit. routine 2.5 E +9005 Follow-up office visit neceatattag prolusions'rare ovet and above routine visit 3.75 Home or Mixing(Convalesomg Home visits 9010 Initial hams visit, routine, new patient or new illness, htstay and examination 6.25 +9011 Initial bame visit, complete diagnostic history and physical ettamination, established patient or minor,clnonic illness including initiation of diagnostic and trtsaneat programs 10.0 +9032 Initial bane Wsit,compsehenive diagnostic history and physical examination, new patient or I mimic'Ulnas, lneltdleg initiation of diagnostic and treatment programs, and requiring at least one hour of time 20.0 p9011 Follow-up bane 'bit,';beton e.g., toaiee infection, minimal doting, ete 3.75 k 9014 Follow-up home visit, routine 5.0 +9015 Follow-up boon Wit nroesiatting prolusions!care over and above routine visit 7.6 • Hospital Vldr 9020 Initial hospltel visit, routine Macey and physical examination, including initiation of diagnostic and treatment organs and prepaid=of hospital records 7.5 +9021 Initial hospital vit t, complete Magmatic history and physical examinition, eumblhbed patient a minor chronic illness, including initiation of diagnostic and dement programs and papers- don of hospital records ' 12.6 +9022 Initial hospital visit, comprebamive hbtory and physical examination, new patient or make Ulnas, initiation of and treatment es provisos and paperatioa of h - pdtal meads, and at finer me of time 17.6 9024 Follow-up hospital visit, routine 2.6 +9026 Follow-up booted visit twoesitatig are over and shove routine visit 5.0 CowNadons A cona anion is considered here to include dose services rendered by a physician whose OPINION o ADVICE is requested by another physician or an agency in the svalnation and/or treatment of a ptiast's illness. When the consultant physician dire par assumes rim CONTINUING CARE of the patient, any subsequent service(s) rendered by him will no longer be considered as a onmnitarian. t , If the medial problem neoedtaa s tbs concurrent services and skills of TWO CH MOM PHYSICIANS, eacb phy- iSian will be=tided to iss.listed vainer of by service (g.. Thesswa alu do not reaaatlty include consults- ! rims involving 1Wgettae. 1 +9028 Damnation requiring limited examination and/or evaluation d a glum system but not requiring a . template tegnae&history asd emnienation, hone, office. or hospital 7 5 +9029 Consultation requiring mime ertmthe examination and/or evaluation but not requiring compleic diagnostic history and emsmiestion, bane, office, a hospital 12 6 X9030 Consultation requiring complete diagnostic history and es urination and/or evaluation, home, office, or haapital 17 6 Medial services preceded by a aces(+)may be used by all physicians, but are to be used when due problem appean m- be of a serious or difficult nature requiring additional time and/a special study, e.g., Internal Medicine. Pediatrics, teleology, eta Mitten repots 111511 be fumbbsd upon requert. GR-231 (8864) (CONTINUED ON REVERSE SIDE) Page 13 (COQ :`'.,„,:1‘ ;j -1 wr yt M.�c'- 4.�,,, y'..v . iF₹... h+ to awn '�"a'p .'. -Y :. .4, r t+. i s >k it:el at+4 Ye�r.� , .i £ M.. 't , emu ---1 �.�^'. . . � "° s s.aan�.Ea4'.�i'fl.'. v ac:�f. �-'"� _ '-sue. RELATIVE VALUE SCHEDULE OF DIAGNOSTIC LABORATORY AND X-RAY PROCEDURES 1 DIAGNOSTIC RADIOLOGY The relative value of cads procedure includes all technical expense, professional radiological services, and pro- fessional administrative service, where applicable. Head and Neck { Relative Value 7000 Cembral Angiography, without setialography(unilateral) 8.0 7006 Pneumoencephalography(not including operative replacement procedure) 10.0 • 7910 Mandible, unilateral 3.0 7011 Mandible, bilateral 4.0 ` 7016 Nasal bones 3.0 7026 Skull 5.0 7028 Skull, including special added views 7.0 Chest 7101 Chest, PA and lateral Rhin 3.0 7108 Chest, brcachography, entire procedure by radiologist 11.0 . 7110 Ribs, unilateral 3.0 7111 Ribs, bilateral 5.0 7112 Sternum 3.0 Spine and Pelvis 7201 Spine, entire spine, AP and lateral 9.0 7225 Myelography 8.0 Upper Extremities 7250 Clavicle 2.0 7252 Shoulder 2.5 7255 Elbow 2.0 Lower Extremities 7306 Ankle 2.0 4 7307 Foot 1.6 7308 Toe 1.2 • Abdomen 7350 Abdomen, single view(independent procedure) 2.0 7351 Abdanen, multiple views 4.0 Gastrointestinal Tract 7358 Upper GI ttta(esophagus, monads, duodenum and upper jejunum) 7,0 7980 Colon--barium enema 4.0 7384 Gallbladder(dtolecystography) 4.0 Special Studies 7460 Venography, extremities 8 0 7470 Aortography, translumbar or catheter route, without serialography 10.0 PATHOLOGY Chemistry 8038 Cephalin flocculation 1.0 8045 Osolesterol(total) 1.4 8168 Sugar 1.4 8188 Urea(BUN) 1.4 Enzymes 8200 Alkaline phosphatase. 1 4 8225 Lactic dehydrogenase(LDH) 1.4 $296 Transaminase, oxalic(SOOT) 1.4 GR-231 (CONTINUED ON REVERSE SIDE) Page 14 (COLO) Endocrinological Studies Relative Value 8288 Protein bound iodine(Pal) 2 0 • 8298 Steroids, urine, 17 hydroxycorticoids ?.5 8900 T3 2 0 Ccrebrospinal Fluid 8330 Cell count including differential 0.5 8359 Test for syphilis(V.D.It.L.) 1.4 i Urine i . . f13375 Addis covet 2.0 8404 Catania:clearance 3.0 8455 "Routine" urinalysis o .. 