HomeMy WebLinkAbout20180922.tiffSUMMARY OF THE LIFE AND HEALTH INSURANCE PROTECTION ASSOCIATION ACT
AND NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS
INTRODUCTION
Residents of Colorado who purchase life insurance, annuities or health insurance should know that the
insurance companies licensed in this state to write these types of insurance are members of the Life and
Health Insurance Protection Association. The purpose of this Association is to assure that policyholders
will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to
meet its obligations. If this should happen, the Association will assess its other member insurance
companies for the money to pay the claims of insured persons who live in Colorado and, in some cases, to
keep coverage in force. The valuable extra protection provided by these insurers through the Association
is limited, however. As noted in the box below, this protection is not a substitute for consumers' care in
selecting companies that are well managed and financially stable.
IMPORTANT DISCLAIMER
The Life and Health Insurance Protection Association may not provide coverage for this policy. If
coverage is provided, it may be subject to substantial limitations or exclusions, and require
residency in Colorado. You should not rely on coverage by the Life and Health Insurance
Protection Association in selecting an insurance company or in selecting an insurance policy.
Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer
or for which you have assumed the risk.
Insurance companies or their agents are required by law to give or send you this notice. However,
insurance companies and their agents are prohibited by law from using the existence of the
association to induce you to purchase any kind of insurance policy.
SUMMARY
The state law that provides for this safety -net coverage is called the Life and Health Insurance Protection
Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary
does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under
the act or the rights or obligations of the Association.
Coverage. Generally, individuals will be protected by the Life and Health Insurance Protection Association
if they live in this state and hold a life or health insurance contract, or an annuity, or if they hold certificates
under a group life or health insurance contract or annuity, issued by a member insurer. The beneficiaries,
payees or assignees of insured persons are protected as well, even if they live in another state. Certain
parties to structured settlement annuity contracts may be entitled to coverage benefits as well based on
defined circumstances.
This Information is Provided By:
Life & Health Insurance
Protection Association
P.O. Box 36009
Denver, CO 80236
(303) 292-5022
Colorado Division of Insurance
1560 Broadway
Suite 850
Denver, CO 80202
(303) 894-7499
e&; 660,e/s-or)ri
2018-0922
ceepo5.2
Exclusions From Coverage. Persons holding such policies or contracts are not protected by this Association
if:
• they are not residents of the State of Colorado, except under certain very specific
circumstances;
• the insurer was not authorized or licensed to do business in Colorado at the time the policy
or contract was issued;
• their policy was issued by a nonprofit hospital or health service corporation, an HMO, a
fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or
similar plan in which the policyholder is subject to future assessments, or by an insurance
exchange.
The Association also does not provide coverage for:
• any policy or portion of a policy which is not guaranteed by the insurer or for which the
individual has assumed the risk;
• any policy of reinsurance (unless an assumption certificate was issued);
• plans of employers, associations or similar entities to the extent they are self -funded or
uninsured (that is, not insured by an insurance company, even if an insurance company
administers them);
• interest rate yields, crediting rate yields or other factors employed in calculating returns,
including but not limited to indexes or other external references stated in the policy or
contract, that exceed an average rate specified in the Association Act;
• dividends;
• experience rating credits;
• credits given in connection with the administration of a policy or contract;
• any unallocated annuity;
• annuity contracts or group annuity certificates used by nonprofit insurance companies to
provide retirement benefits for nonprofit educational institutions and their employees;
• policies, contracts, certificates or subscriber agreements issued by a prepaid dental care
plan;
• sickness and accident insurance when written by a property and casualty insurer as part of
an automobile insurance contract;
• unallocated annuity contracts issued to an employee benefit plan protected under the federal
Pension Benefit Guaranty Corporation;
• policies or contracts issued by an insurer which was insolvent or unable to fulfill its
contractual obligations as of July 1, 1991, except for annuity contracts issued by a member
insurer which was placed into liquidation between July 1, 1991, and August 31, 1991;
• policies or contracts covering persons who are not citizens of the United States;
• any kind of insurance or annuity, the benefits of which are exclusively payable or
determined by a separate account required by the terms of such insurance policy or annuity
maintained by the insurer or by a separate entity.
Limits On Amount Of Coverage. The act also limits the amount the Association is obligated to pay out. The
Association cannot pay more than what the insurance company would owe under a policy or contract. Also,
for any one insured life, no matter how many policies or contracts were issued by the same company, even if
such contracts provided different types of coverages, the Association will pay a maximum of:
• $300,000 in net life insurance death benefits and no more than $100,000 in net cash
surrender and net cash withdrawal values for life insurance;
• for health insurance benefits - $100,000 for coverages not defined as disability, basic
hospital, medical and surgical, or major medical insurance, including any net cash
surrender and net cash withdrawal values; $300,000 for disability insurance; or $500,000
for basic hospital, medical and surgical, or major medical insurance;
• $250,000 in the present value of annuity benefits, including net cash surrender and net cash
withdrawal values; or
• with respect to each payee of a structured settlement annuity, $250,000 in present value
annuity benefits, in the aggregate, including net cash surrender and net cash withdrawal
values; or
• $300,000 for long term care benefits.
The Association shall not be liable to expend more than $300,000 in the aggregate, with respect to any one
life except that with respect to benefits for basic hospital, medical and surgical and major medical insurance,
the aggregate liability of the Association shall not exceed $500,000 with respect to any one individual.
NOTICE
Benefits paid under the Accelerated Benefits provision will reduce the Death Benefit
payable for life insurance.
Benefits payable under the Accelerated Benefits provision may be taxable. If so, the
Employee or the Employee's beneficiary may incur a tax obligation. As with all tax
matters, an Employee should consult with a personal tax advisor to assess the impact of
this benefit. Accelerated Benefits are not payable if life insurance coverage under the
Policy is not in force.
TL -004788
LIFE INSURANCE COMPANY OF NORTH AMERICA
1601 CHESTNUT STREET
PHILADELPHIA, PA 19192-2235
(800) 732-1603 TDD (800) 552-5744
A STOCK INSURANCE COMPANY
POLICYHOLDER:
GROUP POLICY
TRUSTEE OF THE GROUP INSURANCE
TRUST FOR EMPLOYERS IN THE PUBLIC
ADMINISTRATION INDUSTRY
SUBSCRIBER: Weld County Government
POLICY NUMBER: FLX-968032
POLICY EFFECTIVE DATE: January 1, 2018
POLICY ANNIVERSARY DATE: January 1
This Policy describes the terms and conditions of coverage. It is issued in Delaware and shall be
governed by its laws. The Policy goes into effect on the Policy Effective Date, 12:01 a.m. at the
Policyholder's address.
In return for the required premium, the Insurance Company and the Policyholder have agreed to all the
terms of this Policy.
hYJac. A. 'Hi -1,
Anna Krishtul, Corporate Secretary Matthew G. Manders, President
TL -004700
TABLE OF CONTENTS
SCHEDULE OF BENEFITS 1
SCHEDULE OF BENEFITS FOR CLASS 1 2
ELIGIBILITY FOR INSURANCE 8
ENROLLING FOR INSURANCE 10
EFFECTIVE DATE OF INSURANCE 11
TERMINATION OF INSURANCE 12
CONTINUATION OF INSURANCE 13
LIFE INSURANCE BENEFITS 19
LIFE INSURANCE EXCLUSIONS 21
CLAIM PROVISIONS 22
ADMINISTRATIVE PROVISIONS 25
SCHEDULE OF RATES 27
GENERAL PROVISIONS 29
DEFINITIONS 30
DOMESTIC PARTNER/CIVIL UNION PARTNER RIDER 33
STATE MODIFYING PROVISIONS AMENDMENT RIDER 35
SCHEDULE OF BENEFITS
Premium Due Date: The last day of each month
Classes of Eligible Employees
Class 1
All active, full-time Employees of the Employer regularly working a minimum of 30
hours per week, and part-time Employees working a minimum of 20 hours per week, who
are citizens or permanent resident aliens of the United States, and are living and working
in the United States
1
SCHEDULE OF BENEFITS FOR CLASS 1
Eligibility Waiting Period
The Eligibility Waiting Period is the period of time the Employee must be in Active Service to be eligible
for coverage. It will be extended by the number of days the Employee is not in Active Service.
For Employees hired on or
before the Policy Effective Date: The first of the month following completion of one full pay
period
For Employees hired after
the Policy Effective Date: The first of the month following completion of one full pay
period
LIFE INSURANCE BENEFITS
Employee Benefits
Basic Benefit
Guaranteed Issue Amount:
Maximum Benefit:
3 times Annual Compensation
the lesser of 3 times Annual Compensation or $600,000
the lesser of 3 times Annual Compensation or $600,000
The Benefit Amount, Guaranteed Issue Amount and Maximum Benefit will be rounded to the next
higher $1,000, if not already a multiple thereof.
Basic Terminal Illness Benefit
Voluntary Benefit
Guaranteed Issue Amount:
Maximum Benefit:
The insured can elect up to 75% of Basic Life Insurance Benefits
in force on the date the insured is determined by the Insurance
Company to be Terminally Ill, subject to a Maximum Benefit of
$450,000.
An amount elected in units of $1,000
the greater of a) or b) below:
a) $275,000, or
b) an amount equal to the Life Insurance Benefit in effect on
the termination date of the Prior Plan
the lesser of 5 times Annual Compensation or $500,000
The Maximum Benefit will be rounded to the next higher $1,000, if not already a multiple thereof.
Voluntary Terminal Illness
Benefit
The insured can elect up to 75% of Voluntary Life Insurance
Benefits in force on the date the insured is determined by the
Insurance Company to be Terminally Ill, subject to a Maximum
Benefit of $375,000.
2
Age Based Reductions
Continuation Options
For Leave of Absence
Maximum Benefit Period:
For Employee paid vacation
Maximum Benefit Period:
For Injury or Sickness
Maximum Benefit Period:
For Family Medical Leave
Maximum Benefit Period:
Life Insurance Benefit for an Employee age 65 and over will
reduce to the percentage shown below:
65% of the Life Insurance Benefit at age 65
42% of the Life Insurance Benefit at age 70
27% of the Life Insurance Benefit at age 75
21% of the Life Insurance Benefit at age 80
15% of the Life Insurance Benefit at age 85
12% of the Life Insurance Benefit at age 90
9% of the Life Insurance Benefit at age 95
Benefit reductions will be effective on the January 1 coinciding
with or next following the Employee's attainment of age as
specified in schedule above.
