HomeMy WebLinkAbout20180925.tiffNOTICE OF
PROTECTION PROVIDED BY
LIFE AND HEALTH INSURANCE PROTECTION ASSOCIATION
This notice provides a brief summary of the Life and Health Insurance Protection Association ("the
Association") and the protection it provides for policyholders. This safety net was created under
Colorado law, which determines who and what is covered and the amounts of coverage.
The Association was established to provide protection in the unlikely event that your life, annuity or
health insurance company becomes financially unable to meet its obligations and is taken over by its
Insurance Department. If this should happen, the Association will typically arrange to continue coverage
and pay claims, in accordance with Colorado law, with funding from assessments paid by other insurance
companies.
The basic protections provided by the Association per insolvency are:
• Life Insurance
o $300,000 in death benefits
o $100,000 in cash surrender or withdrawal values
• Health Insurance
o $500,000 in hospital, medical and surgical insurance benefits
o $300,000 in disability insurance benefits
o $300,000 in long-term care insurance benefits
o $100,000 in other types of health insurance benefits
• Annuities
o $250,000 in withdrawal and cash values
The maximum amount of protection for each individual, regardless of the number of policies or
contracts, is $300,000. Special rules may apply with regard to hospital, medical and surgical insurance
benefits.
Note: Certain policies and contracts may not be covered or fully covered. For example,
coverage does not extend to any portion(s) of a policy or contract that the insurer does not
guarantee, such as certain investment additions to the account value of a variable life insurance policy
or a variable annuity contract. There are also residency requirements and other limitations under
Colorado law.
To learn more about the above protections, as well as protections relating to group contracts or
retirement plans, please visit the Association's website at http://colorado.lhiga.com, email
jkelldorf@gmail.com or contact:
Colorado Life and Health
Insurance Protection Association
P.O. Box 36009
Denver, CO 80236
(303) 2 92 -5022
Colorado Division of Insurance
1650 Broadway, Suite 850
Denver, CO 80202
(303) 894-7499
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Insurance companies and agents are not allowed by Colorado law to use the existence of the
Association or its coverage to encourage you to purchase any form of insurance. When selecting an
insurance company, you should not rely on Association coverage. If there is any inconsistency between
this notice and Colorado law, then Colorado law will control.
IMPORTANT NOTICES
GROUP ACCIDENT
If a Covered Person resides in one of the following states, the important notice will apply.
New Mexico residents:
This type of plan is NOT considered "minimum essential coverage" under the Affordable
Care Act (ACA) and therefore does NOT satisfy the individual mandate that you have health
insurance coverage. If you do not have other health insurance coverage, you may be subject
to a federal tax penalty. Please consult your tax advisor.
TL-00-6000a.NM
Life Insurance Company of North America
1601 Chestnut Street, Philadelphia, Pennsylvania 19192-2235
A Stock Insurance Company
GROUP ACCIDENT POLICY
POLICYHOLDER:
Trustee of the Group Insurance Trust for
Employers in the Public Administration
Industry
POLICY NUMBER: OK 969517
POLICY EFFECTIVE DATE: January 1, 2018
POLICY ANNIVERSARY DATE: January 1
STATE OF ISSUE: Delaware
This Policy describes the terms and conditions of insurance. This Policy goes into effect subject to its applicable terms and
conditions at 12:01 AM on the Policy Effective Date shown above at the Policyholder's address. The laws of the State of
Issue shown above govern this Policy.
We and the Policyholder agree to all of the terms of this Policy.
THIS IS A GROUP ACCIDENT ONLY INSURANCE POLICY.
IT DOES NOT PAY BENEFITS FOR LOSS CAUSED BY SICKNESS.
THIS IS A LIMITED POLICY.
PLEASE READ IT CAREFULLY.
014.,tc., 47..4,
Anna Krishtul, Corporate Secretary Matthew G. Manders, President
Countersigned
Where Required By Law
GA -00-1000.00
TABLE OF CONTENTS
SECTION
SCHEDULE OF AFFILIATES
SCHEDULE OF BENEFITS
GENERAL DEFINITIONS
ELIGIBILITY AND EFFECTIVE DATE PROVISIONS
COMMON EXCLUSIONS
CONVERSION PRIVILEGE
CLAIM PROVISIONS
ADMINISTRATIVE PROVISIONS
GENERAL PROVISIONS
ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE
EXPOSURE AND DISAPPEARANCE COVERAGE
BEREAVEMENT AND TRAUMA COUNSELING BENEFIT
BUSINESS TRAVEL BENEFIT
SEATBELT AND AIRBAG BENEFIT
SPECIAL EDUCATION BENEFIT
SPOUSE RETRAINING BENEFIT
DOMESTIC PARTNER/CIVIL UNION PARTNER RIDER
TRAVEL ASSISTANCE SERVICES
MODIFYING PROVISIONS AMENDMENT
GA -00-1000.00
PAGE NUMBER
SCHEDULE OF AFFILIATES
The following affiliates are covered under this Policy on the effective dates listed below.
AFFILIATE NAME
None
GA -00-1000.00
LOCATION EFFECTIVE DATE
1
SCHEDULE OF BENEFITS
This Policy is intended to be read in its entirety. In order to understand all the conditions, exclusions and limitations
applicable to its benefits, please read all the policy provisions carefully.
The Schedule of Benefits provides a brief outline of the coverage and benefits provided by this Policy. Please read
the Description of Coverages and Benefits Section for full details.
Subscriber:
Effective Date of Subscriber Participation:
Covered Classes:
Class 1
Weld County Government
January 1, 2018
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.
2
SCHEDULE OF BENEFITS FOR CLASS 1
This Schedule of Benefits shows maximums, benefit periods and any limitations applicable to benefits provided in
this Policy for each Covered Person unless otherwise indicated. Principal Sum, when referred to in this Schedule,
means the Employee's Principal Sum in effect on the date of the Covered Accident causing the Covered Injury or
Covered Loss unless otherwise specified.
Eligibility Waiting Period
The Eligibility Waiting Period is the period of time the Employee must be in a Covered Class to be eligible for coverage.
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.
Time Period for Loss:
Any Covered Loss must occur within: 365 days of the Covered Accident
Maximum Age for Insurance: None
BASIC ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Employee Principal Sum:
3 times Annual Compensation rounded to the next higher $1,000
if not already a multiple thereof subject to a maximum of
$600,000.
SCHEDULE OF COVERED LOSSES
Covered Loss
Loss of Life
Loss of Two or More Hands or Feet
Loss of Sight of Both Eyes
Loss of One Hand or One Foot and Sight in One Eye
Loss of Speech and Hearing (in both ears)
Quadriplegia
Paraplegia
Hemiplegia
Uniplegia
Coma
Monthly Benefit
Number of Monthly Benefits
When Payable
Lump Sum Benefit
When Payable
Loss of One Hand or Foot
Loss of Sight in One Eye
Severance and Reattachment of One Hand or Foot
Loss of Speech
Loss of Hearing (in both ears)
Loss of all Four Fingers of the Same Hand
Loss of Thumb and Index Finger of the Same Hand
Loss of all the Toes of the Same Foot
Benefit
100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum
75% of the Principal Sum
50% of the Principal Sum
25% of the Principal Sum
1% of the Principal Sum
11
At the end of each month during which the Covered
Person remains comatose
100% of the Principal Sum
Beginning of the 12th month
50% of the Principal Sum
50% of the Principal Sum
50% of the Principal Sum
50% of the Principal Sum
50% of the Principal Sum
25% of the Principal Sum
25% of the Principal Sum
20% of the Principal Sum
3
Age Reductions
A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date
preceding the first reduction, as shown below.
Age Percentage of Benefit Amount
65 but less than 70 65%
70 but less than 75 42%
75 but less than 80 27%
80 but less than 85 21%
85 but less than 90 15%
90 but less than 95 12%
95 or over 9%
Benefit reductions will be effective on January 15t following the Covered Person's attainment of age as specified
in schedule above.
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES
Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under
them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and
Dismemberment benefits.
EXPOSURE AND DISAPPEARANCE COVERAGE Principal Sum multiplied by the percentage applicable to the
Covered Loss, as shown in the Schedule of Covered Losses.
ADDITIONAL ACCIDENT BENEFITS
Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental
Death and Dismemberment benefits payable.
BEREAVEMENT AND TRAUMA COUNSELING BENEFIT
Benefit Amount
Maximum Number of Sessions
Maximum Benefit Per Covered Accident
SEATBELT AND AIRBAG BENEFIT
Seatbelt Benefit
Airbag Benefit
Default Benefit
SPECIAL EDUCATION BENEFIT
Surviving Dependent Child Benefit 5% of the Principal Sum subject to a Maximum Benefit of
$5,000
Maximum Number of Annual Payments
For Each Surviving Dependent Child
Default Benefit
$250 per session
4 sessions
$1,000
25% of the Principal Sum subject to a Maximum Benefit of
$25,000
10% of the Principal Sum subject to a Maximum Benefit of
$5,000
$1,000
4
$1,000
SPOUSE OR DOMESTIC PARTNER RETRAINING BENEFIT
Benefit $3,000
4
VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Employee Principal Sum:
Maximum:
Spouse or Domestic Partner Principal Sum:
If no Dependent Children are insured:
If one or more Dependent Children are insured:
Maximum:
Dependent Child Principal Sum:
If Spouse or Domestic Partner is insured:
If no Spouse or Domestic Partner is insured:
Maximum:
Units of $1,000 to the lesser of 10 times Annual Compensation
rounded to the next higher $1,000 if not already a multiple
thereof subject to a minimum of $10,000 and a maximum of
$600,000.