0.6 8488 Stone analysis 1 6 Surgical Pathology 8508 Bons marrow, puncture added=or biopsy and irmprrration 8 0 - 8520 Papanlcoleou(cytology) smears 1.0 Hematology 8555 Lee-white coagulation tone 0.8 8585 Complete blood count(CDC);(includes hemoglobin, henatoait or RBC count, WBC, • and differential) 1 1 8588 Henatoait(macro or micro) 0.4 8686 Protirambin time 0.8 Serology 8680 Anti"sreptolysin titer(ASO) 2 0 8898 HeterophAe antibody(truly) 1.0 8898 RA Out(latex, etc,) 0 8 • lmmumhenatology and Blood Banking 8740 ABO antibody titan 2.0 8787 Rh factor typing 0 6 Bacteriology 8787 Antibiotic sensitivity(disc) 1.0 • 8832 Smear 0 6 8824 T.B.- smear 0.8 8828 T.B. mar and culture 3.0 Virology 8840 Complement fixation(Vitus or ric kettsial) 1.5 Gastrointestinal Tract, Pancreas GASTRIC ANALYSIS 8860 Bernstein Test 4 0 Duodenum 8888 Enzyme study by digestion method 0 8 • Intesttonal Malabsorption and Panacea 8914 Swat chloride, (lontophoresis) 2 5 Feces 8946 Mfaoscopie(ova, parasites, undiggted fibers, etc ) 1 0 Miscellaneous - 8958 Smears, miscellaneous, (nasal secretions for eosinophiles, etc.) 0,4 For procedures not drown in this Schedule, and which are not expressly excluded by the terms of this policy, the In- surance Company will determine the Relative Value of the procedure. A procedure car-parable to the enumerated procedure of closest similarity will be used as the basis of such determination. Y I i Prcacific Mutual Life Insurance Company Los Angeles.California CERTIFICATE AMENDMENT To be attached to Certificate Form No. GR-231-C issued under Group Comprehensive Major Medical Expense Insurance Policy No. GM-8864, a contract between Pacific Mutual Life In- surance Company and WELD COUNTY, COLORADO. In accordance with the terms of Amendment No. 1 attached to and made part of the above numbered group policy as of January 1, 1973, the following changes are made in the Schedule of Benefits on the first two pages of the Certificate: A. The dollar amount specified in item (a) of section 1 is changed to $47. B. The dollar amount specified in the part of section 1 entitled "All Hospital Charges" is changed to $5,000. C. The dollar amount specified in section 3 is changed to $3. D. The dollar amount specified in the sentence immediately preceding the last sentence on the second page is changed to $30,000. This Certificate Amendment forms a part of the Individualls Certificate and is subject to the terms of the above numbered group policy. PACIFIC MUTUAL LIFE INSURANCE COMPANY GR-231-C-AI 1�,►e;%'/`�— �. (1200) 1-'73 President r-N -. Weictial.nalSaCjangelMIT LOS ANGELES, CALIFORNIA (Herein called the Company) APPLICATION is hereby made to the Insurance Company for Group Policy No. Ga-8864 by WELD COUNTY, COLORADO whose Main Office Address is Court House, Greeley, Colorado 80631 Said Group Policy is hereby approved and the terms thereof are hereby accepted. This Application is executed in duplicate, one counterpart being attached to said Group Policy and the other being returned to the Insurance Company. It is agreed that this Application supersedes any previous application for the said Group Policy. THE BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO (Full or�or �� Corporate Name of Applicant) Signed atGreel�, Colorado By s/ /l- mss (Signature and Title) Chairman On__0ctober 4, 1972 Witness (To be signed by Resident Agent where required by law) This Copy is to Remain Attached to the Policy as( (sr) 4181D•s, *; ��rt ,-,Vt11 y �;> ... ....--.... , -I :'±tx° d �vc•-• v .,,.....'_, ,r'4 f',-- ri �''- r3'x. t. s5 Ar ''. r". .... ��"; .;.a' __-----L Grim. -..._ Pace . = , Lif e it Irks „ pc=ny. 1 ( I�s';�= �,y> rr This policy shall be construed in accordance with the laws of Colorado , where it is delivered, and is a contract between the Insurance Company and WELD COUNTY, COLORADO (herein called the Policyholder). The Insurance Company HEREBY INSURES certain persons for the benefits hereinafter described, subject to all of the terms appearing on this and the following pages,which are hereby made a part of this policy. The Policyholder may ad for and on behalf of any and all persons to whom insurance under this policy relates, and every act done by,agreement made with,or notice given to the Policyholder shall be binding on all such persons. J Nothing in this policy shall be construed to mean that any benefits which are contingent on charges made to an Individual shall be payable by the Insurance Company with respect to a hospital confinement in a hospital owned or operated by the United Sates government, or with respect to any surgical, medical, or other treatment received in such a hospital; or with respect to any other hospital confinement or any other