1 month
3 months
12 months
the later of the period of the approved FMLA leave or the leave
period required by the laws of the state in which the Employee is
employed
For Disability for Employees over Age 60
Maximum Benefit Period: 12 months
Applicable Coverages: Life Insurance Benefits for the Employee, his or her Spouse and
Dependent Children, if any
Extended Death Benefit with Waiver of Premium
Extended Death Benefit
Applicable Coverages
Waiver of Premium
Waiver Waiting Period
Maximum Benefit Period
Applicable Coverages
Portability Options
For Employees
Life Insurance Benefits for the Employee, his or her Spouse and
Dependent Children, if any
9 months from the date the Employee's Active Service ends
To Age 65
Life Insurance Benefits for the Employee, his or her Spouse and
Dependent Children, if any
See the Former Employee and Spouse/Domestic Partner of a
Former Employee sections in this Schedule of Benefits for the
amounts of insurance an Insured is eligible to continue under this
option.
3
Spouse or Domestic Partner Benefits
Basic Benefit $5,000
Guaranteed Issue Amount: $5,000
Maximum Benefit: $5,000
Voluntary Benefit
Guaranteed Issue Amount:
Maximum Benefit:
Age Based Reductions
Units of $1,000
the greater of a) or b) below:
a) $100,000, or
b) an amount equal to the Life Insurance Benefit in effect on
the termination date of the Prior Plan
$200,000
Life Insurance Benefit for a Spouse age 65 and over will reduce
to the percentage shown below:
65% of the Life Insurance Benefit at age 65
42% of the Life Insurance Benefit at age 70
27% of the Life Insurance Benefit at age 75
21% of the Life Insurance Benefit at age 80
15% of the Life Insurance Benefit at age 85
12% of the Life Insurance Benefit at age 90
9% of the Life Insurance Benefit at age 95
Benefit reductions will be effective on the January 1 coinciding
with or next following the Spouse's attainment of age as
specified in schedule above.
A Spouse's Life Insurance Benefits cannot exceed 50% of the Employee's Voluntary Life Insurance
Benefits.
Portability Options
For Spouse or Domestic Partner
Terminal Illness Benefit
See the Former Spouse or Domestic Partner section in this
Schedule of Benefits for the amounts of insurance an Insured is
eligible to continue under this option.
The insured can elect up to 75% of Life Insurance Benefits in
force on the date the Insured is determined by the Insurance
Company to be Terminally Ill.
4
Dependent Child Benefits
Basic Benefit
Voluntary Benefit
Maximum Benefit:
$5,000
The Maximum Benefit for a Dependent Child who is less than 6
months old is $500.
Units of $5,000
$5,000
The Maximum Benefit for a Dependent Child who is less than 6
months old is $500.
All Dependent Child benefits are Guaranteed Issue.
Portability Options
For Dependent Children
Annual Enrollment Period
See the Former Dependent Child section in this Schedule of
Benefits for the amounts of insurance an Insured is eligible to
continue under this option.
For Employees
During an Annual Enrollment Period, an Employee currently insured under the Voluntary Life Insurance
portion of this Policy may increase his or her Voluntary Life Insurance Benefit, and an Employee who is
eligible for the Voluntary Life Insurance portion of this Policy but who has not previously enrolled may
become insured under the Policy, as long as the total Benefit does not exceed the Maximum Benefit, by
satisfying the Insurability Requirement. Insurance will be effective on the later of the Policy Anniversary
following the Annual Enrollment Period or the date the Insurance Company agrees in writing to insure the
Employee.
For Spouses
During an Annual Enrollment Period, an eligible Employee may elect coverage for his or her eligible
Spouse. If a Spouse is currently insured under the Voluntary Life Insurance portion of this Policy, his or
her Voluntary Life Insurance Benefit may be increased, as long as the total Benefit does not exceed the
Maximum Benefit, by satisfying the Insurability Requirement. If a Spouse is eligible for the Voluntary
Life Insurance portion of this Policy but has not previously enrolled, he or she may become insured under
the Policy, as long as the total Benefit does not exceed the Maximum Benefit, by satisfying the
Insurability Requirement. Insurance will be effective on the later of the Policy Anniversary following the
Annual Enrollment Period or the date the Insurance Company agrees in writing to insure the Spouse.
Insurance Benefits for an Employee, his or her Spouse and Dependent Children may be reduced at any
time. A request for a Benefit reduction received during an Annual Enrollment Period will become
effective on the Policy Anniversary following the Annual Enrollment Period. Any other Benefit
reduction will be effective on the date the Insurance Company receives the completed change form.
TL -008025-1
5
Life Status Change
For Employees
Within 31 days after a Life Status Change, an Employee currently insured under the Voluntary Life
Insurance portion of this Policy may increase his or her Voluntary Life Insurance Benefit as long as the
total Benefit does not exceed the Guaranteed Issue Amount without satisfying the Insurability
Requirement. An Employee who is eligible for the Voluntary Life Insurance portion of this Policy but
who has not previously enrolled may become insured under the Policy as long as the total Benefit does
not exceed the Guaranteed Issue Amount without satisfying the Insurability Requirement. Guaranteed
Issue Amounts are shown above. Insurance will be effective on the first of the month following the Life
Status Change.
An Employee may increase coverage or become insured for a Benefit in excess of amounts described
above only if he or she satisfies the Insurability Requirement. Any excess amounts will be effective on
the later of the first of the month following the Life Status Change or the date the Insurance Company
agrees in writing to insure the Employee.
Insurance Benefits for an Employee may be reduced at any time. The reduced amount will be effective
on the date the Insurance Company receives the completed change form.
TL -008030-1
Former Employee Benefits
Amount of Insurance
An amount elected subject to the Maximum Benefit amount for
Life Insurance Benefits allowable to an Employee, less any
amount of conversion insurance issued under the Conversion
Privilege for Life Insurance.
Any amount elected in excess of the Life Insurance Benefits in
effect on the date he or she no longer qualifies as an Employee
will be effective on the date the Insurance Company agrees in
writing to insure him or her.
Maximum Benefit Period To Age 70
Terminal Illness Benefit
The insured can elect up to 75% of Life Insurance Benefits in
force on the date the Insured is determined by the Insurance
Company to be Terminally Ill, subject to a Maximum Benefit of
$825,000.
6
Spouse or Domestic Partner of Former Employee Benefits
Amount of Insurance
Maximum Benefit Period
Terminal Illness Benefit
An amount elected subject to the Maximum Benefit amount for
Life Insurance Benefits available to a Spouse or Domestic
Partner.
Any amount elected in excess of the Life Insurance Benefits in
effect on the date the Employee's employment with the
Employer ends will be effective on the date the Insurance
Company agrees in writing to insure him or her.
To Age 70
The insured can elect up to 75% of Life Insurance Benefits in
force on the date the Insured is determined by the Insurance
Company to be Terminally Ill.
Former Spouse or Domestic Partner Benefits
Amount of Insurance
Maximum Benefit Period
Terminal Illness Benefit
Former Dependent Child Benefits
Amount of Insurance
Guaranteed Issue Amount:
Maximum Benefit:
Maximum Benefit Period
TL -004774
An amount elected subject to the Maximum Benefit amount for
Life Insurance Benefits available to a Spouse or Domestic
Partner.
Any amount elected in excess of the Life Insurance Benefits in
effect on the date he or she no longer qualifies as a Spouse or
Domestic Partner will be effective on the date the Insurance
Company agrees in writing to insure him or her.
To Age 70
The insured can elect up to 75% of Life Insurance Benefits in
force on the date the Insured is determined by the Insurance
Company to be Terminally Ill.
Units of $25,000
$25,000
$50,000
To Age 70
7
ELIGIBILITY FOR INSURANCE
A person may be insured only once under the Basic Life portion of this Policy even though he or she may
be eligible under more than one class. A person may also be insured only once under the Voluntary Life
portion of the Policy as an Employee, Spouse or Dependent Child, even though he or she may be eligible
under more than one class.
An Employee who is the Spouse of another Employee may not be insured for Voluntary Life Insurance as
both an Employee and as a Spouse at the same time.
Any Employee, who is eligible for Voluntary Life Insurance, will not be eligible to be insured as a
Dependent Child of another Employee.
If an Employee is eligible and has enrolled as the Spouse of another Employee, but ceases to be eligible to
maintain the amount of insurance for which he or she has enrolled as a Spouse, that Employee may,
within 31 days, enroll for coverage as an Employee, in an amount equal to the lesser of (1) the amount of
Spouse Voluntary Life Insurance terminating, or (2) the maximum amount of Employee Voluntary Life
Insurance for which the Employee is eligible. The Insurability Requirement does not apply. If this
amount is not equal to a Voluntary Life Insurance coverage option, it will be adjusted to the next higher
available Voluntary Life Insurance coverage option. This provision shall be in lieu of the Policy's
provisions, if any, regarding coverage changes following Life Status Changes.
If a Spouse is eligible and has enrolled for Voluntary Life Insurance as an Employee, but ceases to be
eligible to maintain the amount of insurance for which he or she has enrolled as an Employee, the Spouse
may, within 31 days, instead become enrolled as a Spouse of another Employee, in an amount equal to the
lesser of (1) the amount of Employee Voluntary Life Insurance terminating, or (2) the Maximum Benefit
Amount of Spouse Voluntary Life Insurance for which the Spouse is eligible. The Insurability
Requirement does not apply. If this amount is not equal to a Voluntary Life Insurance coverage option, it
will be adjusted to the next higher available Voluntary Life Insurance coverage option.
A Dependent Child of two or more Employees may only be insured once under the Policy. If an
Employee who has elected to insure Dependent Children ceases to be eligible to do so, then the
Employee's Spouse may, within 31 days, elect to insure Dependent Children, provided he or she is
insured as an Employee. In all cases, "Dependent Child" shall be defined with respect to the Employee
who has enrolled dependent children.
In all cases, amounts of insurance referred to in these provisions shall be determined before the
application of any reductions in benefits due to age.
Any amount of Voluntary Life Insurance Coverage which cannot be continued under the above provisions
may be subject to the Conversion Privilege.