$600,000
50% of the Employee's Principal Sum
40% of the Employee's Principal Sum
$300,000
10% of the Employee's Principal Sum
15% of the Employee's Principal Sum
$25,000
SCHEDULE OF COVERED LOSSES
Covered Loss
Loss of Life
Loss of Two or More Hands or Feet
Loss of Sight of Both Eyes
Loss of One Hand or One Foot and Sight in One Eye
Loss of Speech and Hearing (in both ears)
Quadriplegia
Paraplegia
Hemiplegia
Uniplegia
Coma
Monthly Benefit
Number of Monthly Benefits
When Payable
Lump Sum Benefit
When Payable
Loss of One Hand or Foot
Loss of Sight in One Eye
Severance and Reattachment of One Hand or Foot
Loss of Speech
Loss of Hearing (in both ears)
Loss of all Four Fingers of the Same Hand
Loss of Thumb and Index Finger of the Same Hand
Loss of all the Toes of the Same Foot
Benefit
100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum
75% of the Principal Sum
50% of the Principal Sum
25% of the Principal Sum
1% of the Principal Sum
11
At the end of each month during which the Covered
Person remains comatose
100% of the Principal Sum
Beginning of the 12th month
50% of the Principal Sum
50% of the Principal Sum
50% of the Principal Sum
50% of the Principal Sum
50% of the Principal Sum
25% of the Principal Sum
25% of the Principal Sum
20% of the Principal Sum
5
Age Reductions
A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date
preceding the first reduction, as shown below.
Age Percentage of Benefit Amount
65 but less than 70 65%
70 but less than 75 42%
75 but less than 80 27%
80 but less than 85 21%
85 but less than 90 15%
90 but less than 95 12%
95 or over 9%
Benefit reductions will be effective on the January 1st following the Covered Person's attainment of age as
specified in schedule above.
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES
Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under
them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and
Dismemberment benefits.
EXPOSURE AND DISAPPEARANCE COVERAGE Principal Sum multiplied by the percentage applicable to the
Covered Loss, as shown in the Schedule of Covered Losses.
ADDITIONAL ACCIDENT BENEFITS
Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental
Death and Dismemberment benefits payable.
BEREAVEMENT AND TRAUMA COUNSELING BENEFIT
Benefit Amount $250 per session
Maximum Number of Sessions 4 sessions
Maximum Benefit Per Covered Accident $1,000
BUSINESS TRAVEL BENEFIT
SEATBELT AND AIRBAG BENEFIT
Seatbelt Benefit
Airbag Benefit
Default Benefit
SPECIAL EDUCATION BENEFIT
Surviving Dependent Child Benefit
Maximum Number of Annual Payments
For Each Surviving Dependent Child
Default Benefit
25% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $25,000
25% of the Principal Sum subject to a Maximum Benefit of
$25,000
10% of the Principal Sum subject to a Maximum Benefit of
$5,000
$1,000
5% of the Principal Sum subject to a Maximum Benefit of
$5,000
4
$1,000
SPOUSE OR DOMESTIC PARTNER RETRAINING BENEFIT
Benefit $3,000
6
INITIAL PREMIUM RATES
Premium Rate:
Mode of Premium Payment:
Contributions:
Premium Due Dates:
Basic Insurance
Employee Rate: $0.011 per $1,000
Voluntary Insurance
Employee Rate: $0.022 per $1,000
Family Rate: $0.033 per $1,000
Monthly
The cost of the coverage is paid by the Subscriber and the Employee
The Policy Effective Date and the first day of each succeeding modal
period
Premium rates are subject to change in accordance with the Changes in Premium Rates section contained in the
Administrative Provisions section of this Policy.
GA -00-1100.00
7
GENERAL DEFINITIONS
Please note that certain words used in this Policy have specific meanings. The words defined below and capitalized within
the text of this Policy have the meanings set forth below.
Active Service
Age
Aircraft
Annual Compensation
Covered Accident
Covered Injury
Covered Loss
An Employee will be considered in Active Service with his employer on any day
that is either of the following:
1. one of the Employer's scheduled work days on which the Employee is
performing his regular duties on a full-time basis, either at one of the
Employer's usual places of business or at some other location to which the
Employer's business requires the Employee to travel;
2. a scheduled holiday, vacation day or period of Employer -approved paid leave
of absence, other than sick leave, only if the Employee was in Active Service
on the preceding scheduled workday.
A person other than an Employee is considered in Active Service if he is none of
the following:
1. an Inpatient in a Hospital or receiving Outpatient care for chemotherapy or
radiation therapy;
2. confined at home under the care of Physician for Sickness or injury;
3. Totally Disabled.
A Covered Person's Age, for purposes of initial premium calculations, is his Age
attained on the date coverage becomes effective for him under this Policy.
Thereafter, it is his Age attained on his last birthday.
A vehicle which:
1. has a valid certificate of airworthiness; and
2. is being flown by a pilot with a valid license to operate the Aircraft.
Annual Compensation means an Employee's annual earnings for normal work
established by the Subscriber for his job classification, excluding commissions,
bonuses, overtime or other extra compensation.
Changes in the Covered Person's amount of insurance resulting from a change in
the Employee's amount of Annual Compensation take effect, subject to any Active
Service requirement, on the date of change in Annual Compensation.
A sudden, unforeseeable, external event that results, directly and independently of
all other causes, in a Covered Injury or Covered Loss and meets all of the
following conditions:
1. occurs while the Covered Person is insured under this Policy;
2. is not contributed to by disease, Sickness, mental or bodily infirmity;
3. is not otherwise excluded under the terms of this Policy.
Any bodily harm that results directly and independently of all other causes from a
Covered Accident.
A loss that is all of the following:
1. the result, directly and independently of all other causes, of a Covered
Accident;
2. one of the Covered Losses specified in the Schedule of Covered Losses;
3. suffered by the Covered Person within the applicable time period specified in
the Schedule of Benefits.
8
Covered Person
Dependent Child(ren)
Employee
Employer
He, His, Him
Hospital
Inpatient
An eligible person, as defined in the Schedule of Benefits, for whom an enrollment
form has been accepted by Us and required premium has been paid when due and
for whom coverage under this Policy remains in force. The term Covered Person
shall include, where this Policy provides coverage, an eligible Spouse and eligible
Dependent Children.
An Employee's unmarried child who meets the following requirements:
1. A child from live birth to 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
handicap.
A child, for purposes of this provision, includes an Employee's:
1. natural child;
2. 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;
3. stepchild who resides with the Employee and is financially dependent upon the
Employee;
4. child for whom the Employee is the court -appointed legal guardian, as long as
the child resides with the Employee and depends on the Employee for
financial support. Financial support means that the Employee is eligible to
claim the dependent for purposes of Federal and State income tax returns.
For eligibility purposes, an Employee of the Employer who is in one of the
Covered Classes.
The Subscriber and any affiliates, subsidiaries or divisions shown in the Schedule
of Covered Affiliates and which are covered under this Policy on the date of issue
or subsequently agreed to by Us.
Refers to any individual, male or female.
An institution that meets all of the following:
1. it is licensed as a Hospital pursuant to applicable law;
2. it is primarily and continuously engaged in providing medical care and
treatment to sick and injured persons;
3. it is managed under the supervision of a staff of medical doctors;
4. it provides 24 -hour nursing services by or under the supervision of a graduate
registered nurse (R.N.);
5. it has medical, diagnostic and treatment facilities, with major surgical facilities
on its premises, or available on a prearranged basis;
6. it charges for its services.
The term Hospital does not include a clinic, facility, or unit of a Hospital for:
1. rehabilitation, convalescent, custodial, educational or nursing care;
2. the aged, drug addicts or alcoholics;
3. a Veteran's Administration Hospital or Federal Government Hospital unless
the Covered Person incurs an expense.
A Covered Person who is confined for at least one full day's Hospital room and
board. The requirement that a person be charged for room and board does not
apply to confinement in a Veteran's Administration Hospital or Federal
Government Hospital and in such case, the term 'Inpatient' shall mean a Covered
Person who is required to be confined for a period of at least a full day as
determined by the Hospital.
9
Nurse
Outpatient
Physician
A licensed graduate Registered Nurse (R.N.), a licensed practical Nurse (L.P.N.) or
a licensed vocational Nurse (L.V.N.) and who is not:
1. employed or retained by the Subscriber;
2. living in the Covered Person's household; or
3. a parent, sibling, spouse or child of the Covered Person.
A Covered Person who receives treatment, services and supplies while not an
Inpatient in a Hospital.
A licensed health care provider practicing within the scope of his license and
rendering care and treatment to a Covered Person that is appropriate for the
condition and locality and who is not:
1. employed or retained by the Subscriber;
2. living in the Covered Person's household;
3. a parent, sibling, spouse or child of the Covered Person.
Prior Plan The plan of insurance providing similar benefits, sponsored by the Employer in
effect immediately prior to this Policy's Effective Date.
Sickness
Spouse
Subscriber
Totally Disabled or
Total Disability
A physical or mental illness.
The Employee's lawful spouse.
Any participating organization that subscribes to the trust to which this Policy is
issued.
Totally Disabled or Total Disability means either:
1. inability of the Covered Person who is currently employed to do any type of
work for which he is or may become qualified by reason of education, training
or experience; or
2. inability of the Covered Person who is not currently employed to perform all
of the activities of daily living including eating, transferring, dressing,
toileting, bathing, and continence, without human supervision or assistance.
We, Us, Our Life Insurance Company of North America.
GA -00-1200.00 as modified by GA -00-4002.00
10
ELIGIBILITY AND EFFECTIVE DATE PROVISIONS
Subscriber Effective Date
Accident Insurance Benefits become effective for each Subscriber in consideration of the Subscriber's application,
Subscription Agreement and payment of the initial premium when due. Insurance coverage for the Subscriber becomes
effective on the Effective Date of Subscriber Participation.