surgical,medical, or other treatment for which no charge 1 is made that the Individual is required to pay. This policy is issued in consideration of the application of the Policyholder, a copy of which is attached to and made a i part of this policy,and of the payment by the Policyholder of premiums in advance at the Home Office of the Insurance Company or to its authorized agent The first premium under this policy with respect to insured Individuals in any class which is an eligible class on the effective date of this policy shall be due and payable as of such effective date, to cover the period beginning on that date and ending on the day before the next ensuing premium-due date. The first premium with respect to insured Individuals in any class which subsequently becomes an eligible class shall be due and payable as of the date such class becomes an eligible class and shall cover the period beginning on that date and ending on the day before the neat ensuing premitim-due date. Premiums after the first premium shall be due and payable monthly on the first day of each calendar month. The period beginning on the effective date of this policy and ending March 31, 1973 shall be considered the fast policy year.Each policy year thereafter shall commence on the first day of April of each year and end on the thirty-first day of March next following. IN WITNESS WHEREOF, PACIFIC MUTUAL LIFE INSURANCE COMPANY has caused this policy to be executed 1 at Los Angeles,California,as of the fast day of April 19 72 , is effective dace `� Tr � SECRETARY Ida /5.4,4„.„ (1, �) PRESIDENT 1444a4-�, REGISTRAR - GROUP DISABILITY INSURANCE POLICY FAG! I Ire Teo ED �r i i i . GENERAL PROVISIONS INDIVIDUALS' CERTIFICATES. The Insurance Company shall issue to the Policyholder,for delivery to each insured Individual, a certificate setting forth a summary of the essential features of the insurance coverage to which the Individual is entided and stating to whom the benefits are payable. PREMIUM CALCULATIONS—EXPERIENCE RATING. This polity shall not be entitled to share in the surplus earnings of the Insurance Company. The initial premium shall be calculated at the Initial Premium Rate or Rates specified in the respective benefit section or sections of this policy, and each subsequent premium shall be calculated at the premium rate or rates in effect on the date such premium becomes duct. The Insurance Company shall have the right to make experience reductions or increases in premium rates on any premium- due date,and to reduce or lactase premium rates whenever a class of Individuals is made eligible or eliminated from eligibility for insurance under this policy. No increase in premium rates,other than an increase when a class of Individuals is made eligible or elim- i Mated from eligibility for insurance under this policy, shall become effective less than twelve months after the effective date of this policy or less than twelve months after the effective date of any previous increase in premium rates. Each reduction or increase in any premium rare shall be made by written notification to the Policyholder by the Insurance Company. Except as may be otherwise provided, any insurance becoming effettive shall be charged for from the fast day of the policy morith coinciding with or next following the date the insurance takes effect. Premium charges for any insurance terminated shall cease as of the last day of the policy month coinciding with or next following the date the insurance terminates.If premiums ate payable quar- terly,semi-annually,or annually,pfemium charges or credits for a fraction of a premium-paying period required by the foregoing terms of this paragraph shall be made on a pro-rata basis for the number of policy months between the date premium charges commence or cease and the end of the prnmium-paying period. Premium adjustments involving the return of unearned premiums shall be limited to the period of twelve months immediately pre- ceding the date of receipt by the Insurance Company of evidence that such adjustments should be made. Instead of the method of calculation of premiums above provided,premiums may be calculated by any method which produces approx- imately the same total amount of premiums and is mutually agreeable m the Insurance Company and the Policyholder. At the end of each policy year of not less than twelve months' duration throughout which this policy shall have been continuously in effect, the Insurance Company may allow to the Policyholder an experience credit in such amount, if any, as shall be determined by an experience rating plan which the Insurance Company then has in effect. The amount of each such experience credit shall be paid in cash to the Policyholder, or upon request by the Policyholder, shall be applied against the payment of any premium or premiums. If at any time the aggregate of any Individual conuibutions theretofore made under this policy shall exceed