2017_Basic_Life_Contract___Unum.pdf

C.FP-2 C.FP-1 (7/1/2015)

GROUP INSURANCE

SUMMARY OF BENEFITS

NON-PARTICIPATING

IDENTIFICATION NUMBER: 951718 001

EFFECTIVE DATE OF

COVERAGE: July 1, 2015

ANNIVERSARY DATE: July 1

GOVERNING JURISDICTION: Maine

Unum Life Insurance Company of America insures the lives of

Unified Government of Athens-Clarke County under the Select Group Insurance Trust

Policy No. 292000

Unum Life Insurance Company of America (referred to as Unum) will provide benefits under this Summary of Benefits. Unum makes this promise subject to all of this Summary of Benefits' provisions.

The Employer should read this Summary of Benefits carefully and contact Unum promptly with any questions. This Summary of Benefits is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments.

Signed for Unum at Portland, Maine on the Effective Date of Coverage.

President Secretary

Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122

TOC-1 (7/1/2015)

TABLE OF CONTENTS

BENEFITS AT A GLANCE .............................................................................................B@G-LIFE-1

LIFE INSURANCE PLAN ...............................................................................................B@G-LIFE-1

BENEFITS AT A GLANCE .............................................................................................B@G-AD&D-1

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE PLAN .........................B@G-AD&D-1

CLAIM INFORMATION ..................................................................................................LIFE-CLM-1

LIFE INSURANCE..........................................................................................................LIFE-CLM-1

CLAIM INFORMATION ..................................................................................................AD&D-CLM-1

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE....................................AD&D-CLM-1

EMPLOYER PROVISIONS ............................................................................................EMPLOYER-1

CERTIFICATE SECTION ...............................................................................................CC.FP-1

GENERAL PROVISIONS...............................................................................................EMPLOYEE-1

LIFE INSURANCE..........................................................................................................LIFE-BEN-1

BENEFIT INFORMATION ..............................................................................................LIFE-BEN-1

OTHER BENEFIT FEATURES.......................................................................................LIFE-OTR-1

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE....................................AD&D-BEN-1

BENEFIT INFORMATION ..............................................................................................AD&D-BEN-1

OTHER BENEFIT FEATURES.......................................................................................AD&D-OTR-1

STATE REQUIREMENTS ..............................................................................................STATE REQ-1

GLOSSARY....................................................................................................................GLOSSARY-1

B@G-LIFE-1 (7/1/2015)

BENEFITS AT A GLANCE

LIFE INSURANCE PLAN

This life insurance plan provides financial protection for your beneficiary(ies) by paying a benefit in the event of your death. The amount your beneficiary(ies) receive(s) is based on the amount of coverage in effect just prior to the date of your death according to the terms and provisions of the plan. You also have the opportunity to have coverage for your dependents.

EMPLOYER'S ORIGINAL PLAN

EFFECTIVE DATE: July 1, 2015

PLAN YEAR:

July 1, 2015 through June 30, 2016 and each following July 1 through June 30

IDENTIFICATION

NUMBER: 951718 001

ELIGIBLE GROUP(S):

Group 1 All Full-Time Employees not eligible in another group in active employment in the United States with the Employer

Group 2 Employees on file with Unum and the Employer in active employment in the United States with the Employer (Closed Group)

Group 3 Commissioners in active employment in the United States with the Employer

Group 4 Mayor in active employment in the United States with the Employer as of July1, 2015 (Closed Group)

Group 5 Retirees

For retirees, certain terms and conditions in this life insurance plan are affected as follows:

- references to "employee" will read "retiree" as it applies

- references to "active employment" will not apply

- references to "waiting period" will not apply

- the "life insurance premium waiver" provision will not apply

MINIMUM HOURS REQUIREMENT:

Groups 1 and 2 Employees must be working at least 40 hours per week.

Groups 3 and 4 Employees must be working at least 17 hours per week.

WAITING PERIOD:

For employees in an eligible group on or before July 1, 2015: None

For employees entering an eligible group after July 1, 2015: First of the month coincident with or next following 30 days of continuous active employment

B@G-LIFE-2 (7/1/2015)

REHIRE:

If your employment ends and you are rehired within 1 year, your previous work while in an eligible group will apply toward the waiting period. All other Summary of Benefits' provisions apply.