Eligibility
An Employee becomes eligible for insurance under this Policy on the date he meets all of the requirements of one of the
Covered Classes and completes any Eligibility Waiting Period, as shown in the Schedule of Benefits. A Spouse and
Dependent Children of an eligible Employee become eligible for any dependent insurance provided by this Policy on the
later of the date the Employee becomes eligible and the date the Spouse or Dependent Child meets the applicable definition
shown in the Definitions section of this Policy. No person may be eligible for insurance under this Policy as both an
Employee and a Spouse or Dependent Child at the same time.
Effective Date for Individuals
Basic Accidental Death and Dismemberment Benefits
Insurance becomes effective for an eligible Employee, subject to the Deferred Effective Date provision below, on the latest
of the following dates:
1. the effective date of this Policy;
2. the date the Employee becomes eligible.
Voluntary Accidental Death and Dismemberment Benefits
Insurance becomes effective for an eligible Employee who applies and agrees to make required contributions within 31
days of eligibility, and subject to the Deferred Effective Date provision below, on the latest of the following dates:
1. the effective date of this Policy;
2. the date the Employee becomes eligible;
3. the date We receive the Employee's completed enrollment form and the required first premium, during his lifetime.
Insurance becomes effective for an Employee's eligible dependents if the Employee applies and agrees to make required
contributions within 31 days of the date his dependents become eligible and, subject to the Deferred Effective Date
provision below, on the latest of the following dates:
1. the effective date of this Policy;
2. the date the Employee becomes eligible;
3. the date the Employee's insurance becomes effective;
4. the date the dependent meets the definition of Spouse or Dependent Child, as applicable;
5. the date We receive a completed enrollment form for Spouse and Dependent Child coverage and the required first
premium, during each dependent's lifetime.
Insurance becomes effective for a newborn Dependent Child automatically from the moment of the child's live birth.
Insurance for that Dependent Child automatically ends 31 days later unless the Employee has a Spouse or other Dependent
Children insured under this Policy or makes a request to cover the child and pays the required initial premium, during the
child's lifetime.
DEFERRED EFFECTIVE DATE
Active Service
The effective date of insurance will be deferred for any Employee or any eligible Spouse or Dependent Child who is not in
Active Service on the date coverage would otherwise become effective. Coverage will become effective on the later of the
date he returns to Active Service and the date coverage would otherwise have become effective.
11
Life Status Change
A Life Status Change is an event that the Employer determines qualifies an Employee to elect or increase accident
insurance benefits for himself and his Spouse and Dependent Children. Any change in benefit elections must be made
within 31 days of a Life Status Change.
Any increases in benefits or added benefits elected under this Life Status Change provision will become effective on the
first of the month following the Life Status Change.
The Subscriber should seek advice of its tax advisors if Employees may contribute to the cost of any insurance provided by
this Policy with earnings not subject to Federal Income Tax. We cannot provide such advice nor offer any opinions on
taxation or tax status of any contributions toward the cost of insurance.
Effective Date of Changes
Any increase or decrease in the amount of insurance for the Covered Person resulting from:
1. a change in benefits provided by this Policy; or
2. a change in the Employee's Covered Class will take effect on the date of such change.
Increases will take effect subject to any Active Service requirement.
TERMINATION OF INSURANCE
The insurance on a Covered Person will end on the earliest date below:
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.
Termination will not affect a claim for a Covered Loss or Covered Injury that is the result, directly and independently of all
other causes, of a Covered Accident that occurs while coverage was in effect.
CONTINUATION OF INSURANCE
Continuation for Leave of Absence or Family Medical Leave
Insurance for an Employee and Covered Dependents may be continued until the earliest of the following dates if: (a) an
Employee is on an Employer -approved leave of absence or an Employer -approved family medical leave; and (b) required
premium contributions are paid when due.
1. for an Employer -approved leave of absence: 1 month after the leave of absence begins.
2. for an Employer -approved family medical leave: up to the later of the period of the approved FMLA leave or the
leave period required by law in the state in which the Employee is employed.
3. for Total Disability: 12 months immediately following the day the Employee's sick time ended.
Such continuation will run concurrently with, precede a continuation during any other leave.
GA -00-1361.00
12
COMMON EXCLUSIONS
In addition to any benefit -specific exclusions, benefits will not be paid for any Covered Injury or Covered Loss which,
directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically
provided for by name in the Description of Benefits Section:
1. intentionally self-inflicted injury, suicide or any attempt thereat while sane or insane;
2. commission or attempt to commit a felony or an assault;
3. commission of or active participation in a riot or insurrection;
4. bungee jumping; parachuting; skydiving; parasailing; hang-gliding;
5. declared or undeclared war or act of war;
6. flight in, boarding or alighting from an Aircraft or any craft designed to fly above the Earth's surface:
a. except as a passenger on a regularly scheduled commercial airline;
b. being flown by the Covered Person or in which the Covered Person is a member of the crew;
c. being used for:
i. crop dusting, spraying or seeding, giving and receiving flying instruction, fire fighting, sky
writing, sky diving or hang-gliding, pipeline or power line inspection, aerial photography or
exploration, racing, endurance tests, stunt or acrobatic flying; or
ii. any operation that requires a special permit from the FAA, even if it is granted (this does not
apply if the permit is required only because of the territory flown over or landed on);
d. designed for flight above or beyond the earth's atmosphere;
e. an ultra -light or glider;
f. being used for the purpose of parachuting or skydiving;
g. being used by any military authority, except an Aircraft used by the Air Mobility Command or its foreign
equivalent;
7. Sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof,
except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of
contaminated food;
8. travel in any Aircraft owned, leased or controlled by the Subscriber, or any of its subsidiaries or affiliates. An
Aircraft will be deemed to be "controlled" by the Subscriber if the Aircraft may be used as the Subscriber wishes
for more than 10 straight days, or more than 15 days in any year;
9. a Covered Accident that occurs while engaged in the activities of active duty service in the military, navy or air
force of any country or international organization. Covered Accidents that occur while engaged in Reserve or
National Guard training are not excluded until training extends beyond 31 days;
10. operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant
including any prescribed drug for which the Covered Person has been provided a written warning against
operating a vehicle while taking it. Under the influence of alcohol, for purposes of this exclusion, means
intoxicated, as defined by the law of the state in which the Covered Accident occurred;
11. voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a
Physician and taken in accordance with the prescribed dosage;
12. in addition, benefits will not be paid for services or treatment rendered by a Physician, Nurse or any other person
who is:
a. employed or retained by the Subscriber;
b. providing homeopathic, aroma -therapeutic or herbal therapeutic services;
c. living in the Covered Person's household;
d. a parent, sibling, spouse or child of the Covered Person.
GA -00-1403.00
13
CONVERSION PRIVILEGE
1. If the Covered Person's insurance or any portion of it ends for any of the following reasons:
a. employment or membership ends;
b. eligibility ends (except for age for the Employee or Covered Spouse);
the Covered Person may have Us issue converted accident insurance on an individual policy or an individual certificate
under a designated group policy. The Covered Person may apply for an amount of coverage that is:
a. in $1,000 increments;
b. not less than $25,000, regardless of the amount of insurance under the group policy; and
c. not more than the amount of insurance he had under the group policy, except as provided above, up to a maximum
amount of $250,000.
The Covered Person must be under age 70 to get a converted policy.
If the Covered Person's insurance or any portion of it ends for non-payment of premium, he may not convert. If the
Covered Person's insurance ends for a reason described in 2. below, conversion is subject to that section.
The converted policy or certificate will cover accidental death and dismemberment. The policy or certificate will not
contain disability or other additional benefits. The Covered Person need not show Us that he is insurable.
If the Covered Person has converted his group coverage and later becomes insured under the same group plan as
before, he may not convert a second time unless he provides, at his own expense, proof of insurability or proof the
prior converted policy is no longer in force.
The Covered Person must apply for the individual policy within 31 days after his coverage under this Group Policy
ends and pay the required premium, based on Our table of rates for such policies, his Age and class of risk. If the
Covered Person has assigned ownership of his group coverage, the owner/assignee must apply for the individual
policy.
If the Covered Person suffers a Covered Loss or dies during this 31 -day period as the result of an accident that would
have been covered under this Group Policy, We will pay as a claim under this Group Policy the amount of insurance
that the Covered Person was entitled to convert. It does not matter whether the Covered Person applied for the
individual policy or certificate. If such policy or certificate is issued, it will be in exchange for any other benefits under
this Group Policy.
The individual policy or certificate will take effect on the day following the date coverage under the Group Policy
ended; or, if later, the date application is made.
Exclusions
The converted policy may exclude the hazards or conditions that apply to the Covered Person's group coverage at the
time it ends. We will reduce payment under the converted policy by the amount of any benefits paid under the group
policy if both cover the same loss.
2. If the Covered Person's insurance ends because this Group Policy is terminated or is amended to terminate insurance
for the Covered Person's class, and he has been covered under this Group Policy or, any group accident insurance
issued to the Employer which the Group Policy replaced, for at least five years, the Covered Person may have Us issue
an individual policy or certificate of accident insurance subject to the same terms, conditions and limitations listed
above. However, the amount he may apply for will be limited to the lesser of the following:
a. coverage under this Group Policy less any amount of group accident insurance for which he is eligible on the date
this Group Policy is terminated or for which he became eligible within 31 days of such termination, or
b. $10,000.
14
Extension of Conversion Period
If the Covered Person is eligible to convert 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 Covered Person will have 15 days from the date notice is
given to apply for a converted policy or certificate. 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 Covered Person by the Subscriber or mailed to
the Covered Person's last known address as reported by the Subscriber.