8
Employee
An Employee in one of the Classes of Eligible Employees shown in the Schedule of Benefits is eligible to
be insured on the Policy Effective Date or the day after he or she completes the Eligibility Waiting
Period, if later. The Eligibility Waiting Period will not apply to an Employee, in Active Service on the
Policy Effective Date, who was covered under the Prior Plan and satisfied the Eligibility Waiting Period,
if any, of that plan. Credit will be given for any time that was satisfied.
If a person has previously converted his or her insurance under the Policy, he or she will not become
eligible until the converted policy is surrendered. This does not apply to any amount of insurance that was
previously converted under the Policy due to a reduction in the Employee's Life Insurance Benefits based
on age or a change in class unless those conditions no longer affect the amount of coverage available to
the Employee.
Except as noted in the Reinstatement Provision, if an Employee terminates coverage and later wishes to
reapply, or if a former Employee is rehired, a new Eligibility Waiting Period must be satisfied. An
Employee is not required to satisfy a new Eligibility Waiting Period, if insurance ends because he or she
is no longer in a Class of Eligible Employees, but continues to be employed by the Employer, and within
one year becomes a member of an eligible class.
Spouse
If an Insured is eligible to elect Spouse coverage, the Spouse is eligible to be insured on the date the
Employee is eligible or the date he or she becomes a Spouse of an Employee, if later. The eligible
Employee must be insured for Voluntary Life Insurance in order to elect spouse coverage.
For the purpose of eligibility, the Spouse must be the lawful Spouse of the Employee and not legally
separated or divorced from, or widowed by the Employee.
Dependent Child
If an Insured is eligible to elect Dependent Child coverage, the Dependent Child is eligible to be insured
on the date the Insured is eligible or on the date the child qualifies as a Dependent Child, if later.
In no event will a Dependent Child be eligible to become insured more than once under the Policy.
TL -004710-1
9
ENROLLING FOR INSURANCE
Initial Enrollment
For Employees
During the Initial Enrollment Period, an Employee who was insured or who was eligible to be insured
under the Prior Plan may become insured under the Voluntary Term Life Insurance Plan provided by this
Policy for a Benefit up to this Policy's Guaranteed Issue Amount, as shown in the Schedule of Benefits,
without satisfying any Insurability Requirement. See Effective Date of Insurance provision.
If an Employee is not actively at work due to Injury or Sickness, coverage will not become effective for
an Employee on the date his or her coverage would otherwise become effective under this Policy.
Coverage will become effective on the date the Employee returns to Active Service.
An Employee may become insured for an amount in excess of amounts described above only if he or she
satisfies the Insurability Requirement. Any excess amount will be effective on the date the Insurance
Company agrees in writing to insure the Employee.
For Spouses
During the Initial Enrollment Period, an eligible Employee may elect coverage for his or her eligible
Spouse. If a Spouse was insured or eligible to be insured under the Prior Plan, he or she may become
insured under the Voluntary Term Life Insurance Plan provided by this Policy for a Benefit up to this
Policy's Guaranteed Issue Amount, as shown in the Schedule of Benefits, without satisfying any
Insurability Requirement. See Effective Date of Insurance provision.
If an Employee is not actively at work due to Injury or Sickness, the amount of coverage elected during
the Initial Enrollment for his or her Spouse will not become effective on the date the Spouse's coverage
would otherwise become effective under this Policy. Such coverage will become effective on the date the
Employee returns to Active Service.
A Spouse may become insured for an amount in excess of amounts described above only if he or she
satisfies the Insurability Requirement. Any excess amount will be effective on the date the Insurance
Company agrees in writing to insure the Spouse.
If an Employee's eligible Spouse is (a) an inpatient in a hospital, hospice, rehabilitation or convalescence
center, or custodial care facility; or (b) confined to his or her home under the care of a Physician on the
date insurance would otherwise be effective, it will be effective on the date the dependent is no longer an
inpatient in these facilities or confined at home. If such dependent was covered by a Prior Plan on the
date immediately prior to first becoming eligible under this Policy, this provision will not apply to the
amount of coverage in effect on such date, but will apply to any increase in coverage.
TL -008055-1
10
EFFECTIVE DATE OF INSURANCE
An Employee, his or her eligible Spouse or Dependent Child will be insured for an amount not to exceed
the Guaranteed Issue Amount on the date he or she becomes eligible, if the Employee is not required to
contribute to the cost of this insurance.
An Employee or his or her eligible Spouse will be insured for an amount that exceeds the Guaranteed
Issue Amount on the date the Insurance Company agrees in writing to insure that eligible person. The
Insurance Company will require the eligible person to satisfy the Insurability Requirement before it
agrees to insure him or her.
An Employee who is required to contribute to the cost of this insurance may elect insurance for himself or
herself and an eligible Spouse or Dependent Child only by authorizing payroll deduction in a form
approved by the Employer and the Insurance Company. The effective date of this insurance depends on
the date and amount of insurance elected.
If an individual elects coverage within 31 days after becoming eligible to enroll, or for any increases, the
Guaranteed Issue Amount will be effective on the latest of the following dates:
1. The Policy Effective Date.
2. The date payroll deduction is authorized for this insurance.
3. The date the Employer or Insurance Company receives the completed enrollment form.
If Employee or Spouse coverage is elected in an amount that exceeds the Guaranteed Issue Amount or an
enrollment form is received more than 31 days after becoming eligible to elect coverage, this insurance
will be effective on the date the Insurance Company agrees in writing to insure that eligible person. The
Insurance Company will require the eligible person to satisfy the Insurability Requirement before it
agrees to insure him or her.
If coverage for a Dependent Child is in force and another Dependent Child becomes eligible, coverage for
that child is effective on the date the child qualifies as a Dependent Child.
If an eligible Employee is not in Active Service on the date insurance would otherwise be effective, it will
be effective on the date he or she returns to Active Service.
If an eligible Spouse or Dependent Child is:
1. an inpatient in a hospital, hospice, rehabilitation or convalescence center, or custodial care
facility; or
2. confined to his or her home under the care of a Physician
on the date insurance would otherwise be effective, it will be effective on the date he or she is no longer
an inpatient in these facilities or confined at home. If such Spouse or Dependent Child was covered by
the Prior Plan immediately prior to the Policy Effective Date, this provision will not apply to the amount
of coverage in effect as of the Policy Effective Date, but will apply to any increase in coverage. This does
not apply to a Dependent Child who is age 6 months or less.
TL -004712
11
Takeover Provision
Special Terms Applicable to Previously Insured Employees Not in Active Service and Their Dependents
Coverage will not go into effect for an Employee, or his or her Spouse and Dependent Children unless the
Employee is in Active Service on the date the Employee would have first become eligible to be insured
under the Policy.
However:
1. if such Employee, and his or her Spouse or Dependent Children were insured under a Prior Plan
on the date immediately prior to the date the Employee would have first become eligible to be
insured under this Policy had the Employee satisfied the Active Service requirement, and
2. if such Employee, Spouse or Dependent Child dies,
the Insurance Company agrees to provide a Death Benefit only equal to the lesser of:
a. the amount due under this Policy (had the Employee satisfied the Active Service requirement), or
b. the amount that would have been due under the Prior Plan had it remained in force.
The benefit amount will be reduced by any amount paid by the Prior Plan, or that would have been paid
had this Policy not been issued and had timely filing of the claim been made under the Prior Plan.
These special terms will end on the earliest of the following dates:
1. the date the Employee meets the Active Service requirements;
2. the date insurance terminates for one of the reasons stated in the Termination of Insurance
provision;
3. 12 months after the date the Employee first becomes eligible under this Policy; or
4. the last day the Employee, Spouse or Dependent Children would have been covered under the
Prior Plan if coverage of the Employee, Spouse or Dependent Children under that plan was still in
force.
TL -009020-1
TERMINATION OF INSURANCE
An Insured's coverage will end on the earliest of the following dates:
1. the date the Employee is eligible for coverage under a plan intended to replace this coverage;
2. the date the Policy is terminated by the Insurance Company;
3. the last day of the month the Insured is no longer in an eligible class;
4. the date coinciding with the end of the last period for which premiums are paid;
5. the date an Employee is no longer in Active Service;
6. for an Employee, Spouse and Dependent Child, the date the Employer cancels participation under
the Policy; and
7. the date coverage for the Employee ends, for any insured Spouse and Dependent Child.
TL -004714-1
12
CONTINUATION OF INSURANCE
If an Employee is no longer in Active Service, he or she may be eligible to continue insurance. The
following provisions explain the continuation options available under the Policy. Please see the Schedule
of Benefits to determine the applicability of these benefits on a class level.
Continuation for Temporary Leave of Absence, Employee paid vacation, Injury or Sickness or
Family Medical Leave
If an Employee's Active Service ends due to an Employer approved unpaid leave of absence or family
medical leave of absence, insurance will continue for up to the Maximum Benefit Period shown in the
Schedule of Benefits, if the required premium is paid.
Continuation for Disability for Employees over Age 60
If an Employee becomes Disabled and is age 60 or over, the Life Insurance Benefits shown in the
Schedule of Benefits will be continued, provided premiums are paid, until the earlier of the following
dates:
1. The date the Employee is no longer Disabled.
2. The date following the Maximum Benefit Period shown in the Schedule of Benefits.
3. The date coinciding with the end of the last period for which premiums are paid.
4. The date the Policy is terminated by the Insurance Company.
Amount of Insurance
If an Employee dies while he or she is Disabled and coverage is continued under this provision, the
Insurance Company will pay a Death Benefit equal to the amount in effect on the date the Employee
became Disabled. However, the Life Insurance Benefit will be subject to the provisions of the Policy that
reduce the coverage amount because of age, retirement, payment of an Accelerated Benefit or a change in
class. Automatic increases in Life Insurance Benefits will end while coverage is continued under this
provision. The Insurance Company will pay benefits only if due proof of the Employee's continuous
Disability is received within one year of the date of the loss.
"Disability"/"Disabled" means because of Injury or Sickness the Employee is unable to perform all the
material duties of his or her Regular Occupation; or is receiving disability benefits under the Employer's
plan.
"Regular Occupation" means the occupation the Employee routinely performs at the time the Disability
begins. The Insurance Company will consider the duties of the occupation as it is normally performed in
the general labor market in the national economy.
Extended Death Benefit with Waiver of Premium
Extended Death Benefit
If an Employee becomes Disabled and is less than age 60, the Life Insurance Benefits shown in the
Schedule of Benefits will be extended without premium payment until the earlier of the following dates:
1. The date the Employee is no longer Disabled; or
2. 12 months after the end of Active Service.