WHO PAYS FOR THE COVERAGE:

For You:

Basic Life Benefit:

Groups 1, 2, 3, 4 and 5 Your Employer pays the cost of your coverage.

Contributory Life Benefit:

Groups 1, 2, 3 and 4 You pay the cost of your coverage.

For Your Dependents:

Groups 1, 2, 3 and 4 You pay the cost of your dependent coverage.

Group 5 Your Employer pays the cost of your dependent coverage.

ELIMINATION PERIOD:

Groups 1, 2, 3 and 4 Premium Waiver: 9 months

Disability-based benefits begin the day after Unum approves your claim and the elimination period is completed.

LIFE INSURANCE BENEFIT:

AMOUNT OF LIFE INSURANCE FOR YOU

BASIC LIFE BENEFIT

Groups 1, 2 and 3 2 x annual earnings plus $5,000

All amounts are rounded to the next higher multiple of $1,000, if not already an exact multiple thereof.

Group 4 2 x annual earnings plus $15,000

All amounts are rounded to the next higher multiple of $1,000, if not already an exact multiple thereof.

Group 5 $10,000

B@G-LIFE-3 (7/1/2015)

CONTRIBUTORY LIFE BENEFITS:

Groups 1, 2, 3 and 4 Amounts in $10,000 benefit units as applied for by you and approved by Unum.

All amounts are rounded to the next higher multiple of $10,000, if not already an exact multiple thereof.

AMOUNT OF LIFE INSURANCE AVAILABLE IF YOU BECOME INSURED AT CERTAIN AGES OR

HAVE REACHED CERTAIN AGES WHILE INSURED

Groups 1 and 3 If you have reached age 70, but not age 75, your amount of life insurance will be:

- 65% of the amount of life insurance you had prior to age 70; or

- 65% of the amount of life insurance shown above if you become insured on or after age 70 but before age 75.

There will be no further increases in your amount of life insurance.

If you have reached age 75, but not age 80, your amount of life insurance will be:

- 45% of the amount of life insurance you had prior to your first reduction; or

- 45% of the amount of life insurance shown above if you become insured on or after age 75 but before age 80.

There will be no further increases in your amount of life insurance.

If you have reached age 80 or more, your amount of life insurance will be:

- 30% of the amount of life insurance you had prior to your first reduction; or

- 30% of the amount of life insurance shown above if you become insured on or after age 80.

There will be no further increases in your amount of life insurance.

EVIDENCE OF INSURABILITY IS REQUIRED FOR THE AMOUNT OF YOUR INSURANCE (BASIC

AND CONTRIBUTORY LIFE BENEFITS COMBINED) OVER:

Groups 1, 2, 3 and 4 $250,000

Evidence of Insurability is not required for amounts of life insurance you had in force with your Employer's prior carrier on the termination date of the prior carrier's plan.

Evidence of Insurability is required for amounts of life insurance in excess of the greater of:

- The amount(s) of life insurance you had in force with your Employer's prior carrier on the termination date of the prior carrier's plan; or

- The amount(s) of life insurance over the amount shown above.

OVERALL MAXIMUM BENEFIT OF LIFE INSURANCE FOR YOU (BASIC AND CONTRIBUTORY

LIFE BENEFITS COMBINED):

Groups 1, 2, 3 and 4 $500,000

B@G-LIFE-4 (7/1/2015)

AMOUNT OF LIFE INSURANCE FOR YOUR DEPENDENTS

Spouse:

Groups 1, 2, 3 and 4 Option A

No Coverage

Option B

$15,000

Option C

$25,000

Option D

$50,000

Group 5 $2,000

Children:

Groups 1, 2, 3 and 4 Option A

No Coverage

Option B

Live birth to 14 days: $1,000 14 days to 6 months: $1,000 6 months to age 26: $5,000

Option C

Live birth to 14 days: $1,000 14 days to 6 months: $1,000 6 months to age 26: $10,000

Option D

Live birth to 14 days: $1,000 14 days to 6 months: $1,000 6 months to age 26: $15,000

THE AMOUNT OF LIFE INSURANCE FOR A DEPENDENT WILL NOT BE MORE THAN 100% OF

YOUR AMOUNT OF LIFE INSURANCE.