If the Covered Person sustains a Covered Loss or dies during the extended conversion period, but more than 31 days after
his coverage under the Group Policy terminates, benefits will not be paid under the Group Policy. If the Covered Person's
application for a converted policy or certificate is received by Us and the required premium is paid, benefits may be payable
under the converted policy or certificate.
GA -01-1505.00
15
CLAIM PROVISIONS
Notice of Claim
Written or authorized electronic/telephonic notice of claim must be given to Us within 31 days after a Covered Loss occurs
or begins or as soon as reasonably possible. If written or authorized electronic/telephonic notice is not given in that time,
the claim will not be invalidated or reduced if it is shown that written or authorized electronic/telephonic notice was given
as soon as was reasonably possible. Notice can be given to Us at Our Home Office in Philadelphia, Pennsylvania, such
other place as We may designate for the purpose, or to Our authorized agent. Notice should include the Subscriber's name
and policy number and the Covered Person's name, address, policy and certificate number.
Claim Forms
We will send claim forms for filing proof of loss when We receive notice of a claim. If such forms are not sent within 15
days after We receive notice, the proof requirements will be met by submitting, within the time fixed in this Policy for
filing proof of loss, written or authorized electronic proof of the nature and extent of the loss for which the claim is made.
Claimant Cooperation Provision
Failure of a claimant to cooperate with Us 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.
Proof of Loss
Written or authorized electronic proof of loss satisfactory to Us must be given to Us at Our office, within 90 days of the
loss for which claim is made. If (a) benefits are payable as periodic payments and (b) each payment is contingent upon
continuing loss, then proof of loss must be submitted within 90 days after the termination of each period for which We are
liable. If written or authorized electronic notice is not given within that time, no claim will be invalidated or reduced if it is
shown that such notice was given as soon as reasonably possible. In any case, written or authorized electronic proof must
be given not more than one year after the time it is otherwise required, except if proof is not given solely due to the lack of
legal capacity.
Time of Payment of Claims
We will pay benefits due under this Policy for any loss other than a loss for which this Policy provides any periodic
payment immediately upon receipt of due written or authorized electronic proof of such loss. Subject to due written or
authorized electronic proof of loss, all accrued benefits for loss for which this Policy provides periodic payment will be
paid monthly unless otherwise specified in the benefits descriptions and any balance remaining unpaid at the termination of
liability will be paid immediately upon receipt of proof satisfactory to Us.
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.
Payment of Claims
All benefits will be paid in United States currency. Benefits for loss of life will be payable in accordance with the
Beneficiary provision and these Claim Provisions. All other proceeds payable under this Policy, unless otherwise stated,
will be payable to the covered Employee or to his estate.
If We are to pay benefits to the estate or to a person who is incapable of giving a valid release, We may pay $1,000 to a
relative by blood or marriage whom We believe is equitably entitled. Any payment made by Us in good faith pursuant to
this provision will fully discharge Us to the extent of such payment and release Us from all liability.
16
Payment of Claims to Foreign Employees
The Subscriber may, in a fiduciary capacity, receive and hold any benefits payable to covered Employees whose place of
employment is other than the United States of America.
We will not be responsible for the application or disposition by the Subscriber of any such benefits paid. Our payments to
the Subscriber will constitute a full discharge of Our liability for those payments under this Policy.
Physical Examination and Autopsy
We, at Our own expense, have the right and opportunity to examine the Covered Person when and as often as We may
reasonably require while a claim is pending and to make an autopsy in case of death where it is not forbidden by law.
Legal Actions
No action at law or in equity may be brought to recover under this Policy less than 60 days after written or authorized
electronic proof of loss has been furnished as required by this Policy. No such action will be brought more than three years
after the time such written proof of loss must be furnished.
Beneficiary
The beneficiary is the person or persons the Employee names or changes on a form executed by him and satisfactory to Us.
This form may be in writing or by any electronic means agreed upon between Us and the Subscriber. Consent of the
beneficiary is not required to affect any changes, unless the beneficiary has been designated as an irrevocable beneficiary,
or to make any assignment of rights or benefits permitted by this Policy. Any Accidental Death Benefit payable at the death
of the Employee's Spouse or Dependent Child will be paid to the Employee or to his estate.
A beneficiary designation or change will become effective on the date the Employee executes it. However, We will not be
liable for any action taken or payment made before We record notice of the change at our Home Office.
If more than one person is named as beneficiary, the interests of each will be equal unless the Employee has specified
otherwise. The share of any beneficiary who does not survive the Covered Person will pass equally to any surviving
beneficiaries unless otherwise specified.
If there is no named beneficiary or surviving beneficiary, or if the Employee dies while benefits are payable to him, We
may make direct payment to the first surviving class of the following classes of persons:
1. spouse;
2. child or children;
3. mother or father;
4. sisters or brothers;
5. estate of the Covered Person.
Recovery of Overpayment
If benefits are overpaid, We have the right to recover the amount overpaid by either of the following methods.
1. A request for lump sum payment of the overpaid amount.
2. A reduction of any amounts payable under this Policy.
If there is an overpayment due when the Covered Person dies, Us may recover the overpayment from the Covered Person's
estate.
GA -00-1600.00 as modified by RA -GA -1000.00
17
ADMINISTRATIVE PROVISIONS
Premiums
All premium rates are expressed in, and all premiums are payable in, United States currency. The premiums for this Policy
will be based on the rates set forth in the Schedule of Benefits, the plan and amounts of insurance in effect. If a Covered
Person's insurance amounts are reduced due to age, premium will be based on the amounts of insurance in force on the day
after the reduction took place.
Changes in Premium Rates
We may change the premium rates from time to time with at least 31 days advance written notice to the Subscriber. 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, We reserve the right to change rates at any time if any of the following
events take place:
1. the terms of this Policy change;
2. the terms of the Subscriber's participation change;
3. a division, subsidiary, affiliated company or eligible class is added or deleted from this Policy;
4. there is a change in the factors bearing on the risk assumed;
5. any federal or state law or regulation is amended to the extent it affects Our benefit obligation.
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.
Payment of Premium
The first premium is due on the Subscriber's effective date of participation under this Policy. Thereafter, premiums are due
on the Premium Due Dates agreed upon between Us and the Subscriber. If any premium is not paid when due, the
Subscriber's participation under this Policy will be terminated as of the Premium Due Date on which premium was not paid.
Grace Period
A Grace Period of 31 days will be granted to each Subscriber for payment of required premiums under this Policy. A
Subscriber's participation under this Policy will remain in effect during the Grace Period. The Subscriber is liable to Us for
any unpaid premium for the time its participation under this Policy was in force.
A Grace Period of 31 days will be granted for payment of required premiums under this Policy. A Covered Person's
insurance under this Policy will remain in force during the Grace Period. We will reduce any benefits payable for any
claims incurred during the grace period by the amount of premium due. If no such claims are incurred and premium is not
paid during the grace period, insurance will end on the last day of the period for which premiums were paid.
GA -00-1701.00 as modified by IZA-GA-1000.00
18
GENERAL PROVISIONS
Entire Contract; Changes
This Policy, including the endorsements, amendments and any attached papers constitutes the entire contract of insurance.
No change in this Policy will be valid until approved by one of Our executive officers and endorsed on or attached to this
Policy. No agent has authority to change this Policy or to waive any of its provisions.
Subscriber Participation Under This Policy
An organization may elect to participate under this Policy by submitting a signed Subscriber participation agreement to the
Policyholder. No participation by an organization is in effect until approved by Us.
Misstatement of Fact
If the Covered Person has misstated any fact, all amounts payable under this Policy will be such as the premium paid would
have purchased had such fact been correctly stated.
Certificates
Where required by law, We will provide a certificate of insurance for delivery to the Covered Person. Each certificate will
list the benefits, conditions and limits of this Policy. It will state to whom benefits will be paid.
30 Day Right To Examine Certificate
If a Covered Person does not like the Certificate for any reason, it may be returned to Us within 30 days after receipt. We
will return any premium that has been paid and the Certificate will be void as if it had never been issued.
Multiple Certificates
The Covered Person may have in force only one certificate at a time under this Policy. If at any time the Covered Person
has been issued more than one certificate, then only the largest shall be in effect. We will refund premiums paid for the
others for any period of time that more than one certificate was issued.
Assignment
We will be bound by an assignment of a Covered Person's insurance under this Policy only when the original assignment or
a certified copy of the assignment, signed by the Covered Person and any irrevocable beneficiary, is filed with Us. The
assignee may exercise all rights and receive all benefits assigned only while the assignment remains in effect and insurance
under this Policy and the Covered Person's certificate remains in force.
Incontestability
1. Of This Policy or Participation Under This Policy
All statements made by the Subscriber to obtain this Policy or to participate under this Policy are considered representations
and not warranties. No statement will be used to deny or reduce benefits or be used as a defense to a claim, or to deny the
validity of this Policy or of participation under this Policy unless a copy of the instrument containing the statement is, or
has been, furnished to the Subscriber.
After two years from the Policy Effective Date, no such statement will cause this Policy to be contested except for fraud.
2. Of A Covered Person's Insurance
All statements made by a Covered Person are considered representations and not warranties. No statement will be used to
deny or reduce benefits or be used as a defense to a claim, unless a copy of the instrument containing the statement is, or
has been, furnished to the claimant.
After two years from the Covered Person's effective date of insurance, or from the effective date of increased benefits, no
such statement will cause insurance or the increased benefits to be contested except for fraud or lack of eligibility for
insurance.
In the event of death or incapacity, the beneficiary or representative shall be given a copy.
19
Policy Termination
We may terminate coverage on or after the first anniversary of the policy effective date. The Subscriber may terminate
coverage on any premium due date. Written or authorized electronic notice must be given at least 31 days prior to such
premium due date.
Termination will not affect a claim for a Covered Loss that is the result, directly and independently of all other causes, of a
Covered Accident that occurs while coverage was in effect.