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Amount of Insurance
If an Employee dies while he or she is Disabled and coverage is extended under this provision, the
Insurance Company will pay a Death Benefit equal to the amount in effect on the date the Employee
became Disabled. However, the Life Insurance Benefit will be subject to the provisions of the Policy that
reduce the coverage amount because of age, retirement, payment of an Accelerated Benefit or a change in
class. Automatic increases in Life Insurance Benefits will end while premiums are waived. The
Insurance Company will pay benefits only if due proof of the Employee's continuous Disability is
received within one year of the date of the loss.
"Disability"/"Disabled" means because of Injury or Sickness the Employee is unable to perform the
material duties of his or her Regular Occupation; or is receiving disability benefits under the Employer's
plan.
"Regular Occupation" means the occupation the Employee routinely performs at the time the Disability
begins. The Insurance Company will consider the duties of the occupation as it is normally performed in
the general labor market in the national economy.
Waiver of Premium
If such an Employee submits satisfactory proof that he or she has been continuously Disabled for the
Waiver Waiting Period shown in the Schedule of Benefits, coverage will be extended up to the Maximum
Benefit Period shown in the Schedule of Benefits.
Such proof must be submitted to the Insurance Company no later than 3 months after the date the Waiver
Waiting Period ends. Premiums will be waived from the date the Insurance Company agrees in writing to
waive premiums for that Employee.
After premiums have been waived for 12 months, they will be waived for future periods of 12 months, if
the Employee remains Disabled and submits satisfactory proof that Disability continues. Satisfactory
proof must be submitted to the Insurance Company 3 months before the end of the 12 -month period.
Amount of Insurance
If an Employee dies while he or she is Disabled and coverage is continued under this provision, the
Insurance Company will pay a Death Benefit equal to the amount in effect on the date the Employee
became Disabled. However, the Life Insurance Benefit will be subject to the provisions of the Policy that
reduce the coverage amount because of age, retirement, payment of an Accelerated Benefit or a change in
class. Automatic increases in Life Insurance Benefits will end while premiums are waived. The
Insurance Company will pay benefits only if due proof of the Employee's continuous Disability is
received within one year of the date of the loss.
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Termination of Waiver
Insurance will end for any Employee whose premiums are waived on the earliest of the following dates.
1. The date he or she is no longer Disabled;
2. The date he or she refuses to submit to any physical examination required by the Insurance
Company;
3. The date he or she refuses to participate in a Rehabilitation Plan for which the Insurance
Company determines him or her to be eligible;
4. The last day of the 12 -month period of Disability during which he or she fails to submit
satisfactory proof of continued Disability;
5. The date following the end of the Maximum Benefit Period shown in the Schedule of Benefits.
"Disability/Disabled" means because of Injury or Sickness an Employee is unable to perform the material
duties of his or her Regular Occupation, or is receiving disability benefits under the Employer's plan,
during the initial 9 months of Disability. Thereafter, the Employee must be unable to perform all of the
material duties of any occupation which he or she may reasonably become qualified based on education,
training or experience, or is subject to the terms of a Rehabilitation Plan approved by the Insurance
Company.
"Regular Occupation" means the occupation the Employee routinely performs at the time the Disability
begins. The Insurance Company will consider the duties of the occupation as it is normally performed in
the general labor market in the national economy.
Rehabilitation During a Period of Disability
If the Insurance Company determines that a Disabled Employee is a suitable candidate for rehabilitation,
the Insurance Company may require the Employee to participate in an assessment and Rehabilitation
Plan, not to exceed 18 months, at our expense. The Insurance Company has the sole discretion to approve
the Employee's participation in a Rehabilitation Plan and to approve a program as a Rehabilitation Plan.
If an Employee fails to fully cooperate in all required phases of the Rehabilitation Plan and assessment
without Good Cause, insurance under the Policy will end.
"Good Cause" means a medical reason preventing participation, in whole or in part, in the Rehabilitation
Plan. Satisfactory proof of Good Cause must be provided to the Insurance Company.
"Rehabilitation Plan" means a written plan designed to enable the Employee to return to work. The
Rehabilitation Plan will consist of one or more of the following phases:
1. Rehabilitation, under which the Insurance Company may provide, arrange or authorize
educational, vocational or physical rehabilitation or other appropriate services;
2. Work, which may include modified work and work on a Part-time basis.
"Part-time" means regularly working less than the number of full time hours set by the Employer as a
regular work day for Employees in an Eligible Class of Employees in the Policy.
TL -009745 as modified by TL -009745-1
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Portability Options
For Employees
If an Employee's coverage under the Policy ends prior to age 70, for any of the following reasons:
a. termination of employment; or
b. termination of membership in an eligible class under the Policy;
Life Insurance Benefits may be continued up to the Maximum Benefit shown in the Schedule of Benefits
for this option.
The Employee must apply to the Insurance Company and pay the required premium. If the Employee
continues coverage, Spouse or Dependent Child coverage may also be continued by the Employee. The
Spouse or Dependent Child must be covered under the Policy on the date coverage would otherwise end.
The application must be submitted:
a. within 31 days of the Employee's termination of employment or membership in an eligible class
under the Policy; or
b. during the time that the Employee has to exercise the Conversion Privilege.
Coverage under this option may not be elected at a later date.
When applying for this option, the Employee must name a beneficiary. Any beneficiary named
previously under the Policy is no longer in effect. If there is no named or surviving beneficiary, Death
Benefits will be paid to the first surviving class of the following living relatives:
a. spouse;
b. child or children;
c. mother or father;
d. brothers or sisters; or
e. the executors or administrators of the Insured's estate.
When coverage is continued under this option, the Employee becomes a Former Employee. The Spouse
becomes a Spouse of a Former Employee. The Dependent Child becomes a Dependent Child of a Former
Employee.
If the Former Employee later acquires a Spouse or Dependent Child, he or she may elect coverage for
them. The Former Employee must apply to the Insurance Company and pay the required premium.
Coverage for the Spouse or Dependent Child will be effective on the date the Insurance Company agrees
in writing to insure them. The Insurance Company may require that the Spouse or Dependent Child
satisfy the Insurability Requirement before it agrees to insure him or her.
Coverage will end on the earliest of the following dates.
a. The date the Insurance Company cancels coverage for all Former Employees.
b. The end of the period for which premiums are paid.
c. The date an Insured reaches age 70.
d. The date the Maximum Benefit Period shown in the Schedule of Benefits for this option ends.
Also, coverage for any Dependent Child will end on any of the dates listed above or when he or she no
longer qualifies as a Dependent Child, if earlier.
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For Spouses
If prior to age 70, a Spouse is:
a. legally separated, divorced; or
b. widowed
from an insured Employee or Former Employee, Life Insurance Benefits may be continued. Coverage
may be continued up to the Maximum Benefit shown in the Schedule of Benefits for this option. The
Spouse must apply to the Insurance Company and pay the required premium.
A Spouse who continues coverage may also continue coverage for a Dependent Child. The Dependent
Child must be covered under the Policy on the date coverage would otherwise end. A Spouse must elect
to continue insurance under this option within 31 days after coverage ends. Coverage may not be elected
at a later date.
When applying for this option, a Spouse must name a beneficiary. Any beneficiary named previously
under the Policy is no longer in effect. If there is no named or surviving beneficiary, Death Benefits will
be paid to the first surviving class of the following living relatives:
a. spouse;
b. child or children;
c. mother or father;
d. brothers or sisters; or
e. the executors or administrators of the Spouse's estate.
When coverage is continued under this option, the Spouse becomes a Former Spouse. A separate
certificate of insurance will be issued to the Former Spouse. Coverage will be effective on the date after
coverage as a Spouse ends if the required premium is paid.
Coverage will end on the earliest of the following dates.
a. The date the Insurance Company cancels coverage for all Former Spouses.
b. The end of the period for which premiums are paid.
c. The date the Former Spouse reaches age 70.
d. The date the Maximum Benefit Period shown in the Schedule of Benefits for this option ends.
Also, coverage for a Dependent Child will end on any of the dates listed above or when he or she no
longer qualifies as a Dependent Child, if earlier.
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For Dependent Children
If a Dependent Child is insured under the Policy and is at least 19 years of age, Life Insurance Benefits
may be continued under this option. Coverage may be continued up to the Maximum Benefit shown in
the Schedule of Benefits for this option.
The Dependent Child must apply to the Insurance Company and pay the required premium. If a
Dependent Child does not elect to continue insurance within 31 days after reaching age 19; or the date he
or she no longer qualifies as a Dependent Child, if later, coverage under this option may not be elected at
a later date.
When applying for this option, a Dependent Child must name a beneficiary. Any beneficiary named
previously under the Policy is no longer in effect. If there is no named or surviving beneficiary, Death
Benefits will be paid to the first surviving class of the following living relatives:
a. spouse;
b. child or children;
c. mother or father;
d. brothers or sisters; or
e. the executors or administrators of the Dependent Child's estate.
When a Dependent Child continues coverage under this option, he or she becomes a Former Dependent
Child. A separate certificate of insurance will be issued to the Former Dependent Child. Coverage for a
Former Dependent Child will be effective on the following dates.
a. For any Guaranteed Issue Amount, immediately following the date his or her coverage as a
Dependent Child ends, provided the Insurance Company receives the required premium.
b. For any amount of insurance that exceeds the Guaranteed Issue Amount, the date the Insurance
Company agrees in writing to insure him or her. The Insurance Company will require the Former
Dependent Child to satisfy the Insurability Requirement before it agrees to insure him or her.
Coverage will end on the earliest of the following dates.
a. The date the Insurance Company cancels coverage for all Former Dependent Children.
b. The end of the period for which premiums are paid.
c. The date the Former Dependent Child is age 70.
d. The date the Maximum Benefit Period shown in the Schedule of Benefits for this option ends.
TL -004716 as modified by TL -009330
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DESCRIPTION OF BENEFITS
The following provisions explain the benefits available under the Policy. Please see the Schedule of
Benefits for the applicability of these benefits on a class level.
LIFE INSURANCE BENEFITS
Death Benefit
If an Insured dies, the Insurance Company will pay the Life Insurance Benefit in force for that Insured on
the date of his or her death.