SOME LOSSES MAY NOT BE COVERED UNDER THIS PLAN.

OTHER FEATURES:

Groups 1, 2, 3 and 4 Accelerated Benefit

Conversion

Continuity of Coverage

Portability

B@G-LIFE-5 (7/1/2015)

NOTE: Portability under this plan is available to an insured spouse in the event of divorce from an insured employee, subject to all terms and conditions otherwise applicable to ported spouse coverage.

Group 5 Conversion

The above items are only highlights of this plan. For a full description of your coverage, continue reading your certificate of coverage section. The plan includes enrollment, risk management and other support services related to your Employer's Benefit Program.

B@G-AD&D-1 (7/1/2015)

BENEFITS AT A GLANCE

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE PLAN

This accidental death and dismemberment insurance plan provides financial protection for your beneficiary(ies) by paying a benefit in the event of your death or for you in the event of any other covered loss. The amount you or your beneficiary(ies) receive(s) is based on the amount of coverage in effect just prior to the date of your death or any other covered loss according to the terms and provisions of the plan.

EMPLOYER'S ORIGINAL PLAN

EFFECTIVE DATE: July 1, 2015

PLAN YEAR:

July 1, 2015 through June 30, 2016 and each following July 1 through June 30

IDENTIFICATION

NUMBER: 951718 001

ELIGIBLE GROUP(S):

Group 1 All Full-Time Employees not eligible in another group in active employment in the United States with the Employer

Group 2 Employees on file with Unum and the Employer in active employment in the United States with the Employer (Closed Group)

Group 3 Commissioners in active employment in the United States with the Employer

Group 4 Mayor in active employment in the United States with the Employer as of July 1, 2015 (Closed Group)

MINIMUM HOURS REQUIREMENT:

Groups 1 and 2 Employees must be working at least 40 hours per week.

Groups 3 and 4 Employees must be working at least 17 hours per week.

WAITING PERIOD:

For employees in an eligible group on or before July 1, 2015: None

For employees entering an eligible group after July 1, 2015: First of the month coincident with or next following 30 days of continuous active employment

REHIRE:

If your employment ends and you are rehired within 1 year, your previous work while in an eligible group will apply toward the waiting period. All other Summary of Benefits' provisions apply.

WHO PAYS FOR THE COVERAGE:

Basic AD&D Benefit:

Your Employer pays the cost of your coverage.

B@G-AD&D-2 (7/1/2015)

Contributory AD&D Benefit:

You pay the cost of your coverage.

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT:

AMOUNT OF ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE FOR YOU

(FULL AMOUNT)

BASIC AD&D BENEFIT

An amount equal to your life amount.

CONTRIBUTORY AD&D BENEFIT

An amount equal to your life amount.

AMOUNT OF ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE AVAILABLE IF YOU

BECOME INSURED AT CERTAIN AGES OR HAVE REACHED CERTAIN AGES WHILE INSURED

Groups 1 and 3 If you have reached age 70, but not age 75, your amount of AD&D insurance will be:

- 65% of the amount of AD&D insurance you had prior to age 70; or

- 65% of the amount of AD&D insurance shown above if you become insured on or after age 70 but before age 75.

There will be no further increases in your amount of AD&D insurance.

If you have reached age 75, but not age 80, your amount of AD&D insurance will be:

- 45% of the amount of AD&D insurance you had prior to your first reduction; or

- 45% of the amount of AD&D insurance shown above if you become insured on or after age 75 but before age 80.

There will be no further increases in your amount of AD&D insurance.

If you have reached age 80 or more, your amount of AD&D insurance will be:

- 30% of the amount of AD&D insurance you had prior to your first reduction; or

- 30% of the amount of AD&D insurance shown above if you become insured on or after age 80.

There will be no further increases in your amount of AD&D insurance.