Reinstatement
This Policy may be reinstated if it lapsed for nonpayment of premium. Requirements for reinstatement are written
application of the Subscriber satisfactory to Us and payment of all overdue premiums. Any premium accepted in
connection with a reinstatement will be applied to a period for which premium was not previously paid.
Clerical Error
A Covered Person's insurance will not be affected by error or delay in keeping records of insurance under this Policy. If
such error or delay is found, We will adjust the premium fairly.
Conformity with Statutes
Any provisions in conflict with the requirements of any state or federal law that apply to this Policy are automatically
changed to satisfy the minimum requirements of such laws.
Policy Changes
We may agree with the Subscriber to modify a plan of benefits without the Covered Person's consent.
Workers' Compensation Insurance
This Policy is not in place of and does not affect any requirements for coverage under any Workers' Compensation law.
Examination of the Policy
This Group Policy will be available for inspection at the Subscriber's office during regular business hours.
Examination of Records
We will be permitted to examine all of the Subscriber's records relating to this Group Policy. Examination may occur at
any reasonable time while the Group Policy is in force; or it may occur:
1. at any time for two years after the expiration of this Group Policy; or, if later,
2. upon the final adjustment and settlement of all Group Policy claims.
The Subscriber is acting as an agent of the Covered Person for transactions relating to this insurance. The actions of the
Subscriber will not be considered Our actions.
Ownership of Records
All records maintained by the Insurance Company are, and shall remain, the property of the Insurance Company.
GA -00-1800.00
20
DESCRIPTION OF COVERAGES AND BENEFITS
This Description of Coverages and Benefits Section describes the Accident Coverages and Benefits provided by this
Policy. Benefit amounts, benefit periods and any applicable aggregate and benefit maximums are shown in the
Schedule of Benefits. Certain words capitalized in the text of these descriptions have special meanings within this
Policy and are defined in the General Definitions section. Please read these and the Common Exclusions sections in
order to understand all of the terms, conditions and limitations applicable to these coverages and benefits.
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Covered Loss
We will pay the benefit for any one of the Covered Losses listed in the Schedule of Benefits, if
the Covered Person suffers a Covered Loss resulting directly and independently of all other
causes from a Covered Accident within the applicable time period specified in the Schedule of
Benefits.
If the Covered Person sustains more than one Covered Loss as a result of the same Covered
Accident, benefits will be paid for the Covered Loss for which the largest available benefit is
payable. If the loss results in death, benefits will only be paid under the Loss of Life benefit
provision. Any Loss of Life benefit will be reduced by any paid or payable Accidental
Dismemberment benefit. However, if such Accidental Dismemberment benefit equals or
exceeds the Loss of Life benefit, no additional benefit will be paid.
Definitions Loss of a Hand or Foot means complete Severance through or above the wrist or ankle
joint.
Loss of Sight means the total, permanent loss of all vision in one eye which is
irrecoverable by natural, surgical or artificial means.
Loss of Speech means total and permanent loss of audible communication which is
irrecoverable by natural, surgical or artificial means.
Loss of Hearing means total and permanent loss of ability to hear any sound in both
ears which is irrecoverable by natural, surgical or artificial means.
Loss of a Thumb and Index Finger of the Same Hand or Four Fingers of the Same
Hand means complete Severance through or above the metacarpophalangeal joints of
the same hand (the joints between the fingers and the hand).
Loss of Toes means complete Severance through the metatarsalphalangeal joint.
Paralysis or Paralyzed means total loss of use of a limb. A Physician must determine
the loss of use to be complete and irreversible.
Quadriplegia means total Paralysis of both upper and both lower limbs.
Hemiplegia means total Paralysis of the upper and lower limbs on one side of the body.
Paraplegia means total Paralysis of both lower limbs or both upper limbs.
Uniplegia means total Paralysis of one upper or one lower limb.
21
Coma means a profound state of unconsciousness which resulted directly and
independently from all other causes from a Covered Accident, and from which the
Covered Person is not likely to be aroused through powerful stimulation. This
condition must be diagnosed and treated regularly by a Physician. Coma does not mean
any state of unconsciousness intentionally induced during the course of treatment of a
Covered Injury unless the state of unconsciousness results from the administration of
anesthesia in preparation for surgical treatment of that Covered Accident.
Severance means the complete and permanent separation and dismemberment of the
part from the body.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions section.
GA -00-2100.00
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES
Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under
them are shown in the Schedule of Covered Losses and will not be paid in addition to any other Accidental Death and
Dismemberment benefits payable.
EXPOSURE AND DISAPPEARANCE COVERAGE
Benefits for Accidental Death and Dismemberment, as shown in the Schedule of Covered Losses, will be payable if a
Covered Person suffers a Covered Loss which results directly and independently of all other causes from unavoidable
exposure to the elements following a Covered Accident.
If the Covered Person disappears and is not found within one year from the date of the wrecking, sinking or disappearance
of the conveyance in which the Covered Person was riding in the course of a trip which would otherwise be covered under
this Policy, it will be presumed that the Covered Person's death resulted directly and independently of all other causes from
a Covered Accident.
Exclusions The exclusions that apply to this coverage are in the Common Exclusions Section.
GA -00-2202.00
ADDITIONAL ACCIDENT BENEFITS
Accidental Death and Dismemberment benefits are provided under the following Additional Benefits. Any benefits
payable under them will be paid in addition to any other Accidental Death and Dismemberment benefit payable.
BEREAVEMENT AND TRAUMA COUNSELING BENEFIT
We will pay counseling sessions, up to the Maximum Benefit Amount shown in the Schedule of Benefits and subject to the
following conditions and exclusions, when the Covered Person or Immediate Family Member requires bereavement and
trauma counseling because the Covered Person suffered a Covered Loss that resulted directly and independently of all other
causes from a Covered Accident. Such counseling must meet all of the following conditions:
1. covered bereavement and trauma counseling expenses must be incurred within one year from the date of the
Covered Accident causing the Covered Loss;
2. the expense is charged for a bereavement or trauma counseling session for the Covered Person or one or more of
his Immediate Family Members;
3. counseling is provided under the care, supervision or order of a Physician;
4. a charge would have been made if no insurance existed.
22
Definitions For purposes of this benefit:
Immediate Family Member means a person who is related to the Covered Person in any of the
following ways: Spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-
law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or
stepsister) or child (includes legally adopted child or stepchild).
Exclusions Covered bereavement and trauma counseling benefits do not include any expense for which the Covered
Person is entitled to benefits under any Workers' Compensation Act or similar law.
Other exclusions that apply to this benefit are in the Common Exclusions Section.
GA -00-2214.00
BUSINESS TRAVEL BENEFIT
We will pay the benefit shown in the Schedule of Benefits, subject to the following conditions and exclusions, if the covered
Employee suffers a Covered Loss resulting directly and independently of all other causes from a Covered Accident that
occurs during a business trip authorized in advance by the Employer. The Covered Loss must be sustained:
1. in the course of the covered Employee's job;
2. away from the premises of the Employer in the covered Employee's city of permanent assignment.
Coverage will begin at the actual start of a business trip authorized by the Employer. It does not matter if the trip starts at
the covered Employee's home, place of work, or any other place. Coverage will end when the covered Employee arrives at
his home or place of work, whichever happens first.
Definitions For purposes of this benefit:
Personal Deviation means an activity that meets all of the following conditions:
1. is not reasonably related to the Subscriber's business trip;
2. is not incidental to the Subscriber's business;
3. occurs prior to the end of the trip.
A Personal Deviation does not include extension of a business trip authorized in advance by the
Subscriber as necessary to reduce transportation costs.
Exclusions Coverage for business travel is not provided during any of the following:
1. normal commuting between the covered Employee's home and place of work;
2. travel in an Aircraft owned, leased, operated or controlled by the Employer;
3. travel to another location where the Employee is expected to be assigned for more than
60 days by the Employer;
4. a covered Employee's Personal Deviation.
Other exclusions that apply to this benefit are in the Common Exclusions Section.
GA -00-2220.00
23
SEATBELT AND AIRBAG BENEFIT
We will pay the benefit shown in the Schedule of Benefits, subject to the conditions and exclusions described below, when
the Covered Person dies directly and independently of all other causes from a Covered Accident while wearing a seatbelt
and operating or riding as a passenger in an Automobile. An additional benefit is provided if the Covered Person was also
positioned in a seat protected by a properly -functioning and properly deployed Supplemental Restraint System (Airbag).
Verification of proper use of the seatbelt at the time of the Covered Accident and that the Supplemental Restraint System
properly inflated upon impact must be a part of an official police report of the Covered Accident or be certified, in writing,
by the investigating officer(s) and submitted with the Covered Person's claim to Us.
If such certification or police report is not available or it is unclear whether the Covered Person was wearing a seatbelt or
positioned in a seat protected by a properly functioning and properly deployed Supplemental Restraint System, We will pay
a default benefit shown in the Schedule of Benefits to the Covered Person's beneficiary.
In the case of a child, seatbelt means a child restraint, as required by state law and approved by the National Highway
Traffic Safety Administration, properly secured and being used as recommended by its manufacturer for children of like
Age and weight at the time of the Covered Accident.
Definitions For purposes of this benefit:
Supplemental Restraint System means an airbag that inflates upon impact for added protection to the
head and chest areas.
Automobile means a self-propelled, private passenger motor vehicle with four or more wheels which is a
type both designed and required to be licensed for use on the highway of any state, province or country.
Automobile includes, but is not limited to, a sedan, station wagon, sport utility vehicle, or a motor vehicle
of the pickup, van, camper, or motor -home type. Automobile does not include a mobile home or any
motor vehicle which is used in mass or public transit.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section.