TL -004730
Accelerated Benefits
Any benefits payable under this and under any similar Accelerated Benefits provision accelerated under a
Prior Plan will reduce the Death Benefit payable for Life Insurance. We will deduct from any Death
Benefit payable under this Policy, the amount of any similar accelerated benefit paid under a Prior Plan.
Any automatic increases in Life Insurance Benefits will end when benefits are payable under this
provision, unless the Insured is determined by the Insurance Company not to be eligible for Accelerated
Benefits.
Terminal Illness Benefit
The Insurance Company will pay a Terminal Illness Benefit to an Insured who has incurred a Terminal
Illness while insured under this provision.
The Terminal Illness Benefit is shown on the Schedule of Benefits.
A claim for a similar terminal illness benefit under a Prior Plan or group policy intended to replace this
Policy shall be deemed payable until such time as it is finally determined not to be payable.
Determination of Terminal Illness
For the purpose of determining the existence of a Terminal Illness, the Insurance Company will require
the Insured submit the following proof:
1. A written diagnosis and prognosis by a licensed Physician; and
2. Supportive evidence satisfactory to the Insurance Company, including but not limited to,
radiological, histological or laboratory reports documenting the Terminal Illness.
The Insurance Company may require, at its expense, an examination of the Insured and a review of the
documented evidence by a Physician of its choice.
Such proofs must be submitted to the Insurance Company within the period of time provided in the Proof
of Loss section of the Policy. For purposes of this Benefit, the date of loss shall be the date of first
prognosis of Terminal Illness.
"Terminal Illness" means that, due to an Injury or Sickness, the Insured has a prognosis of
12 months or less to live without reasonable prospect of recovery, as determined by the Insurance
Company.
Payment of Terminal Illness Benefit
The Terminal Illness Benefit will be payable in accordance with the provisions of the To Whom Payable
section of the Policy.
The Terminal Illness Benefit is payable only once under the Policy in an Insured's lifetime.
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Conditions Applicable to Coverage
Unless the Insured qualifies for waiver of premium, premium payments must continue to be paid on the
full amount of group life insurance, including during any Continuation of Insurance under the Policy, in
accordance with the Premium section in the Administrative Provisions.
The amount of Life Insurance which may be converted under the Conversion Privilege cannot exceed the
amount of the reduced death benefit payable under the Policy.
Before a Terminal Illness Benefit is paid in a Community Property state, the Insurance Company may
require the written consent of the Insured's Spouse.
Exclusions Applicable to Terminal Illness Benefit
A Terminal Illness Benefit will not be payable:
1. when the Insured has irrevocably assigned group life insurance under this Policy;
2. when all or a portion of group life insurance benefits under this Policy are to be paid to a former
spouse as part of a qualified domestic relations order;
3. for any intentionally self-inflicted Injury or Sickness, or suicide attempt;
4. if the Insured's coverage ends under the Termination of Insurance provision prior to the
prognosis of Terminal Illness;
5. if the required premium is due and unpaid;
6. if this Policy terminates prior to the prognosis of Terminal Illness;
7. if the Employee or Insured is only provided coverage under the Takeover provision of the Policy
(Employees Not in Active Service on the Policy Effective Date); or
8. if the date of first prognosis of Terminal Illness occurs more than 12 months before the
submission of the Terminal Illness claim.
TL -004748a
Conversion Privilege for Life Insurance
Each Insured may convert all or any portion of his or her Life Insurance that would end under the Policy
due to:
1. termination of employment;
2. termination of membership in an eligible class under the Policy;
3. termination of the Policy.
The Insured may apply for any type of life insurance the Insurance Company offers to persons of the
same age in the amount applied for, except the Insured may not:
1. choose term insurance;
2. apply for an amount of insurance greater than the coverage amount terminating under the Policy
(also, the conversion policy will not provide accident, disability or other benefits); or
3. apply for more than $10,000 of insurance if the Policy is terminated or amended to terminate the
insurance for any class of Insureds, or the Employer cancels participation under the Policy.
Conversion in these cases is only permitted if the Insured has been covered by the Policy or, any
group life insurance policy issued to the Employer which the Policy replaced, for at least 3 years.
If the Insured becomes eligible for coverage under any group life policy within 31 days of termination of
coverage under this Policy, the Insured may not convert an amount of insurance greater than the amount
of coverage terminating under the Policy less the amount for which he or she may be covered under the
other policy.
To apply for conversion insurance, the Insured must, within 31 days after coverage under the Policy ends:
1. submit an application to the Insurance Company; and
2. pay the required premium.
Evidence of insurability is not required.
20
Premium for the conversion insurance will be based on the age and class of risk of the Insured and the
type and amount of coverage issued.
If the Insured has assigned ownership of his group coverage, the owner/assignee must apply for the
individual policy.
Conversion insurance will become effective on the 31st day after the date coverage under the Policy ends
provided the application is received by the Insurance Company and the required premium has been paid.
If the Insured dies during the 31 -day conversion period, the Life Insurance benefits will be paid under the
Policy regardless of whether he or she applied for conversion insurance. If a conversion policy is issued,
it will be in exchange for any further benefits for that type and amount of insurance from this Policy.
Extension of Conversion Period
If an Insured is eligible for conversion insurance and is not notified of this right at least 15 days prior to
the end of the 31 -day conversion period, the conversion period will be extended. The Insured will have
15 days from the date notice is given to apply for conversion insurance. In no event will the conversion
period be extended beyond 90 days. Notice, for the purpose of this section, means written notice
presented to the Insured by the Employer or mailed to the Insured's last known address as reported by the
Employer.
If the Insured dies during the extended conversion period, but more than 31 days after his or her coverage
under the Policy terminates, Life Insurance benefits:
1. will not be paid under the Policy; and
2. will be payable under the conversion insurance; provided:
a. the Insured's application for conversion insurance has been received by the Insurance
Company; and
b. the required premium has been paid.
Prior Conversion Limitation
If an Insured is covered under a life insurance conversion policy previously issued by the Insurance
Company, he or she will not be eligible for this Conversion Privilege unless the prior coverage has ended.
TL -009740
LIFE INSURANCE EXCLUSIONS
If an Insured commits suicide, while sane or insane, within 2 years from the date his or her insurance
under the Policy becomes effective, Voluntary Life Insurance Benefits will be limited to a refund of the
premiums paid on the Insured's behalf. The suicide exclusion applies from the effective date of any
additional benefits or increases in Life Insurance Benefits.
Except for any amount of benefits in excess of the Prior Plan's benefits, this exclusion will not apply to
any person covered under the Prior Plan for more than two years. If a person was not insured for two
years under the Prior Plan, credit will be given for the time he or she was insured.
If a Dependent Child commits suicide and is survived by other Dependent Children covered under the
same certificate, no refund of premiums will be paid.
TL -004752
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CLAIM PROVISIONS
Notice of Claim
Written notice, or notice by any other electronic/telephonic means authorized by the Insurance Company,
must be given to the Insurance Company within 31 days after a covered loss occurs or begins or as soon
as reasonably possible. If written notice, or notice by any other electronic/telephonic means authorized
by the Insurance Company, is not given in that time, the claim will not be invalidated or reduced if it is
shown that notice was given as soon as was reasonably possible. Notice can be given at our home office
in Philadelphia, Pennsylvania or to our agent. Notice should include the Employer's Name, the Policy
Number and the claimant's name and address.
Written notice or any other electronic/telephonic means authorized by the Insurance Company of a
diagnosis of a Terminal Illness on which claim is based must be given to us within 60 days after the
diagnosis. If notice is not given in that time, the claim will not be invalidated or reduced if it is shown
that written notice or any other electronic/telephonic means authorized by the Insurance Company was
given as soon as reasonably possible.
Claim Forms
When the Insurance Company receives notice of claim, the Insurance Company will send claim forms for
filing proof of loss. If claim forms are not sent within 15 days after notice is received by the Insurance
Company, the proof requirements will be met by submitting, within the time required under the "Proof of
Loss" section, written proof, or proof by any other electronic/telephonic means authorized by the
Insurance Company, of the nature and extent of the loss.
Claimant Cooperation Provision
Failure of a claimant to cooperate with the Insurance Company in the administration of the claim may
result in termination of the claim. Such cooperation includes, but is not limited to, providing any
information or documents needed to determine whether benefits are payable or the actual benefit amount
due.
Insurance Data
The Employer is required to cooperate with the Insurance Company in the review of claims and
applications for coverage. Any information the Insurance Company provides in these areas is
confidential and may not be used or released by the Employer if not permitted by applicable privacy laws.
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Proof of Loss
Written proof of loss, or proof by any other electronic/telephonic means authorized by the Insurance
Company, must be given to the Insurance Company within 90 days after the date of the loss for which a
claim is made. If written proof of loss, or proof by any other electronic/telephonic means authorized by
the Insurance Company, is not given in that 90 day period, the claim will not be invalidated nor reduced if
it is shown that it was given as soon as was reasonably possible. In any case, written proof of loss, or
proof by any other electronic/telephonic means authorized by the Insurance Company, must be given not
more than one year after that 90 day period. If written proof of loss, or proof by any other
electronic/telephonic means authorized by the Insurance Company, is provided outside of these time
limits, the claim will be denied. These time limits will not apply while the person making the claim lacks
legal capacity.
Written proof, or any other electronic/telephonic means authorized by the Insurance Company, of loss for
Accelerated Benefits must be furnished 90 days after the date of diagnosis. This proof must describe the
occurrence, character and diagnosis for which claim is made.
In case of claim for any other loss, proof must be furnished within 90 days after the date of such loss.
If it is not reasonably possible to submit proof of loss within these time periods, the Insurance Company
will not deny or reduce any claim if proof is furnished as soon as reasonably possible. Proof must, in any
case, be furnished not more than a year later, except for lack of legal capacity.
Time of Payment
Benefits due under the Policy for a loss, other than a loss for which the Policy provides installment
payments, will be paid immediately upon receipt of due written proof of such loss.
Subject to the receipt of satisfactory written proof of loss, all accrued benefits for loss for which the
Policy provides installments will be paid monthly; any balance remaining unpaid upon the termination of
liability will be paid immediately upon receipt of due written proof, unless otherwise stated in the
Description of Benefits.