OVERALL MAXIMUM BENEFIT OF ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

FOR YOU (BASIC AND CONTRIBUTORY AD&D BENEFITS COMBINED):

$500,000

REPATRIATION BENEFIT FOR YOU

Maximum Benefit Amount:

Up to $5,000

The Repatriation Benefit is separate from any accidental death and dismemberment benefit which may be payable. To receive the Repatriation Benefit, your accidental death benefit must be paid first.

SEATBELT(S) AND AIR BAG BENEFIT FOR YOU

Benefit Amount:

Seatbelt(s): 10% of the Full Amount of your accidental death and dismemberment insurance benefit.

Air Bag: 5% of the Full Amount of your accidental death and dismemberment insurance benefit.

B@G-AD&D-3 (7/1/2015)

Maximum Benefit Payment:

Seatbelt(s): $25,000

Air bag: $5,000

The Seatbelt(s) and Air Bag Benefit is separate from any accidental death and dismemberment benefit which may be payable. To receive the Seatbelt(s) and Air Bag Benefit, your accidental death benefit must be paid first.

EDUCATION BENEFIT

Each Qualified Child

Benefit Amount per Academic Year for which a Qualified Child is enrolled:

6% of the Full Amount of the employee's accidental death and dismemberment insurance to a maximum of $6,000.

Maximum Benefit Payments:

4 per lifetime

Maximum Benefit Amount:

$24,000

Maximum Benefit Period:

6 years from the date the first benefit payment has been made.

The Education Benefit is separate from any accidental death and dismemberment benefit which may be payable. In order for your Qualified Child to receive the Education Benefit, your accidental death benefit must be paid first.

COMMON CARRIER BENEFIT

Maximum Benefit: The Full Amount

The Common Carrier Benefit is separate from any accidental death and dismemberment benefit which may be payable. To receive the Common Carrier benefit your accidental death benefit must be paid first.

EXPOSURE AND DISAPPEARANCE BENEFIT FOR YOU

Maximum Benefit Amount: The Full Amount

CHILD CARE BENEFIT

Each Qualified Child

Annual Benefit Amount:

Birth through age 13

The lesser of:

- 5% of the Full Amount of your or your spouse's accidental death and dismemberment insurance; or

- $3,000

B@G-AD&D-4 (7/1/2015)

Maximum Benefit Amount:

$12,000

Maximum Benefit Period:

4 consecutive years

If, at the time of your or your spouse's death, you have no Qualified Child eligible for the Child Care Benefit, we will pay 5% of the Full Amount to a maximum benefit of $2,000 to you, your spouse, your beneficiary or your or your spouse's authorized representative.

The Child Care Benefit is separate from any accidental death and dismemberment benefit which may be payable. In order for your Qualified Child to receive the Child Care Benefit, your or your spouse's accidental death benefit must be paid first.

This benefit will only be paid once per accident, even if you and your spouse suffers an injury in the same accident

COMA BENEFIT FOR YOU

Monthly Benefit Amount:

1% of the Full Amount of your accidental death and dismemberment insurance benefit

Maximum Number of Months:

100 months

SOME LOSSES MAY NOT BE COVERED UNDER THIS PLAN.

OTHER FEATURES:

Portability

Continuity of Coverage is available under this plan - refer to the ACCIDENTAL DEATH AND DISMEMBERMENT OTHER BENEFIT FEATURES for further details.

The above items are only highlights of this plan. For a full description of your coverage, continue reading your certificate of coverage section. The plan includes enrollment, risk management and other support services related to your Employer's Benefit Program.

LIFE-CLM-1 (7/1/2015)

CLAIM INFORMATION

LIFE INSURANCE

WHEN DO YOU OR YOUR AUTHORIZED REPRESENTATIVE NOTIFY UNUM OF A

CLAIM?

We encourage you or your authorized representative to notify us as soon as possible, so that a claim decision can be made in a timely manner.

If a claim is based on your disability, written notice and proof of claim must be sent no later than 90 days after the end of the elimination period.

If a claim is based on death, written notice and proof of claim must be sent no later than 90 days after the date of death.

If it is not possible to give proof within these time limits, it must be given no later than 1 year after the proof is required as specified above. These time limits will not apply during any period you or your authorized representative lacks the legal capacity to give us proof of claim.