GA -00-2251.00
24
SPECIAL EDUCATION BENEFIT
We will pay the benefit, up to the Maximum Benefit shown in the Schedule of Benefits, for each qualifying Dependent
Child. The Covered Person's death must result, directly and independently of all other causes from a Covered Accident for
which an Accidental Death Benefit is payable under this Policy. This benefit is subject to the conditions and exclusions
described below.
A qualifying Dependent Child must:
1. a. be enrolled as a full-time student in an accredited school of higher learning beyond the 12th grade level on the date
of the covered Employee's Covered Accident; or
b. be at the 12th grade level on the date of the covered Employee's Covered Accident and then enroll as a full-time
student at an accredited school of higher learning within 365 days from the date of the Covered Accident and
continue his education as a full-time student.
2. continue his education as a full-time student in such accredited school of higher learning; and
3. incur expenses for tuition, fees, books, room and board, transportation and any other costs payable directly to, or
approved and certified by, such school.
Payments will be made to each qualifying Dependent Child or to the child's legal guardian, if the child is a minor at the end
of each year for the number of years shown in the Schedule of Benefits. We must receive proof satisfactory to Us of the
Dependent Child's enrollment and attendance within 31 days of the end of each year. The first year for which a Special
Education Benefit is payable will begin on the first of the month following the date the covered Employee died, if the
surviving Dependent Child was enrolled on that date in an accredited school of higher learning beyond the 12th grade;
otherwise on the date he enrolls in such school. Each succeeding year for which benefits are payable will begin on the date
following the end of the preceding year.
If no Dependent Child qualifies for Special Education Benefits within 365 days of the covered Employee's death, We will
pay the default benefit shown in the Schedule of Benefits to the covered Employee's beneficiary.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section.
GA -00-2252a.00
SPOUSE RETRAINING BENEFIT
We will pay expenses incurred, as described below, up to the Maximum Benefit shown in the Schedule of Benefits, to
enable the covered Employee's Spouse to obtain occupational or educational training needed for employment if the covered
Employee dies directly and independently of all other causes from a Covered Accident. This benefit is subject to the
conditions and exclusions described below.
This benefit will be payable if the covered Employee dies within one year of a Covered Accident and is survived by his
Spouse who:
1. enrolls, within three years after the covered Employee's death in any accredited school for the purpose of
retraining or refreshing skills needed for employment; and
2. incurs expenses payable directly to, or approved and certified by, such school.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section.
GA -00-2254a.00
25
AMENDATORY RIDER
DOMESTIC PARTNER/CIVIL UNION PARTNER COVERAGE
Subscriber: Weld County Government
Policy No.: OK 969517 Effective Date: January 1, 2018
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 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 the Domestic Partner/Civil Union Partner marries another person.
2. A person who was legally married to the Employee under the laws of a state permitting marriage of partners of the
same sex, where the 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 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:
a. Shares a permanent residence with the Employee;
b. Has resided with the Employee for at least 6 months and is expected to continue to reside with the 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 during the previous six months, and is the Employee's sole Domestic Partner;
d. Has signed a Domestic Partner declaration with the Employee, if the 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 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 has named the Domestic Partner as attorney -in -fact under a durable power of attorney with
authority over health care decisions.
6. The Employee has designated the Domestic Partner as beneficiary under a retirement plan or a life insurance
policy.
7. The Employee has designated the Domestic Partner as beneficiary of the Employee's will.
8. Each partner has agreed in writing to assume the financial responsibility for the welfare of the other.
g•
h.
Is not so closely related by blood to the Employee as to prohibit legal marriage in their state of residence;
Is no less than 18 years of age.
The 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.
26
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, 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 and Domestic Partner/Civil Union 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/Civil Union Partner are met.
3. A Domestic Partner/Civil Union Partner shall be deemed eligible to be enrolled for insurance or eligible for Additional
Benefits 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 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 or eligible for Additional Benefits
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 is changed
by the following:
In the case of any person of the same sex as the Employee, the exclusion of persons legally able to marry will not apply for
the first 12 months that the 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
01),dirt •14 470)--Lia,
Matthew G. Manders, President
TL -007153
27
LIFE INSURANCE COMPANY OF NORTH AMERICA
AMENDATORY RIDER
TRAVEL ASSISTANCE SERVICES
Policyholder: Weld County Government
Policy No.: OK 969517 Effective Date: January 1, 2018
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.
Travel Assistance Services
We will pay the cost of the Covered Services described below, subject to all applicable conditions and exclusions, resulting,
directly and independently of all other causes, from a Covered Medical Emergency. The Covered Medical Emergency
must occur and Covered Services must be incurred during the course of travel or other activities covered by the Policy, and
while the Covered Person is either more than 100 miles from his permanent residence or outside of his country of
permanent residence.
To obtain services, the Covered Person must contact Us or our authorized service provider at the phone number provided
by the Policyholder. All services must be provided by our authorized service provider unless authorized by Us.
Covered Services
Covered Services includes the reasonable costs for medically necessary services provided by Us or by our authorized
service provider, and which are provided by our authorized service provider unless authorized by Us, for any of the
following.
Emergency Medical Evacuation
Medically necessary expenses for Transportation of the Covered Person to the nearest adequate medical facility, if adequate
medical care is not available at the Covered Person's location.
Cost of any medically necessary services or equipment that the Covered Person receives during transportation covered
under this provision.
Cost of transporting qualified and licensed medical professional(s) or an Immediate Family Member or a Travel
Companion if medically required to escort the Covered Person during transportation covered under this provision.
Transportation will be provided by medically equipped specialty aircraft, commercial airline, train or ambulance depending
upon the medical needs and available transportation specific to each case.
Return Transportation
Any increase in the cost of the Covered Person's return transportation to his or her home or work location following
emergency medical evacuation covered under this benefit, above the cost of the Covered Person's original scheduled return
transportation.
Any increased cost of the transportation for an Immediate Family Member or Travel Companion of the Covered Person to
return to his or her primary residence, if he or she accompanied the Covered Person on the trip where the emergency
occurred, and was as a result not able to return to his or her primary residence when originally scheduled.
Unless it is medically necessary for another means of transportation to be provided, such return transportation costs will be
covered for the same class of travel as the Covered Person's original transportation.
28
In the case of an Immediate Family Members who is a child under age 18, who is left without a parent, guardian or other
adult to accompany the child, we will cover the reasonable cost of an escort to accompany the child to the nearest airport.
If under the applicable rules of the airline, the child is too young to travel unaccompanied by an adult, we will pay the
round trip economy airfare for an adult family member from the child's place of residence to the airport nearest the child.
Immediate Family Member Visit
Expenses for an Immediate Family Member or Friend of the Covered Person to visit the Covered Person during
hospitalization away from the Covered Person's primary residence, if the Covered Person is hospitalized or expected to
remain hospitalized for 7 or more consecutive days following emergency medical evacuation covered under this benefit.
Such expenses shall be limited to one person only, and shall include round-trip economy airfare, and an allowance of
$150.00 per day for up to 7 days for meals and lodging.
If a Dependent Child is evacuated, we will pay the expenses of an adult Immediate Family Member who accompanied the
Dependent Child on the trip where the emergency occurred, to accompany the Dependent Child during the evacuation and
during the Dependent Child's return to his or her place of residence. If the Dependent Child was not accompanied by an
adult Immediate Family Member on the trip where the emergency occurred, we will pay expenses described in the
preceding paragraph, without regard to the expected duration on the hospitalization.
Repatriation of Remains
If the Covered Person dies as a result of a Covered Medical Emergency, or during a Medical Evacuation covered by this
Policy, the following expenses will be covered:
1. Embalming;
2. Cremation in the locality where death occurred and urn for return ashes;
3. A container appropriate for transportation of remains;
4. Autopsy if required by law;
5. Expenses of securing documentation necessary for return of remains;
6. Transportation of the body or remains to the Covered Person's place of permanent residence.
Definitions
"Covered Medical Emergency" means an injury, illness or disease diagnosed by a Physician which causes severe or acute
symptoms that, if not provided with immediate care or treatment, would reasonably be expected to result in serious
deterioration of the Covered Person's health or place his life in jeopardy; and which first manifests itself suddenly and
unexpectedly during the travel or other hazards covered by the Policy.
"Immediate Family Member" means a spouse, parent, child, step-parent, step -child, brother or sister, step -brother or step-
sister, grandparent, or Domestic Partner.
"Travel Companion" means an individual, other than an Immediate Family Member, who accompanied the Covered Person
on the trip where the emergency occurred.
"Friend" means a person chosen by the Covered Person, other than an Immediate Family Member who is able to visit the
Covered Person.
Limitations
Covered Expenses are secondary to, and in excess of, any expenses for medical or transportation services paid or payable
under any workers' compensation law.
No payment will be made for services without authorization of those services by Us or the express written approval of Our
approved vendor.
If coverage for these services is provided under more than one policy issued by the Insurance Company, we will only
provide or pay for these services under one such policy.
29
Exclusions
The exclusions listed in the Policy's Common Exclusions section will not apply to Medical Evacuation and Repatriation
Expenses, except for exclusions relating to war or acts of war, suicide or intentionally self-inflicted injury. In addition, the
following exclusions apply specifically to this coverage:
1. Non -Emergency, routine or minor medical problems, tests and exams where there is no clear or significant risk of
death or imminent serious Injury or harm to the Covered Person;
2. a condition which would allow for treatment at a future date convenient to the Covered Person and which does not
require Emergency evacuation or repatriation;
3. expenses incurred if a purpose of the Covered Person's trip is to obtain medical treatment;
4. services provided for which no charge is normally made, in the absence of insurance;
5. transportation for the Covered Person's vehicle and/or other personal belongings;
6. Initial transport by ambulance following a Covered Medical Emergency occurring in the United States;
7. services incurred while serving in the armed forces of any country;
8. services required or obtained in any location which, due to war, insurrection, natural disaster or other reasons, is not
reasonably accessible to our designated service provider, unless approved in advance by us;
9. claim payments that are illegal under applicable law;
10. expenses which are paid or payable under any workers' compensation law;
11. Medical care or services scheduled for your or your doctor's convenience which are not considered an emergency.
Except for the above this rider does not change the Policy or Certificate to which it is attached.