the aggregate of premiums theretofore paid under this policy (after giving effect to any experience credits),such excess shall be applied by the Policyholder for the sole benefit of Individuals, but the Insurance Company shall not be obliged to see to the application of any such excess. .GRACE PERIOD—DISCONTINUANCE OF POLICY. A grace period of thirty-one days following the due date shall be allowed F the Policyholder for the payment of each premium after the first. If any premium with respect to the insured Individuals in any class is not paid before the expiration of the grace period, this policy shall automatically discontinue with respect to all Individuals in such class at the expiration of the grace period, except that if the Policyholder shall have given the Insurance Company written notice in advance of discontinuance at the commencement of or during the grace period, this policy shall discontinue with respett to all Individuals in such class as of such earlier date. As to each class, the Policyholder shall be liable to the Insurance Company for all unpaid premiums with respect to the insured Individuals in such class for the period (including a pro-rata premium for the grace period or fraction thereof) during which this policy was in force with respect to such insured Individuals The Insurance Company reserves the right to discontinue this policy on any premium-due date (a) with respect to all eland of Individuals, when fewer than 25 Individuals are insured under this policy; or • (b) with respect to any clans of Individuals, when less than seventy-five per cent. of the eligible Individuals in such class are insured hereunder; provided that the Insurance Company shall give the Policyholder at least thirty-one days' notice of its intent to discontinue. TRUSTEE POLICYHOLDER If the Policyholder is a Trustee or Trustees of a trust fund,then f (1) should there be more than one Trustee,the Insurance Company shall be entitled to rely upon the signature or signatures of such of E the Trustees as are designated to the Insurance Company in writing by all the Trustees from time to time as having been empowered to act in behalf of all the Trustees in any and all matters pertaining to this policy; and (2) the rights and obligations under this policy of all persons shall be determined by the terms of this policy without regard to the terms of any trust agreement or of any instrument amending or supplementing or replacing any such trust agreement DATA REQUIRED—CLERICAL ERROR. The Policyholder shall furnish the Insurance Company with all information which the Insurance Company may reasonably require with regard to any matters pertaining to this policy. All documenn furnished to the Policyholder in connection with the insurance, together with such records as may have a bearing on the insurance under this policy, shall be open for inspection by the Insurance Company at all reasonable times. Neither clerical error in keeping any records pertaining to the insurance under this policy, nor delays in making entries thereon, shall invalidate insurance otherwise validly in force or continue insurance otherwise validly terminated, but upon discovery of such error or delay an equitable adjustment of premiums shall be made. If any relevant facts pertaining to any person to whom insurance under this policy relates shall be found to have been incorrectly reported to the Policyholder or to the Insurance Company, an equitable adjustment of premiums shall be made, and if such mis- statement affects the existence or the amount of insurance, the true facts shall be used in determining whether insurance is in force under the terms of this policy and in what amount. Eo'a a•se GENERAL PROVISIONS Pwaaaa . 1 '1 STANDARD PROVISIONS THE CONTRACT.This policy and the application of the Policyholder constitute the entire contract between the patties. All statements made by the Policyholder shall, in the absence of fraud, be deemed representations and not warranties and no such statement shall be used in defense to a claim hereunder unless it is contained in a written application. No agent has authority to change this policy or to waive any of its provisions.No change in this policy shall be valid unless approved by an executive officer of the Insurance Company and evidenced by endorsement hereon,or by amendment hereto signed by the Policyholder and by an executive officer of the Insurance Company. NOTICE AND PROOF OF CLAIM. Written notice of injury or of sickness upon which claim may be based must be given to the Insurance Company within twenty days of the date of the commencement of the fins loss for which benefits arising out of each such injury or sickness may be claimed Notice given by or in behalf of the claimant to the Insurance Company at its Home Office or to any authorized agent of the Insurance Company,with particulars sufficient to identify the insured Individual,shall be deemed to be notice to