The claim form is available from your Employer, or you or your authorized representative can request a claim form from us. If you or your authorized representative does not receive the form from Unum within 15 days of the request, send Unum written proof of claim without waiting for the form.

If you have a disability, you must notify us immediately when you return to work in any capacity, regardless of whether you are working for your Employer.

HOW DO YOU FILE A CLAIM FOR A DISABILITY?

You or your authorized representative, and your Employer must fill out your own sections of the claim form and then give it to your attending physician. Your physician should fill out his or her section of the form and send it directly to Unum.

WHAT INFORMATION IS NEEDED AS PROOF OF YOUR CLAIM?

If your claim is based on your disability, your proof of claim, provided at your expense, must show:

- that you are under the regular care of a physician;

- the date your disability began;

- the cause of your disability;

- the extent of your disability, including restrictions and limitations preventing you from performing your regular occupation or any gainful occupation; and

- the name and address of any hospital or institution where you received treatment, including all attending physicians.

We may request that you send proof of continuing disability indicating that you are under the regular care of a physician. This proof, provided at your expense, must be received within 45 days of a request by us.

LIFE-CLM-2 (7/1/2015)

If claim is based on death, proof of claim, provided at your or your authorized representative's expense, must show the cause of death. Also a certified copy of the death certificate must be given to us.

In some cases, you will be required to give Unum authorization to obtain additional medical and non-medical information as part of your proof of claim or proof of continuing disability. Unum will deny your claim if the appropriate information is not submitted.

WHEN CAN UNUM REQUEST AN AUTOPSY?

In the case of death, Unum will have the right and opportunity to request an autopsy where not forbidden by law.

HOW DO YOU DESIGNATE OR CHANGE A BENEFICIARY? (Beneficiary Designation)

At the time you become insured, you should name a beneficiary on your enrollment form for your death benefits under your life insurance. You may change your beneficiary at any time by filing a form approved by Unum with your Employer. The new beneficiary designation will be effective as of the date you sign that form.

However, if we have taken any action or made any payment before your Employer receives that form, that change will not go into effect.

It is important that you name a beneficiary and keep your designation current. If more than one beneficiary is named and you do not designate their order or share of payments, the beneficiaries will share equally. The share of a beneficiary who dies before you, or the share of a beneficiary who is disqualified, will pass to any surviving beneficiaries in the order you designated.

If you do not name a beneficiary, or if all named beneficiaries do not survive you, or if your named beneficiary is disqualified, your death benefit will be paid to your estate.

Instead of making a death payment to your estate, Unum has the right to make payment to the first surviving family members of the family members in the order listed below:

- spouse;

- child or children;

- mother or father; or

- sisters or brothers.

If we are to make payments to a beneficiary who lacks the legal capacity to give us a release, Unum may pay up to $2,000 to the person or institution that appears to have assumed the custody and main support of the beneficiary. This payment made in good faith satisfies Unum's legal duty to the extent of that payment and Unum will not have to make payment again.

Also, at Unum's option, we may pay up to $1,000 to the person or persons who, in our opinion, have incurred expenses for your last sickness and death.

LIFE-CLM-3 (7/1/2015)

In addition, if you do not survive your spouse, your spouse may continue dependent life coverage by applying for portability. Your surviving spouse should name a beneficiary according to the requirements specified above for you.

HOW WILL UNUM MAKE PAYMENTS?

If your or your dependent's life claim is at least $10,000, Unum will make available to the beneficiary a retained asset account (the Unum Security Account).

Payment for the life claim may be accessed by writing a draft in a single sum or drafts in smaller sums. The funds for the draft or drafts are fully guaranteed by Unum.

If the life claim is less than $10,000, Unum will pay it in one lump sum to you or your beneficiary.

Also, you or your beneficiary may request the life claim to be paid according to one of Unum's other settlement options. This request must be in writing in order to be paid under Unum's other settlement options.

If you do not survive your spouse, your spouse may continue dependent life coverage by applying for portability. Your surviving spouse's death claim will be paid to your surviving spouse's beneficiary.