LIFE INSURANCE COMPANY OF NORTH AMERICA
/1...z,,
Matthew G. Manders, President
GA -00-2230c.00
30
Life Insurance Company of North America
1601 Chestnut Street
Philadelphia, Pennsylvania 19192-2235
MODIFYING PROVISIONS AMENDMENT
Subscriber: Weld County Government Policy No.: OK 969517
Amendment Effective Date: January 1, 2018
This amendment is attached to and made part of the Policy specified above and the Certificates issued under it. Its
provisions are intended to conform this Policy to the laws of the state in which the insured resides.
The Policy and any Certificates delivered under the Group Policy are amended as follows:
Arkansas residents:
1. Under the General Definitions section, the definition of Covered Accident does not include reference to an
"external" event.
2. Under the General Definitions section, item 2 of the second paragraph of the definition of Dependent Child is
replaced with the following:
2. adopted child, or a child under the charge, care or control of the Employee, Member for whom the Employee,
Member has filed a petition to adopt.
Connecticut residents:
1. The following benefit is added to the Schedule of Benefits section:
AMBULANCE BENEFIT
Basic Benefit Equal to the lesser of billed charges or rate established by the CT
Dept. of Public Health
2. In the General Definitions section the definition of Hospital and Totally Disabled are replaced with the following:
Hospital
An institution that meets all of the following:
1. it is licensed as a Hospital pursuant to applicable law;
2. it is primarily and continuously engaged in providing medical care and treatment to
sick and injured persons;
3. it is managed under the supervision of a staff of medical doctors;
4. it provides 24 -hour nursing services by or under the supervision of a graduate
registered nurse (R.N.);
5. it has medical, diagnostic and treatment facilities, with major surgical facilities on
its premises, or available on a prearranged basis;
6. it charges for its services.
31
Hospital shall include a Veteran's Administration Hospital or Federal Government
Hospital and the requirement that a patient must incur an expense as an Inpatient shall
be waived.
The term Hospital does not include a clinic, facility, or unit of a Hospital for:
1. rehabilitation, convalescent, custodial, educational or nursing care;
2. the aged, drug addicts or alcoholics;
3. a Veteran's Administration Hospital or Federal Government Hospital unless the
Covered Person incurs an expense.
Totally Disabled or
Total Disability
Totally Disabled or Total Disability means either:
1. inability of the Covered Person who is currently employed to do any type of work
for which he is or may become qualified by reason of education, training or
experience; or
2. inability of the Covered Person who is not currently employed to perform the
normal activities of a person of like age and sex and who is under the regular care
of a Physician who certifies that such person is Totally Disabled.
3. In the Eligibility and Effective Date Provisions, the Eligibility section is replaced with the following:
Eligibility
An Employee becomes eligible for insurance under this Policy on the date he meets all of the requirements of one
of the Covered Classes and completes any Eligibility Waiting Period, as shown in the Schedule of Benefits. A
Spouse and Dependent Children of an eligible Employee become eligible for any dependent insurance provided by
this Policy on the later of the date the Employee becomes eligible and the date the Spouse or Dependent Child
meets the applicable definition shown in the Definitions section of this Policy. No person may be eligible for
insurance under this Policy as both an Employee and a Spouse or Dependent Child at the same time. However,
this limitation will not apply when the Employee and the Spouse are employed by the same Employer and by
reason to their employment are both participating in a group insurance plan.
4. In the General Provisions section, the following provision is replaced:
Incontestability
1. Of This Policy or Participation Under This Policy
All statements made by the Subscriber to participate under this Policy are considered representations and not
warranties. No statement will be used to deny or reduce benefits or be used as a defense to a claim, or to deny the
validity of this Policy or of participation under this Policy unless a copy of the instrument containing the statement
is, or has been, furnished to the Subscriber.
After two years from the Policy Effective Date, no such statement will cause this Policy to be contested.
2. Of A Covered Person's Insurance
All statements made by a Covered Person are considered representations and not warranties. No statement will be
used to deny or reduce benefits or be used as a defense to a claim, unless a copy of the instrument containing the
statement is, or has been, furnished to the claimant.
After two years from the Covered Person's effective date of insurance, or from the effective date of increased
benefits, no such statement will cause insurance or the increased benefits to be contested except for lack of
eligibility for insurance.
In the event of death or incapacity, the beneficiary or representative shall be given a copy.
32
5. The following benefit is added to the Description of Benefits section:
AMBULANCE BENEFIT
We will pay the benefit shown in the Schedule of Benefits, subject to the following conditions and exclusions, if
the Covered Person requires ambulance services due to a Covered Injury resulting directly and independently of
all other causes from a Covered Accident.
The Covered Person must be transported by ambulance to a Hospital and admitted as an inpatient Any payment
will be paid directly to the ambulance provider rendering such service if such provider has not received payment
for such service from any other source and includes the following statement on the face of each bill: "NOTICE:
This bill subject to mandatory assignment pursuant to Connecticut general statutes."
In the event any Covered Person is covered under more than one policy, the Hospital Policy will be primary and
pay benefits.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section.
GA -00-2212.07
6. The following Conversion Privilege section applies:
Conversion Privilege
1. If the Covered Person's insurance or any portion of it ends for a reason other than non-payment of premium,
the Covered Person's Age or those reasons described in Paragraph 2 below, the Covered Person may have Us
issue converted accident insurance on an individual policy or an individual certificate under a designated
group policy. The Covered Person may not apply for an amount greater than his coverage under this Group
Policy less the amount of any other group accident insurance for which he becomes eligible within 31 days
after the date coverage under this Group Policy terminated. The policy or certificate will not contain
disability or other additional benefits. The Covered Person need not show Us that he is insurable.
The Covered Person must apply for the individual policy within 31 days after his coverage under this Group
Policy ends and pay the required premium, based on Our table of rates for such policies, his Age and class of
risk.
The individual policy or certificate will take effect on the day following the date coverage under the Group
Policy ended. If the Covered Person dies during this 31 -day period as the result of an accident that would
have been covered under this Group Policy, We will pay as a claim under this Group Policy the amount of
insurance that the Covered Person was entitled to convert. It does not matter whether the Covered Person
applied for the individual policy or certificate. If such policy or certificate is issued, it will be in exchange for
any other benefits under this Group Policy.
2. If the Covered Person's insurance ends because this Group Policy is terminated or is amended to terminate
insurance for the Covered Person's class, and he has been covered under this Group Policy for at least five
years, the Covered Person may have Us issue an individual policy or certificate of accident insurance subject
to the same terms, conditions and limitations listed above. However, the amount he may apply for will be
limited to the lesser of the following:
a. coverage under this Group Policy less any amount of group accident insurance for which he is eligible on
the date this Group Policy is terminated or for which he became eligible within 31 days of such
termination, or
b. $10,000.
33
District of Columbia residents:
Under the General Definitions section, item 4 of the second paragraph of the definition of Dependent Child is replaced
with the following:
4. minor grandchildren, nieces, or nephews under the Employee's primary care, and if the legal guardian of the
minor grandchild, niece, or nephew, if other than the Employee, is not covered by an accident or sickness
policy. Here "primary care" means that the Employee provides food, clothing, and shelter, on a regular and
continuous basis, for the minor grandchild, niece, or nephew during the time the District of Columbia public
schools are in regular session.
Georgia residents:
Under the General Definitions section, item 2 of the first paragraph of the definition of Dependent Child is replaced
with the following:
2. A child shall continue to be insured up to and including age 26 so long as the coverage of the Employee
continues in effect, the child remains a dependent of the insured parent or guardian, and the child, in each
calendar year since reaching age 19, has been enrolled for five calendar months or more as a full-time student
at a postsecondary institution of higher learning or, if not so enrolled, would have been eligible to be so
enrolled and was prevented from being so enrolled due to Sickness or Injury.
Louisiana residents:
1. Under the General Definitions section, the definition of Dependent Child is replaced with the following:
Dependent Child(ren) An Employee's unmarried child who meets the following requirements:
1. A child from live birth to 21 years old;
2. A child who is 21 or more years old but less than 26 years old, enrolled in a
school, including vocational, technical, vocation -technical, trade schools and
colleges, as a full-time student and primarily supported by the Employee;
3. A child who is 21 or more years old, primarily supported by the Employee and
incapable of self-sustaining employment by reason of mental physical
handicap.
A child, for purposes of this provision, includes an Employee's:
1. natural child;
2. adopted child, beginning with any waiting period pending finalization of the
child's adoption;
3. stepchild who resides with the Employee;
4. child for whom the Employee is legal guardian, as long as the child resides
with the Employee and depends on the Employee for financial support.
Financial support means that the Employee is eligible to claim the dependent
for purposes of Federal and State income tax returns.
5. unmarried grandchild who is under 21 years of age and who is in the legal
custody of and residing with the Employee.
2. In the Common Exclusions section, item 11 is replaced with the following:
11. voluntary ingestion of any narcotic drug, poison, gas or fumes, unless prescribed or taken under the direction
of a Physician and taken in accordance with the prescribed dosage;
34
3. In the Administrative Provisions section, the following provision is replaced as follows:
Changes in Premium Rates
We may change the premium rates from time to time with at least 31 days advance written notice to the
Subscriber. If the rate increase is twenty percent or more there will be 45 days written notice which may be
waived for groups covering one hundred or more persons, provided this is agreed to by Us and the Policyholder.