the Insurance Company.Failure to furnish notice within the time provided in this policy shall not invalidate any claim if it shall be shown not to have been reasonably possible to furnish such notice and that such notice was furnished as soon as was reasonably possible. The Insurance Company,upon receipt of the notice required by this policy,will furnish to the claimant such forms asaaeusually furnished by it for filing proof of loss.If such forms are not so furnished within fifteen days after the Insurance Company receives such notice,the claimant shall be deemed to have complied with the requirements of this policy as to proof of lass upon submitting,within the time fixed in this policy for filing proofs of loss,written proof covering the occurrence,character and extent of the lass for which claim is made. Affirmative proof of loss of time on account of hospital confinement for which claim is made must be furnished to the Insurance Company within ninety days after the termination of the period for which claim is made. Affirmative proof of any other loss on .:hick claim may be based must be furnished to the Insurance Company not later than ninety days after the date of such loss. EXAMINATION.The Insurance Company shall have the right and opportunry to examine the person of the insured Individual when and so often as it may reasonably require during pendency of claim hereunder,and also the right and opportunity to make an autopsy in case of death where it is not forbidden by law. PAYMENT OF CLAIM.Upon request of the insured Individual and subject to due proof of lots the accrued daily hospital and weekly disability benefits will be paid each week during any period for which the Insurance Company is liable,and any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of due proof. All other benefits provided in this policy will be paid immediately after receipt of due proof. Benefits for loss of life of the insured Individual are payable to the insured Individual's beneficiary,if surviving the insured Individual, and otherwise to the estate of the insured IndividuaL All other benefits are payable to the insured Individual All payments under this policy shall be in accordsnce with the above provision,except that in the event of the death of the insured Indi- vidual any benefits due and payable to the insured Individual which have not then been paid may be paid to the designated beneficiary. If any benefits remain or become payable at the death of the insured Individual and the total amount thereof does nor exceed$260.00, the Insurance Company may pay such amount to any person or institution determined by the Insurance Company to be equitably entitled thereto. If the total amount of such benefits remaining or becoming payable at the death of the insured Individual does not exceed $1,000.00, and there is no designated beneficiary surviving, at the time due proof is presented, or the insured Individual's estate is the beneficiary the Insurance Company may pay such amount to the husband or wife or any relative by blood of the insured In- . dividuaI determined by the insurance Company to be equitably entitled thereto. Any payment in accordance with this provision shall discharge the obligation of the Insurance Company hereunder to the extent of such payment CONSENT TO CHANGE.Consent of an Individual's beneficiary shall not be requisite to any change of beneficiary. LEGAL PROCEEDINGS.No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty days after proof of loss has been filed in accordance with the requirements of this policy, nor shall such action be brought at all unless brought within two years from the expiration of the time within which proof of loss is required by this policy. TIME LIMITATION. If any time limitation of this policy with respect to giving notice of claim or furnishing proof of loss or the bringing of an action at law or in equity is less than that permitted by the law of the state in which this policy is delivered, such limitation is hereby extended to agree with the minimum period permitted by such law. WORKMEN'S COMPENSATION NOT AFFECTED. This policy is not in lieu of and does no affect any requirement for coverage by workmen s compensation insurance. Mk. GR•1a3 STANDARD PROVISIONS ►A6[ 3a !Oran . 