All other benefits will be paid to you.

WHAT HAPPENS IF UNUM OVERPAYS YOUR CLAIM?

Unum has the right to recover any overpayments due to:

- fraud; and

- any error Unum makes in processing a claim.

You must reimburse us in full. We will determine the method by which the repayment is to be made.

Unum will not recover more money than the amount we paid you.

WHAT ARE YOUR ASSIGNABILITY RIGHTS FOR THE DEATH BENEFITS UNDER

YOUR LIFE INSURANCE? (Assignability Rights)

The rights provided to you by the plan for life insurance are owned by you, unless:

- you have previously assigned these rights to someone else (known as an "assignee"); or

- you assign your rights under the plan(s) to an assignee.

We will recognize an assignee as the owner of the rights assigned only if:

- the assignment is in writing, signed by you, and acceptable to us in form; and

- a signed or certified copy of the written assignment has been received and registered by us at our home office.

LIFE-CLM-4 (7/1/2015)

We will not be responsible for the legal, tax or other effects of any assignment, or for any action taken under the plan(s') provisions before receiving and registering an assignment.

AD&D-CLM-1 (7/1/2015)

CLAIM INFORMATION

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

WHEN DO YOU OR YOUR AUTHORIZED REPRESENTATIVE NOTIFY UNUM OF A

CLAIM?

We encourage you or your authorized representative to notify us as soon as possible, so that a claim decision can be made in a timely manner.

If a claim is based on death or other covered loss, written notice and proof of claim must be sent no later than 90 days after the date of death or the date of any other covered loss.

If a claim is based on the Education Benefit, written notice and proof of claim must be sent no later than 60 days after the date of your death.

If it is not possible to give proof within these time limits, it must be given no later than 1 year after the time proof is required as specified above. These time limits will not apply during any period you or your authorized representative lacks the legal capacity to give us proof of claim.

The claim form is available from your Employer, or you or your authorized representative can request a claim form from us. If you or your authorized representative does not receive the form from Unum within 15 days of your request, send Unum written proof of claim without waiting for the form.

HOW DO YOU FILE A CLAIM FOR A COVERED LOSS?

You or your authorized representative and your Employer must fill out your own sections of the claim form and then give it to your attending physician. Your physician should fill out his or her section of the form and send it directly to Unum.

WHAT INFORMATION IS NEEDED AS PROOF OF CLAIM?

If claim is based on death or other covered loss, proof of claim for death or covered loss, provided at your or your authorized representative's expense, must show:

- the cause of death or covered loss;

- the extent of the covered loss;

- the date of covered loss; and

- the name and address of any hospital or institution where treatment was received, including all attending physicians.

Also, in case of death, a certified copy of the death certificate must be given to us.

In some cases, you will be required to give Unum authorization to obtain additional medical and non-medical information as part of your proof of claim. Unum will deny your claim if the appropriate information is not submitted.

If a claim is based on the Education Benefit, proof of claim, provided at your authorized representative's expense, must show:

AD&D-CLM-2 (7/1/2015)

- the date of enrollment of your qualified child in an accredited post-secondary institution of higher learning;

- the name of the institution;

- a list of courses for the current academic term; and

- the number of credit hours for the current academic term.

WHEN CAN UNUM REQUEST AN AUTOPSY?

In the case of death, Unum will have the right and opportunity to request an autopsy where not forbidden by law.

HOW DO YOU DESIGNATE OR CHANGE A BENEFICIARY? (Beneficiary Designation)

At the time you become insured, you should name a beneficiary on your enrollment form for your death benefits under your accidental death and dismemberment insurance. You may change your beneficiary at any time by filing a form approved by Unum with your Employer. The new beneficiary designation will be effective as of the date you sign that form. However, if we have taken any action or made any payment before your Employer receives that form, that change will not go into effect.

It is important that you name a beneficiary and keep your designation current. If more than one beneficiary is named and you do not designate their order or share of payments, the beneficiaries will share equally. The share of a beneficiary who dies before you, or the share of a beneficiary who is disqualified, will pass to any surviving beneficiaries in the order you designated.