Manner of Payment of Claims
The Subscriber authorizes that any benefit payment due as a lump sum of $5,000 or more shall be
credited to a draft account with the Insurance Company, in the name of the beneficiary. The beneficiary
may withdraw the entire proceeds at any time by issuing one or more drafts, or may withdraw lesser
amounts, subject to a minimum account balance set by the Insurance Company from time to time. Interest
shall be credited to such account at rates as determined from time to time by the Insurance Company.
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To Whom Payable
Death Benefits will be paid to the Insured's named beneficiary, if any, on file at the time of payment. If
there is no named beneficiary or surviving beneficiary, Death Benefits will be paid to the first surviving
class of the following living relatives: spouse; child or children; mother or father; brothers or sisters; or to
the executors or administrators of the Insured's estate. The Insurance Company may reduce the amount
payable by any indebtedness due.
All benefits payable under the Accelerated Benefits section are payable to the Insured, if living. If the
Insured dies prior to the payment of an eligible claim for an Accelerated Benefit, benefits will be paid in
accordance with the provisions applicable to the payment of Life Insurance proceeds, unless the Insured
has directed us otherwise in writing. However, any payment made by us prior to notice of the Insured's
death shall discharge us of any benefit that was paid.
All other benefits, unless otherwise stated in the Policy, will be payable to the Insured or the certificate
owner if other than the Insured.
Any other accrued benefits which are unpaid at the Insured's death may, at the Insurance Company's
option, be paid either to the Insured's beneficiary or to the executor or administrator of the Insured's
estate.
If the Insurance Company pays benefits to the executor or administrator of the Insured's estate or to a
person who is incapable of giving a valid release, the Insurance Company may pay up to $1,000 to a
relative by blood or marriage whom it believes is equitably entitled. This good faith payment satisfies the
Insurance Company's legal duty to the extent of that payment.
Change of Beneficiary
The Insured may change the beneficiary at any time by giving written notice to the Employer or the
Insurance Company. The beneficiary's consent is not required for this or any other change which the
Insured may make unless the designation of beneficiary is irrevocable.
No change in beneficiary will take effect until the form is received by the Employer or the Insurance
Company. When this form is received, it will take effect as of the date of the form. If the Insured dies
before the form is received, the Insurance Company will not be liable for any payment that was made
before receipt of the form.
Physical Examination and Autopsy
The Insurance Company, at its expense, will have the right to examine any person for whom a claim is
pending as often as it may reasonably require. The Insurance Company may, at its expense, require an
autopsy unless prohibited by law.
Legal Actions
No action at law or in equity may be brought to recover benefits under the Policy less than 60 days after
written proof of loss, or proof by any other electronic/telephonic means authorized by the Insurance
Company, has been furnished as required by the Policy. No such action shall be brought more than 3
years after the time satisfactory proof of loss is required to be furnished.
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Time Limitations
If any time limit stated in the Policy for giving notice of claim or proof of loss, or for bringing any action
at law or in equity, is less than that permitted by the law of the state in which the Employee lives when
the Policy is issued, then the time limit provided in the Policy is extended to agree with the minimum
permitted by the law of that state.
Physician/Patient Relationship
The Insured will have the right to choose any Physician who is practicing legally. The Insurance
Company will in no way disturb the Physician/patient relationship.
TL -004724
ADMINISTRATIVE PROVISIONS
Premiums
The premiums for this Policy will be based on the rates currently in force, the plan and the amount of
insurance in effect.
If the Insured's coverage amount is reduced due to acceleration of his or her Death Benefit, his or her
premium will be based on the amount of coverage he or she has in force on the day before the reduction
took place. If the Insured's coverage amount is reduced due to his or her attained age, premium will be
based on the amount of coverage in force on the day after the reduction took place.
Changes in Premium Rates
The premium rates may be changed by the Insurance Company from time to time with at least 31 days
advance written notice. No change in rates will be made until 36 months after the Policy Effective Date.
An increase in rates will not be made more often than once in a 12 month period. However, the Insurance
Company reserves the right to change the rates even during a period for which the rate is guaranteed if
any of the following events take place.
1. The terms of the Policy change.
2. A division, subsidiary, affiliated company or eligible class is added or deleted from the Policy.
3. There is a change in the factors bearing on the risk assumed.
4. Any federal or state law or regulation is amended to the extent it affects the Insurance Company's
benefit obligation.
5. The Insurance Company determines that the Employer has failed to promptly furnish any
necessary information requested by the Insurance Company, or has failed to perform any other
obligations in relation to the Policy.
If an increase or decrease in rates takes place on a date that is not a Premium Due Date, a pro rata
adjustment will apply from the date of the change to the next Premium Due Date.
Reporting Requirements
The Employer must, upon request, give the Insurance Company any information required to determine
who is insured, the amount of insurance in force and any other information needed to administer the plan
of insurance.
Payment of Premium
The first premium is due on the Policy Effective Date. After that, premiums will be due monthly unless
the Employer and the Insurance Company agree on some other method of premium payment.
If any premium is not paid when due, the plan will be canceled as of the Premium Due Date, except as
provided in the Policy Grace Period section.
25
Notice of Cancellation
The Employer or the Insurance Company may cancel the Policy as of any Premium Due Date by giving
31 days advance written notice. If a premium is not paid when due, the Policy will automatically be
canceled as of the Premium Due Date, except as provided in the Policy Grace Period section.
Policy Grace Period
A Policy Grace Period of 31 days will be granted for the payment of the required premiums under this
Policy. This Policy will be in force during the Policy Grace Period. The Employer is liable to the
Insurance Company for any unpaid premium for the time this Policy was in force.
Draft Accounts
The Insurance Company shall be entitled to retain, as part of its compensation, any earnings on draft
accounts created in connection with benefit claims, in excess of interest credited under the terms of the
policy.
Grace Period for the Insured
If the required premium is not paid on the Premium Due Date, there is a 31 day grace period after each
premium due date after the first. If the required premium is not paid during the grace period, insurance
will end on the last day for which premium was paid.
If benefits are paid during the Grace Period for the Insured, the Insurance Company will deduct any
overdue premium from the proceeds payable under the Policy.
Reinstatement of Insurance
Coverage may be reinstated without satisfying the Insurability Requirement, if an Employee's insurance
ends because he or she is on an unpaid leave of absence and he or she applies for Reinstatement within 31
days of his return to Active Service.
After an Insured's coverage has ceased, it may be reinstated at any date prior to five years after the date of
termination if the following conditions are met:
1. The Policy is still in force.
2. The Insured is eligible under the Policy.
3. A written request for reinstatement and a new enrollment form are sent to the Insurance
Company.
4. The required premium is paid.
5. The Insurability Requirement, if any, is satisfied.
TL -004720
26
SCHEDULE OF RATES
The following monthly rates apply to all Classes of Eligible Persons unless otherwise indicated.
FOR EMPLOYEE BENEFITS
Basic Life Insurance $.122 Per $1,000
Voluntary Life Insurance
Monthly Rates are based on units of $1,000
Under Age 20
Age 20 - 24
Age 25 — 29
Age 30-34
Age 35-39
Age 40 - 44
Age 45 - 49
Age 50 - 54
Age 55 - 59
$.05
$.05
$.05
$.08
$.09
$.10
$.15
$.23
$.43
Age 60 - 64 $.66
Age65-69 $1.27
Age 70 - 74 $2.06
Age 75 - 79 $2.06
Age 80 - 84 $2.06
Age 85 - 89 $2.06
Age 90 - 94 $2.06
Age 95 and over $2.06
A change in rates due to a change in the Employee's age will become effective on the January 1 the
Employee's birthday.
FOR SPOUSE OR DOMESTIC PARTNER BENEFITS
Voluntary Life Insurance
Monthly Rates are based on units of $1,000.
Under Age 20 $.05
Age 20 - 24 $.05
Age 25 - 29 $.05
Age 30 - 34 $.08
Age 35 - 39 $.09
Age 40 - 44 $.10
Age 45 - 49 $.15
Age 50 - 54 $.23
Age 55 - 59 $.43
Age 60 - 64 $.66
Age 65 - 69 $1.27
Age 70 - 74 $2.06
Age 75 - 79 $2.06
Age 80 - 84 $2.06
Age 85 - 89 $2.06
Age 90 - 94 $2.06
Age 95 and over $2.06
Spouse rates are based on the spouse's date of birth. A change in rates due to a change in the Spouse's
age will become effective on the January 1 the Spouse's birthday.
FOR DEPENDENT CHILD BENEFITS
Voluntary Life Insurance $.142 Per $1,000
FOR SPOUSE AND DEPENDENT CHILD BENEFITS
Basic Life Insurance $.71 Per Family Unit
27
FOR FORMER EMPLOYEE BENEFITS
Monthly Rates are based on units of $1,000.
Under Age 20
Age 20 - 24
Age 25 - 29
Age 30-34
Age 35-39
Age 40 - 44
$.153
$.144
$.153
$.177
$.19
$.243
Age 45 - 49
Age 50-54
Age 55-59
Age 60 - 64
Age 65 - 69
$.384
$.726
$1.347
$2.461
$4.065
A change in rates due to a change in the Former Employee's age will become effective on the Policy
Anniversary coinciding with or following the Former Employee's birthday.
FOR FORMER SPOUSE OR DOMESTIC PARTNERS OR SPOUSE OR DOMESTIC PARTNERS OF FORMER
EMPLOYEE BENEFITS
Monthly Rates are based on units of $1,000.
Under Age 20
Age 20 - 24
Age 25 - 29
Age 30-34
Age 35-39
Age 40 - 44
$.153
$.144
$.153
$.177
$.19
$.243
Age 45 - 49
Age 50-54
Age 55-59
Age 60 - 64
Age 65 - 69
$.384
$.726
$1.347
$2.461
$4.065
Spouse rates are based on the spouse's date of birth. A change in rates due to a change in the Spouse's
age will become effective on the Policy Anniversary coinciding with or following the Spouse's
birthday.
FOR FORMER DEPENDENT CHILD BENEFITS
Rates are based on $25,000 per Month.
Under Age 20
Age 20 - 24
Age 25-29
Age 30-34
Age 35-39
Age 40 - 44
$2.377
$2.777
$2.977
$3.600
$4.177
$6.200
Rates are based on $50,000 per Month
Under Age 20
Age 20 - 24
Age 25 - 29
Age 30-34
Age 35-39
Age 40 - 44
Age 45 - 49
Age 50 - 54
Age 55-59
Age 60 - 64
Age 65 - 69
$4.750 Age 45 - 49
$5.550 Age 50 - 54
$5.950 Age 55 - 59
$7.200 Age 60 - 64
$8.350 Age 65 - 69
$12.400
$9.777
$16.377
$23.477
$38.250
$54.077
$19.550
$32.750
$46.950
$76.500
$108.150
A change in rates due to a change in the Former Dependent Child's age will become effective on the
Policy Anniversary Date coinciding with or following the Former Dependent Child's birthday.