3 • i • INSURING PROVISIONS APPLICABLE TO INDIVIDUALS ELIGIBILITY.The word"Individual"as used in this policy shall mean anyone who is employed by the Policyholder, or is an elected official of the Policyholder. I I The classes of Individuals eligible f«insurance under this policy shall be only those classes which are reported in writing to the Insurance Company by the Policyholder; provided, however, that Individuals, other than elected officials, who are part-tithe employees (but excepting Individuals who are full-time employees temporarily working on a part-time basis) and Individuals who are temporary employees shall not be eligible for insurance hereunder. As used herein, the term "part-time employees" shall mean employees who are customarily employed by the Policyholder less than thirty hours per week, and the term "temporary employees" shall mean employees who are customarily employed by the Policyholder on a full-time basis less than five months during a policy year. Upon wrinen request from the Policyholder to the meta t Company that any class of Individuals be eliminated from the sasses of Individuals eligible for jasmine hereunder, such class shall be eliminated as of the date stated in such tequest, and upon such date this policy shall discontinue with respect to an Individuals in suds class. Upon written request from the Policyholder to the Insurance p , and subject so written acknowledgment of the Insurance npa Cpny, any cos of Individuals not eligible for incur m e hereuaiies�niay be made eligible for Snot beretmdec as of the date stated in such request. If the policyholder or any eligible class ha ppeopriworship oe puemenhip, the individual proprietor « punnets thereof shall be deemed to be employees of the ptoptleeersfiip « peemenhip if and while devoting bit tine service to ter psoptiamnhip « partnership. An Individual in an eligible dam of Individuals shell became digbie for insurance under this policy es follows: (a) on the effective date of this policy provided the Individual's class is then an eligible class; otherwise (b) on the first day of the policy month coinciding with or next following the date the Individual completes three months of continuous membership in an eligible class. If an Individual's insurance terminates by reason of termination of employment and if the Individual returns to active work in an eligible class within twelve months after such termination, such Individual shall again become eligible for insurance under this policy on the date he returns to active work in an eligible class, anything hereinabove to the contrary notwithstanding. INDIVIDUAIS'CONTRIBUTIONS. Contributions from Individuals are required, but only for Supplement:Accidental Death and Dismemberment Benefits. EFFECTIVE DATE OF AN INDIVIDUAL'S INSURANCE. The insurance hereunder for sa eligible Individual shell become effective on the applicable date sec tote below: 1. If no contributions from Individuals are requked, the Insunnet shall become shake on the due the Individual becomes eligible for insurance. 2 If contributions from Individuals see milked,the insures:a dell become effective as follows,plodded the Individual makes wdteen request for insurance on forms provided by the Insurance Company tad agues to make the required contributions: (a) When the date of written mutt is on or Wine the date the Individual becomes eligible for insurance, the influence shall become effective on the date the Individual becomes eligible foe insurance. (b) When the date of written request is not later than ehittyote days after the Individual becomes eligible for insunece, the insurance shall become tiive on the date of such request, provided the Individual is then in a dam of Individuals eligible for insurance. (c) When the due of written request is more than Mintage days site ohs Individual becomes eligible foe khsunnee, or is after previous termination of insurance Inoue of failure to nuke tiny :squired contribution, the Insurance Company re- serves the right to require of the Individual, without expense to the Insurance Company evidence of Insunbaky setafanory to the Insurance Company before he may become insured. U suds evidence is cerpsissj red submitted, the insurance sbaB become effective on the due the lesuaeae Company determines the evidence to be ambhctce►, peovided the Individual is then in a dot of I dividuak eligible for iawtanet In snr instance in whkh an Individual Is both disabled sad not working on the date he would otherwise become insured, the effec- tive due of his Invents, smell be deferred until Ile serum to active work kt a els of Itdividmds eligible foe insurance. M INJURING PROVISIONS APIKX.Wl TO INDIVIDUALS uses 4 • • ADJUSTMENTS OF AN INDIVIDUAL'S INSURANCE. If the amount of any insurance under this policy is contingent upon the classification of an Individual, and if at any time the Individual's classification warrants an amount of insurance greater or less than that for which he is then insured, the amount of his insurance shall be increased or reduced to that warranted by his new classification on the policy anniversary date coinciding with or next following the date of change in the Individual's classification as determined from the Policy- holder's records; provided, however, that in any instance in which the Individual is both disabled and not-working on the !