No change in rates will be made until 12 months after the Policy Effective Date. An increase in rates will not be
made more often than once in a 12 -month period. However, We reserve the right to change rates at any time if
any of the following events take place:
1. the terms of this Policy change;
2. the terms of the Subscriber's participation change;
3. a division, subsidiary, affiliated company or eligible class is added or deleted from this Policy;
4. there is a change in the factors bearing on the risk assumed;
5. any federal or state law or regulation is amended to the extent it affects Our benefit obligation.
4. In the General Provisions section, the following provisions are replaced:
Policy Termination
We may terminate coverage on or after the first anniversary of the policy effective date as of any premium due
date. Subscriber may terminate coverage on any premium due date. Written notice by certified mail must be
given at least 60 days prior to such premium due date. Failure by Subscriber to pay premiums when due or within
the grace period shall be deemed notice to Us to terminate coverage at the end of the period for which premium
was paid. Cancellation for nonpayment of premium or failure to meet the requirements for being a group will not
be subject to this 60 day requirement.
Termination will not affect a claim for a Covered Loss that is the result, directly and independently of all other
causes, of a Covered Accident that occurs while coverage was in effect.
Conformity with Statutes
Any provisions in conflict with the requirements of Louisiana or federal law that apply to this Policy are
automatically changed to satisfy the minimum requirements of such laws.
Massachusetts residents:
Under the Eligibility and Effective Date Provisions section, the following is added:
Continuation of Insurance after leaving the group
If a Covered Person leaves the group covered under the Policy, insurance for such Covered Person will be continued
until the earliest of the following dates:
1. 31 days from the date the Covered Person leaves the group;
2. the date the Covered Person becomes eligible for similar benefits.
Continuation of Insurance due to a Plant Closing or Partial Closing
If an Employee leaves the group due to termination of employment resulting from a Plant Closing or Partial Closing,
insurance for such Employee will be continued until the earliest of the following dates:
1. 90 days from the date of the Plant Closing or Partial Closing;
2. the date the Employee becomes eligible for similar benefits.
Definitions: For purposes of this provision:
Plant Closing means a permanent cessation or reduction of business at a facility which results or will result as
determined by the director in the permanent separation of at least 90% of the employees of said facility within a period
of six months prior to the date of certification or with such other period as the director shall prescribe, provided that
such period shall fall within the six month period prior to the date of certification.
Partial Closing means a permanent cessation of a major discrete portion of the business conducted at a facility which
results in the termination of a significant number of the employees of said facility and which affects workers and
communities in a manner similar to that of Plant Closings.
35
Missouri residents:
1. Under the General Definitions section, the definition of Covered Accident does not include reference to an
"external" event.
2. Under the General Definitions section, the definition of Totally Disabled or Total Disability means either:
a) the inability of the Covered Person who is currently employed to perform the material and substantial duties
of the Covered Person's occupation for a period of at least twelve months. After the initial benefit period, total
disability shall mean the Covered Person's inability to perform the material and substantial duties of any
occupation for which the Covered Person is qualified by education, training or experience; or
b) the inability of the Covered Person who is not currently employed to perform all of the activities of daily
living including eating, transferring, dressing, toileting, bathing, and continence, without human supervision
or assistance.
Montana residents:
Under the General Definitions section, the definition of Sickness is replaced with the following:
Sickness A physical or mental illness including pregnancy
New Hampshire residents:
1. Under the General Definitions section, the definition of Covered Accident does not include reference to an
"external" event.
2. If applicable, the definition of Emergency Room Treatment is replaced with the following:
Emergency Room Treatment Emergency medical services and care given in a Hospital as an out or
inpatient, for a sudden, unexpected onset of a medical condition that manifests
itself by symptoms of sufficient severity that in the absence of immediate
medical attention could be expected to result in any of the following:
1. serious jeopardy to the covered Employee's health;
2. serious impairment to bodily functions; or
3. serious dysfunction of any bodily organ or part.
3. The definition of Hospital is replaced with the following.
Hospital
An institution that meets all of the following:
1. it is operated pursuant to applicable law;
2. it is primarily and continuously engaged in providing medical care and
treatment to sick and injured persons;
3. it is managed under the supervision of a staff of medical doctors;
4. it provides 24 -hour nursing services by or under the supervision of a
graduate registered nurse (R.N.);
5. it has medical, diagnostic and treatment facilities, with major surgical
facilities on its premises, or available on a prearranged basis;
6. it charges for its services.
36
Hospital shall include a Veteran's Administration Hospital or Federal
Government Hospital and the requirement that a patient must incur an expense
as an Inpatient shall be waived.
The term Hospital does not include a clinic, facility, or unit of a Hospital for:
1. rehabilitation, convalescent, custodial, educational or nursing care;
2. the aged, drug addicts or alcoholics;
3. a Veteran's Administration Hospital or Federal Government Hospitals
unless the Covered Person incurs an expense.
South Carolina residents:
1. Under the General Definitions section, the definition of Covered Accident does not include reference to an
"external" event.
2. Under the Claim Provisions, the following changes are made.
a. The Claimant Cooperation Provision does not apply.
b. The provision titled Physical Examination and Autopsy is replaced with the following:
Physical Examination and Autopsy
We, at Our own expense, have the right and opportunity to examine the Covered Person when and as often as
We may reasonably require while a claim is pending. If an autopsy is performed, it will be in the State of
South Carolina and during the period of contestability unless prohibited by law.
c. The provision titled Legal Actions is replaced with the following:
Legal Actions
No action at law or in equity may be brought to recover under this Policy less than 60 days after written or
authorized electronic proof of loss has been furnished as required by this Policy. No such action will be
brought more than six years after the time such written proof of loss must be furnished.
3. Under the General Provisions, the following changes are made.
The Multiple Certificates provision does not apply.
South Dakota residents:
Under the Common Exclusions section, the following changes are not permitted:
1. the Covered Person being legally intoxicated as determined according to the laws of the jurisdiction in which
the Covered Accident occurred;
2. the Covered Person being Intoxicated. "Intoxicated" means having a blood alcohol level of .08 or higher;
3. the Covered Person operating a motorized vehicle while under the influence of alcohol or drugs as defined
according to the laws of the jurisdiction in which the Accident occurred;
4. voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction
of a Physician and taken in accordance with the prescribed dosage;
5. occupational injuries for which benefits are not paid under the Workers' Compensation Law or any similar
law;
6. operating any type of vehicle while under the influence of alcohol or any drug , narcotic or other intoxicant
including any prescribed drug for which the Covered Person has been provided a written warning against
operating a vehicle while taking it. Under the influence of alcohol, for purposes of this exclusion, means
intoxicated, as defined by the law of the state in which the Covered Accident occurred;
7. the Covered Person was driving a Private Passenger Automobile at the time of the Covered Accident that
resulted in the Covered Loss; and he was intoxicated, as that term is defined by the laws of the state in which
the Covered Accident occurred.
37
Texas residents:
Under the General Definitions section, the definition of Dependent Child is replaced with the following:
Dependent Child(ren) An Employee's unmarried child who meets the following requirements:
1. A child from live birth to 26 years old. The initial coverage period for
newborn children shall continue for a period of at least 31 days.
2. A child who is 26 or more years old, chiefly dependent on the Employee for
support and maintenance and incapable of self-sustaining employment by
reason of mental or physical disability.
A child, for purposes of this provision, includes an Employee's:
1. natural child;
2. adopted child, including a child for whom the Employee is a party to a suit to
seek the adoption of the child. It also means the adopted child of the
Employee's Spouse or Domestic Partner/Partner to a Civil Union provided the
child is living with, and is financially dependent upon the Employee;
3. grandchild of the Employee who is a dependent on the Employee for federal
income tax purposes at the time the application for coverage of such
grandchild is made;
4. child for whom the Employee is required to provide medical support under
court order;
5. stepchild who resides with the Employee and is financially dependent upon the
Employee;
6. child for whom the Employee is the court -appointed legal guardian, as long as
the child resides with the Employee and depends on the Employee for
financial support. Financial support means that the Employee is eligible to
claim the dependent for purposes of Federal and State income tax returns.
7. a child of the Employee's Domestic Partner /Partner to a Civil Union, provided
the child is living with, and is financially dependent upon the Employee;
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 unions. The language is as follows:
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.
38
West Virginia residents:
1. Under the General Definitions section, the definition of Covered Accident does not include reference to an
"external" event.
2. Under the General Definitions section, the definition of Hospital does not require that an institution be licensed as
a Hospital pursuant to applicable law, but does require that an institution operate pursuant to applicable law.
3. Under the General Definitions section, the definition of Totally Disabled or Total Disability is replaced with the
following:
Totally Disabled or Total Disability
Totally Disabled or Total Disability means either:
1. inability of the Covered Person who is currently employed to perform substantially all of the material duties
of his job, or any other job for which he is or may become qualified by reason of education, training or
experience; or
2. inability of the Covered Person who is not currently employed to perform all of the activities of daily living
including eating, transferring, dressing, toileting, bathing, and continence, without human supervision or
assistance.
Signed for the
Life Insurance Company of North America
0)1e,frt, A. 474.-.L,
Matthew G. Manders, President
GA -00-3000.00
39
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 OK 969517 issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA to the
TRUSTEE OF THE GROUP INSURANCE TRUST FOR EMPLOYERS IN THE PUBLIC ADMINISTRATION
INDUSTRY. We acknowledge that benefits will be provided in accordance with the terms and provisions of
the policy, which will be the sole contract under which benefits are paid.
This applicatigp is to be signed.
Sign:
Title:
teve Moreno, Chair, Board of
Weld County Commissioners
Date: MAR 2 6 2018
Weld County Government
TL -008890
O20/f- D 9oZ
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