TL -004718
28
GENERAL PROVISIONS
Entire Contract
The entire contract will be made up of the Policy, the application of the Employer, a copy of which is
attached to the Policy, and the applications, if any, of the Insureds.
Incontestability
All statements made by the Employer or by an Insured are representations not warranties. No statement
will be used to deny or reduce benefits or as a defense to a claim, unless a copy of the instrument
containing the statement has been furnished to the claimant. In the event of death or legal incapacity, the
beneficiary or representative must receive the copy.
After two years from an Insured's effective date of insurance, or from the effective date of any added or
increased benefits, no such statement will cause insurance to be contested except for fraud or eligibility
for coverage.
Misstatement of Age
If an Insured's age has been misstated, the Insurance Company will adjust all benefits to the amounts that
would have been purchased for the correct age.
Policy Changes
No change in the Policy will be valid until approved by an executive officer of the Insurance Company.
This approval must be endorsed on, or attached to, the Policy. No agent may change the Policy or waive
any of its provisions.
Workers' Compensation Insurance
The Policy is not in lieu of and does not affect any requirements for insurance under any Workers'
Compensation Insurance Law.
Certificates
A certificate of insurance will be delivered to the Employer for delivery to Insureds. Each certificate will
list the benefits, conditions and limits of the Policy. It will state to whom benefits will be paid.
Assignment of Benefits
The Insurance Company will not be affected by the assignment of an Insured's certificate until the
original assignment or a certified copy of the assignment is filed with the Insurance Company. The
Insurance Company will not be responsible for the validity or sufficiency of an assignment. An
assignment of benefits will operate so long as the assignment remains in force provided insurance under
the Policy is in effect. This insurance may not be levied on, attached, garnisheed, or otherwise taken for a
person's debts. This prohibition does not apply where contrary to law.
Clerical Error
A person's insurance will not be affected by error or delay in keeping records of insurance under the
Policy. If such an error is found, the premium will be adjusted fairly.
Agency
The Employer and Plan Administrator are agents of the Employee for transactions relating to insurance
under the Policy. The Insurance Company is not liable for any of their acts or omissions.
Ownership of Records
All records maintained by the Insurance Company are, and shall remain, the property of the Insurance
Company.
TL -004726
29
DEFINITIONS
Please note, certain words used in this document have specific meanings. These terms will be capitalized
throughout this document. The definition of any word, if not defined in the text where it is used, may be
found either in this Definitions section or in the Schedule of Benefits.
Accident
An Accident is a sudden, unforeseeable external event that causes bodily Injury to an Insured while
coverage is in force under the Policy.
Active Service
An Employee will be considered in Active Service with the Employer on a day which is one of the
Employer's scheduled work days if either of the following conditions are met.
1. He or she is actively at work. This means the Employee is performing his or her regular
occupation for the Employer on a Full-time basis, either at one of the Employer's usual places of
business or at some location to which the Employer's business requires the Employee to travel.
2. The day is a scheduled holiday, vacation day or period of Employer approved paid leave of
absence, other than disability or sick leave after 7 days.
An Employee is considered in Active Service on a day which is not one of the Employer's scheduled
work days only if he or she was in Active Service on the preceding scheduled work day.
Annual Compensation
An Employee's annual wage or salary as reported by the Employer for work performed for the Employer
as of the date the covered loss occurs. It does not include amounts received as bonuses, commissions,
overtime pay or other extra compensation. Annual Compensation is determined initially on the date an
Employee applies for coverage. A change in the amount of Annual Compensation is effective on the date
of the change, if the Employer gives the Insurance Company written notice of the change and the required
premium is paid.
Dependent Child
An unmarried child who meets the following requirements.
1. A child from live birth but less than 26 years old;
2. A child who is 26 or more years old, primarily supported by the Employee and incapable of self-
sustaining employment by reason of mental or physical incapacity.
The term "child" means:
a. the Employee's natural child;
b. the Employee's legally adopted child, beginning with any waiting period pending finalization of
the child's adoption. It also means the legally adopted child of the Employee's Spouse provided
the child is living with, and is financially dependent upon the Employee;
c. a stepchild born to the Employee's Spouse and who is living with and financially dependent upon
the Employee;
d. a child for whom the Employee is the court -appointed legal guardian and who resides with, and is
financially dependent upon the Employee.
Employee
For eligibility purposes, an Employee is an employee of the Employer in one of the "Classes of Eligible
Employees." Otherwise, Employee means an employee of the Employer who is insured under the Policy.
30
Employer
The Employer who has subscribed to the Policyholder and for the benefit of whose Employees this policy
has been issued. The Employer, named as the Subscriber on the front of this Policy, includes any
affiliates or subsidiaries covered under the Policy. The Employer is acting as an agent of the Insured for
transactions relating to this insurance. The actions of the Employer shall not be considered the actions of
the Insurance Company.
Full-time
Full-time means the number of hours set by the Employer as a regular work day for Employees in the
Employee's eligibility class.
Initial Enrollment Period
The period in the calendar year when an eligible Employee who was hired on or before the Policy
Effective Date may enroll for the first time for Insurance Benefits under this Policy. This period must be
agreed upon by the Employer and the Insurance Company. Refer to Initial Open Enrollment under the
Enrolling for Insurance section of the Policy.
Injury
Any accidental loss or bodily harm which results directly and independently of all other causes from an
Accident.
Insurability Requirement
An eligible person will satisfy the Insurability Requirement for an amount of coverage on the day the
Insurance Company agrees in writing to accept him or her as insured for that amount. To determine a
person's acceptability for coverage, the Insurance Company will require evidence of good health and may
require it be provided at the Employee's expense.
Insurance Company
The Insurance Company underwriting the Policy is named on the Policy cover page.
Insured
A person who is eligible for insurance under the Policy, for whom insurance is elected, the required
premium is paid and coverage is in force under the Policy.
Life Status Change
A Life Status Change is an event recognized by the Employer's Flexible Benefits Plan as qualifying an
Employee to make changes in benefit selections at a time other than an Annual Enrollment Period.
If there is no Employer sponsored Flexible Benefits Plan, or if it is no longer in effect, the following
events are Life Status Changes.
1. Marriage
2. Divorce, annulment or legal separation
3. Birth or adoption of a child
4. Death of a spouse
5. Termination of a spouse's employment
6. A change in the benefit plan available to the Employee's spouse
7. A change in the Employee's or his or her spouse's employment status that affects either person's
eligibility for benefits
31
Physician
Physician means a licensed doctor practicing within the scope of his or her license and rendering care and
treatment to an Insured that is appropriate for the condition and locality. The term does not include an
Employee, an Employee's spouse, the immediate family (including parents, children, siblings or spouses
of any of the foregoing, whether the relationship derives from blood or marriage), of an Employee or
spouse, or a person living in an Employee's household.
Policy Anniversary
A Policy Anniversary is the date stated on the policy cover and the same date that follows every 12
months for as long the Policy is in effect.
Policy Effective Date
The Policy Effective Date is the date stated on the policy cover.
Prior Plan
The Prior Plan refers to the plan of insurance providing similar benefits sponsored by the Employer in
effect directly prior to the Policy Effective Date. A Prior Plan will include the plan of an employer in
effect on the day prior to that employer's addition to this policy.
To be covered under the Policy, required premium must be paid for all covered Employees.
Sickness
Any physical or mental illness.
Spouse
The current lawful Spouse of an Employee.
TL -004708-1
32
AMENDATORY RIDER
DOMESTIC PARTNER/CIVIL UNION PARTNER COVERAGE
Policy No. FLX-968032
Effective Date: January 1, 2018
Eligible Classes to which this Rider applies: All Classes
This rider amends the Policy and Certificate to which it is attached. It is effective on the Effective Date
shown above, and expires when the Policy expires.
Domestic Partner/Civil Union Partner means any of the following:
1. A person with whom the Employee or Former Employee has a registered civil union or domestic
partnership under state law which imposes legal obligations on the parties substantially similar to
marriage. Such person will continue to be recognized as a Domestic Partner or Civil Union Partner
unless and until: (1) the civil union or domestic partnership is dissolved under applicable law; or (2)
either the Employee or Former Employee or the Domestic Partner/Civil Union Partner marries
another person.
2. A person who was legally married to the Employee or Former Employee under the laws of a state
permitting marriage of partners of the same sex, where the Employee or Former Employee and
Domestic Partner/Civil Union Partner currently reside in a state that does not recognize a valid
marriage. This shall not apply if:
a. the marriage has been terminated by legal process, or;
b. either the Employee or Former Employee or the Domestic Partner/Civil Union Partner has
entered into a valid marriage, civil union or domestic partnership under state law.
3. A person meeting all of the following requirements, with respect to an Employee or Former
Employee:
a. Shares a permanent residence with the Employee or Former Employee;
b. Has resided with the Employee or Former Employee for at least 6 months and is expected to
continue to reside with the Employee or Former Employee indefinitely;
c. Has not been legally married to any other person within the previous six months, and has no
Domestic Partner other than the Employee or Former Employee during the previous six months,
and is the Employee's or Former Employee's sole Domestic Partner;
d. Has signed a Domestic Partner declaration with the Employee or Former Employee, if the
Employee or Former Employee resides in a jurisdiction which provides for Domestic Partner
declarations;
e. Has not signed a Domestic Partner declaration with any other person within the last 6 months;
f. Is interdependent with the Employee or Former Employee in three or more of the following
ways:
1. Both partners are registered under any municipal ordinance as domestic partners.
2. Both partners are jointly parties to a lease, mortgage or deed.
3. Both partners jointly own one or more motor vehicles.
4. Both partners jointly own one or more bank or credit accounts.
5. The Employee or Former Employee has named the Domestic Partner as attorney -in -fact
under a durable power of attorney with authority over health care decisions.
6. The Employee or Former Employee has designated the Domestic Partner as beneficiary under
a retirement plan or a life insurance policy.
7. The Employee or Former Employee has designated the Domestic Partner as beneficiary of the
Employee's or Former Employee's will.