- date his insurance would otherwise be increased, the effective date of the increase in the Individual's insurance shall be deferred until his return to active work. i If an Individual's classification is contingent upon earnings and if a retroactive change in the Individual's rate of eam I ings warrants an increase or reduction in the amount of his insurance, such increase or reduction shall become effective on the policy anniversary date coinciding with or next following the date the change in rate of earnings was actually determined by die Policyholder as shown in the Policyholder's records, anything in the preceding paragraph to the contrary notwithstanding; provided, however, that in any instance in which the Individual is both disabled and not working on the date his insurance would otherwise be increased, the effective date of the increase in the Individual's insurance shall be deferred until his ream to active work. TERMINATION OF AN INDIVIDUAL'S INSURANCE. An Individual's insurance under this policy shall terminate at die earliest time indicated below: (a) In the event an Individual fails to make any required contribution for his insurance, die insurance for which a contribu- tion is required and is not made shall terminate at cite end of the period for which contribution has been made. (b) If an Individual's insurance under this policy is contingent upon employment, the insuraee of such Individual shall terminate on the last day of the policy month in which employment terminates. Cessation of active work shall be deemed termination of employment, except that while an Individual is absent on account of sickness or injury, employment shall be deemed to continue until premium payments for such Individual's • insurance are discontinued. At die option of the Policyholder, the insurance of an Individual may he continued during a temporary lay-off but not beyond the end of the policy month following the policy month in which the lay-off starts, r or may be continued during.an authorized leave of absence grated by the Policyholder for reasons other than sickness or injury but not beyond the period ending three months after such leave of absence starts. (c) The insurance of an Individual shall terminate on the date such Individual ceases to be member of a class of individuals eligible for insurance hereunder. (d) The insurance of an Individual shall terminate on the date of discontinuance of this policy with respect to die class of Individuals of which he is a member. _ (e) The Supplemental Accidental Death and Dismemberment Insurance of an Individual dull terminate on the date such Individ- ual attains the age of 70 yean. EXTENDED INSURANCE BENEFIT. If any insurance hereunder with respect to an Individual, other than any Weekly Disability Benefits insurance or any Accidental Death and Dismemberment insurance, terminates while the Individual is totally disabled, such insurance shall be extended without payment of premiums during such total disability, but not beyond the period ending three months after such termination; provided, however, that this paragraph shall not be con- strued so as to extend insurance with respect to any benefits payable under this policy on account of pregnancy or result- ing childbirth or miscarriage, or complications therefrom, nor so as to extend any insurance under this policy widt respect to dependents. oR•rt5(8864) - - PAGE S•AlVG INSURING PROVISIONS APPLICABLE TO INDIVIDUALS MED 1 .--. j ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS FOR INDIVIDUALS ! The Insurance Company shall pay a benefit determined from the following Table of Benefits if an Individual sustains any of the losses listed in said Table of Benefitr, provided, however, that (a) the accident causing the loss occurred while the Individual was insured under this section, and (b) such loss restated directly,and independently of all other causes, from bodily injuries (including bodily injuries arising out of or in the course of employment) sustained solely through accidental means, and (e) such loss occurred within ninety dap after the date of the accident causing such loss. TABLE OF BENEFITS Iw tba Eves of Lorr of The Be** sviii be Lite The Principal Sum A Hand One-Half The Principal Sum A Foot One-Half The Principal Sum An Eye One-Half The Principal Sum More than one of the above through one accident The Principal Sum The words "Principal Sum", as used herein, mean the Principal Sum of Accidental Death and Dismemberment Insurance shown in the Schedule of Benefits. Wide respect to a hand or a foot, "loss"means dismemberment by severance through or above the wrist or ankle joint. With respect to an eye, "loss" means die entire and irrecoverable loss of the sight of such eye. In no case shall more than the full Principal Sum be paid for all losses sustained by the Individual through one accident. EXCLUSIONS. The Accidental Death and Dismemberment Benefits do not cover any loss caused directly or indirectly, wholly or partly,or contributed to substantially,by bodily or mental infirmity; or ptomaines; or bacterial infections (except pyogenic infectious which shall occur through an =tit—al rut or wound); or any other kind of disease; or medical or surgical treatment (except such as may rank directly from surgical operations made necessary solely by injuries covered under this section); or war, or any act of war, or suicide or attempt thaw,sane or insane. BENEFICIARY. The Individual may designate a brat Entry, or change his designation of beneficiary,from time to time by written request filed with die Policyholder or at the Home Office of dte Insurance Company.Such designation or change shall take effect as of the date of execution of rich request,whether or not the Individual be living at the time of such filing, but without prejudice to the Insurance Company on account of any payments made by it before receipt of such request at is Home OBE. Except as may be otherwise specifically provided by the Individual, r E (a) if any designated beneficiary predeceases the Individual,the share which such beneficiary would have received if he had survived the Individual shall be payable equally to the remaining designated beneficiary or beneficiaries, if any, who survive the Individual; fand (b) if no designated beneficiary survives the Individual, or if no beneficiary has been designated, payment shall be made to the In- dividuals widow or widower, if surviving the Individual; if not surviving the Individual, in equal shares to the Individual's children who survive the Individual; if none survives the Individual, to the Individual's parents, equally, or to the survivor; if neither survives the Individual, in equal sharp to the Individual's brothers and sisters who survive the Individual; or, if f none survives the Individual, to the Individual's executor or administrators. ASSIGNMENT—CLAIMS OF CREDITORS. Neither the Individual nor his beneficiaries may assign the insurance or tither benefits provided under this section. Euepe so far as may be contrary to the laws of any state having jurisdiction in the premises, the insurance and other benefits pro- whaled under this section shall be exempt from execution,attachment, garnishment, or other legal or equitable pmeess, for the debts or liabilities of the Individual Of his beneficiaries. ANA • • • MMO.as i (8864) ACC/DENTAL DEATH AND DISMEMBERMENT BENEFITS FOR INDIVIDUALS PAGE II She • ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS FOR INDIVIDUALS (Continued) SCHEDULE OF BENEFITS • 9 BASIC ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Classification of Individuals Amount of Principal Sum of Basic Accidental Death and Dismemberment Insurance Class 1- Individuals who have been employed by the Policyholder for at least five years $5,000 Class 2 Individuals who have been employedby the Policyholder for less than five years $2,500 Anything heteinabove to the contrary notwithstanding; A. The amount of Principal Sum of Basic Accidental Death and Dismemberment Insurance in force with inspect to an Individual who is 65 years of age but under 70 years of age on the date he becomes insured under this policy or who attains the age of 65 years while insured hereunder shall not exceed $2,500. B. The amount of Principal Sum of Basic Accidental Death and Dismemberment Insurance in force with respect to an Individual who is 70 years of age or over on the date he becomes insured under this policy or who attains the age of 70 years while insured hereunder shall not exceed $1,000. C. Any reduction in the amount of Principal Sum in force with respect to an Indivudual who attains age 65 or age 70 while insured hereunder shall become effective on the policy anniversary date coinciding with or next following the date the Individual attains said age. • SUPPLEMENTAL ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Classification of Individuals Amount of Principal Sum of Supplemental Accidental Deadi and Dismemberment Insurance Class 1 Individuals whose basic monthly salary is $500 or over $5.000 Class 2 Individuals whose basic monthly salary is less than $500 $2,500 . . Anything hereinabove to the contrary notwithstanding; A. The amount of Principal Sum of Supplemental Accidental Death and Dismemberment Insurance in force with respect to an Individual who is 65 years of age but under 70 years of age on die date he becomes insured under this policy or who attains the age of 65 years while insured hereunder shall not exceed 50%of the amount of Principal Sum of Supplemental Accidental Death and Dismemberment Insurance as determined from the above Schedule of Benefits. B. Any reduction in the amount of Principal Sum in force with respect to an Individual who attains age 65 while insured hereunder shall become effective on the policy anniversary date coinciding with or next following the date the Individual attains said age. - INITIAL PREMIUM RATE Initial Premium Rate for benefits provided in this section: $ .07 monthly per $1,000 of Principal Sum. CR-225(8864) ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS FOR INDIVIDUALS Page 6-1 ADD-O Hello