8. Each partner has agreed in writing to assume the financial responsibility for the welfare of the
other.
33
g. Is not so closely related by blood to the Employee or Former Employee as to prohibit legal
marriage in their state of residence;
h. Is no less than 18 years of age.
The Employee or Former Employee and Domestic Partner must furnish the Employer and Insurance
Company with a signed declaration that the above requirements are met, at the time of enrollment.
All references in the policy to "Spouse" shall be changed to read "Spouse, Domestic Partner, and Civil
Union Partner except as follows:
1. The definition of "Spouse" remains unchanged.
2. For purposes of any provision of the policy providing for payment of benefits to relatives of the
Employee or Former Employee, a Domestic Partner/Civil Union Partner shall be included only if:
a. the Domestic Partner/Civil Union Partner meets the requirements of the definition of Domestic
Partner/Civil Union Partner referenced in item 1 or 2, or;
b. the Employee or Former Employee and Domestic Partner have furnished the Employer or the
Insurance Company with a signed statement affirming that the requirements referenced in item 3
within the definition of Domestic Partner are met.
3. A Domestic Partner/Civil Union Partner shall be deemed eligible to be enrolled for insurance on the
latest of:
a. the date of registration under Item 1 of the definition of Domestic Partner/Civil Union Partner;
b. the date that the Employee or Former Employee is eligible for insurance under the Policy; or;
c. the effective date of this Amendment to the Policy.
4. A child of a Domestic Partner/Civil Union Partner may only be eligible to be insured if:
a. the child is primarily dependent on the Employee for financial support;
b. the Employee has a legal obligation of support of the child; or
c. the Employee is the child's legal guardian.
Any provision of the Policy that otherwise excludes any person who is not legally able to marry the
Employee or Former Employee is changed by the following:
In the case of any person of the same sex as the Employee or Former Employee, the exclusion of persons
legally able to marry will not apply for the first 12 months that the Employee's or Former Employee's
state of residence allows same -sex couples to marry.
Except for the above this rider does not change the Policy or Certificate to which it is attached.
LIFE INSURANCE COMPANY OF NORTH AMERICA
Matthew G. Manders, President
TL -007153
34
LIFE INSURANCE COMPANY OF NORTH AMERICA
1601 CHESTNUT STREET
PHILADELPHIA, PA 19192-2235
STATE MODIFYING PROVISIONS AMENDMENT RIDER
Subscriber: Weld County Government
Policy No. FLX-968032
Amendment Effective Date: January 1, 2018
This amendment is attached to and made part of the Policy/Certificate specified above. Its provisions are
intended to conform this Policy/Certificate to the laws of the state in which the insured resides.
The Policy delivered under the Group Policy are amended as follows:
APPLICABLE TO CALIFORNIA RESIDENTS:
1. Conversion Privilege for Life Insurance
Insured Employees and Insured Spouses may convert to an individual policy of life insurance for an
amount not greater than the Conversion Amount shown below when the Policy ends, without regard
to any requirement that the person be insured under the policy for a specified period of time, if all of
the following apply.
a. The Insured became Totally Disabled while covered for the Life Benefit of the Policy.
Totally Disabled means the person is unable to perform all the material duties of any
occupation for which he or she may reasonably be qualified based on training, education and
experience.
b. The Insured remained Totally Disabled until the Policy ended while covered for the Life
Benefit of this Policy.
c. The Policy does not provide a Waiver of Premium, Extended Death Benefit Provision or
monthly payments to Totally Disabled Insureds for the Life Benefit.
d. The person meets all other conditions for converting the insurance.
Conversion Amount - Insured's life insurance amount under the Policy on the date the Policy ends
minus the amount for which the Insured is insured under a group policy that provides life coverage to
employees of the Insured Employee's Employer covered under this Policy. The dollar limit that
applies to the amount for conversion at Policy termination does not apply.
The requirement that the Insured be covered under the Policy for the stated number of years in order
to convert life insurance does not apply.
NOTICE: FOR EMPLOYERS LOCATED IN CALIFORNIA, YOU MUST PROVIDE COVERAGE
TO CALIFORNIA RESIDENTS WHO ARE IN A REGISTERED DOMESTIC PARTNERSHIP.
APPLICABLE TO FLORIDA RESIDENTS:
The benefits of the policy providing your coverage are governed primarily by the law of a state other than
Florida.
35
APPLICABLE TO MARYLAND RESIDENTS:
The Group Insurance Policy was issued in a jurisdiction other than Maryland and may not provide all of
the benefits required by Maryland law.
APPLICABLE TO MISSOURI RESIDENTS:
Applicable to Voluntary Life Insurance Benefits
If an Insured commits suicide, while sane or insane, within 1 year from the date his or her insurance under
the Policy becomes effective, Voluntary Life Insurance Benefits will be limited to a refund of the
premiums paid on the Insured's behalf. The suicide exclusion applies from the effective date of any
additional benefits or increases in Life Insurance Benefits.
Except for any amount of benefits in excess of the Prior Plan's benefits, this exclusion will not apply to
any person covered under the Prior Plan for more than one year. If a person was not insured for one year
under the Prior Plan, credit will be given for the time he or she was insured.
If a Dependent Child commits suicide and is survived by other Dependent Children covered under the
same certificate, no refund of premiums will be paid.
APPLICABLE TO NORTH DAKOTA RESIDENTS:
The Suicide exclusion, if any, is limited to one year from the effective date of insurance. The suicide
exclusion with respect to any increase in death benefits which results from an application of the insured
subsequent to the effective date, if any, is limited to one year from the effective date of the increase.
APPLICABLE TO OREGON RESIDENTS:
NOTICE: MUST PROVIDE DOMESTIC PARTNER COVERAGE FOR OREGON RESIDENTS
APPLICABLE TO VERMONT RESIDENTS:
To the extent the Policy provides insurance coverage to a spouse, the identical consideration must be
applied to same sex marriages and Civil Union Partners.
1. Civil Union Partner means:
a. A person with whom the Employee has a registered civil union under Vermont law which
imposes obligations on the parties substantially similar to marriage. Such person will continue to
be recognized as a Civil Union Partner unless and until: (1) the civil union is dissolved under
applicable law; or (2) either the Employee or the Civil Union Partner marries another person.
2. Spouse means:
a. "Lawful spouse" and includes a lawful spouse of the same sex.
b. This also includes a partner to a civil union recognized under Vermont Law.
36
APPLICABLE TO WASHINGTON RESIDENTS:
1. The following Continuation of Insurance provision is added to the Policy:
Continuation of Life Coverage During Labor Disputes
If an Employee's Active Service ends because of a Labor Dispute and his or her premium for Life
Insurance Benefits under the Policy is paid either by the Employer, in whole or in part, or by the
Employee through payroll deductions, then the Employee may continue his or her Life Insurance
Benefits. The Employer will send written notice of the right to continue coverage to each insured
Employee at his or her most recent address as on file with the Employer.
To continue coverage, the Employee must pay premiums directly to the Employer, who will remit the
premiums to the Insurance Company. Premiums must be paid by the date they are due, subject to the
31 day grace period. Policy coverages and premiums will stay the same during a Labor Dispute;
however, the Insurance Company may make normal changes in premium rates when the Policy is
renewed, under the terms set forth in the Policy.
Coverage continued in this manner will end on the earliest of the following dates.
a. The date the Labor Dispute has ended.
b. The date coverage has been continued for 6 months.
If the Labor Dispute continues beyond 6 months, the Employee may apply for an individual insurance
policy, as set forth in detail under "Conversion Privilege for Life Insurance."
"Labor Dispute," as used here, means a strike, lockout, or other labor dispute between the Employer
and its Employees, during which time the Employee is not paid by the Employer.
2. If the Policy provides coverage to dependents, benefits for a Spouse or Dependent Child are limited to
100% of the insured Employee's coverage amount . Stand-alone Spouse and Dependent Child
coverage (when Employee is not insured) is not permitted.
3. The Suicide Exclusion, if any, does not apply.
4. To the extent the policy includes Accelerated Benefits, the following resolution of disputes
requirements are added to the Policy.
• For Terminal Illness — Determination of Terminal Illness
In the event the Physician representing the Insurance Company disputes the existence of a
Terminal Illness, and the dispute cannot be resolved, the Insured has the right to mediation and
binding arbitration in accordance with Washington Administrative Code 284-23-730.
5. The Incontestability Provision is replaced as follows:
Incontestability
All statements made by the Employer or by an Insured are representations not warranties. No
statement will be used to deny or reduce benefits or as a defense to a claim, unless a copy of the
instrument containing the statement has been furnished to the claimant. In the event of death or legal
incapacity, the beneficiary or representative must receive the copy.
After two years from an Insured's effective date of insurance, or from the effective date of any added
or increased benefits, no such statement will cause insurance to be contested.
37
6. If the term "Accident" is defined in the Policy, it is replaced by the following:
Accident
An Accident is a sudden, unforeseeable event that causes bodily Injury to an Insured while coverage
is in force under the Policy.
7. If the Policy provides coverage/benefits to a Spouse, a Domestic Partner will be afforded the same
coverage/benefits provided to a Spouse.
Domestic Partner means a person with whom the Employee has a registered domestic partnership
under Washington state law which imposes legal obligations on the parties substantially similar to
marriage.
8. NOTICE: MUST PROVIDE DOMESTIC PARTNER COVERAGE FOR WASHINGTON
RESIDENTS
Please refer to your Certificate of Insurance which describes the benefit provisions and limitations
applicable to you as a resident of this state.
Signed for the
Life Insurance Company of North America
/1)74,trt_,
Matthew G. Manders, President
TL -00-3000.00
38
LIFE INSURANCE COMPANY OF NORTH AMERICA
PHILADELPHIA, PA 19192-2235
We, Weld County Government, whose main office address is Greeley, CO, hereby approve and accept the
terms of Group Policy Number FLX-968032 issued by the LIFE INSURANCE COMPANY OF NORTH
AMERICA to the TRUSTEE OF THE GROUP INSURANCE TRUST FOR EMPLOYERS IN THE
PUBLIC ADMINISTRATION INDUSTRY.
This application is to be signed.
Weld County Government
Signature:
Date: MAR 2 6 2018
Steve Moreno, Chair, Board of
Title: Weld County Commissioners
TL -008890
02011-D9o2oZ
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