If you do not name a beneficiary, or if all named beneficiaries do not survive you, or if your named beneficiary is disqualified, your death benefit will be paid to your estate.

Instead of making a death payment to your estate, Unum has the right to make payment to the first surviving family members of the family members in the order listed below:

- spouse;

- child or children;

- mother or father; or

- sisters or brothers.

If we are to make payments to a beneficiary who lacks the legal capacity to give us a release, Unum may pay up to $2,000 to the person or institution that appears to have assumed the custody and main support of the beneficiary. This payment made in good faith satisfies Unum's legal duty to the extent of that payment and Unum will not have to make payment again.

Also, at Unum's option, we may pay up to $1,000 to the person or persons who, in our opinion, have incurred expenses for your last sickness and death.

HOW WILL UNUM MAKE PAYMENTS?

If your accidental death or dismemberment claim is at least $10,000 Unum will make available to you or your beneficiary a retained asset account (the Unum Security Account).

AD&D-CLM-3 (7/1/2015)

Payment for the accidental death or dismemberment claim may be accessed by writing a draft in a single sum or drafts in smaller sums. The funds for the draft or drafts are fully guaranteed by Unum.

If the accidental death or dismemberment claim is less than $10,000, Unum will pay it in one lump sum to you or your beneficiary.

Also, your beneficiary may request the accidental death claim to be paid according to one of Unum's other settlement options. This request must be in writing in order to be paid under Unum's other settlement options.

The Child Care Benefit will be paid to you, your spouse, your beneficiary or your or your spouse's authorized representative.

The Education Benefit will be paid to your qualified child or the qualified child's legal representative.

All other benefits will be paid to you.

WHAT HAPPENS IF UNUM OVERPAYS YOUR CLAIM?

Unum has the right to recover any overpayments due to:

- fraud; and

- any error Unum makes in processing a claim.

You must reimburse us in full. We will determine the method by which the repayment is to be made.

Unum will not recover more money than the amount we paid you.

WHAT ARE YOUR ASSIGNABILITY RIGHTS FOR THE DEATH BENEFITS UNDER

YOUR ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE BENEFITS?

(Assignability Rights)

The rights provided to you by the plan(s) for accidental death insurance benefits are owned by you, unless:

- you have previously assigned these rights to someone else (known as an "assignee"); or

- you assign your rights under the plan(s) to an assignee.

We will recognize an assignee as the owner of the rights assigned only if:

- the assignment is in writing, signed by you, and acceptable to us in form; and

- a signed or certified copy of the written assignment has been received and registered by us at our home office.

We will not be responsible for the legal, tax or other effects of any assignment, or for any action taken under the plan(s') provisions before receiving and registering an assignment.

EMPLOYER-1 (7/1/2015)

EMPLOYER PROVISIONS

WHAT DOES THIS SUMMARY OF BENEFITS CONSIST OF FOR THE EMPLOYER?

This Summary of Benefits consists of:

- all Summary of Benefits' provisions and any amendments and/or attachments issued;

- the Employer's Participation Agreement;

- each employee's application for insurance (employee retains his own copy); and

- the certificate of coverage issued for each employee of the Employer.

This Summary of Benefits may be changed in whole or in part. Only an officer or a registrar of Unum can approve a change. The approval must be in writing and endorsed on or attached to this Summary of Benefits. No other person, including an agent, may change this Summary of Benefits or waive any part of it.

WHAT IS THE COST OF THIS INSURANCE?

LIFE INSURANCE

Premium payments are required for an insured while he or she is disabled under this plan.

The initial premium for each plan is based on the initial rate(s) shown in the Rate Information Amendment(s).

PREMIUM WAIVER

Groups 1, 2, 3 and 4 Unum does not require premium payments for an insured employee's life coverage if he or she is under age 60 and disabled for 9 months. Proof of disability, provided at the insured employee's expense, must be filed by the insured employee and approved by Unum.

INITIAL RATE GUARANTEE AND RATE CHANGES

Refer to the Rate Information Amendment(s).

ACCIDENTAL DEATH AND DISMEMBERMENT

INSURANCE

The initial premium for each plan is based on the initial rate(s) shown in the Rate Information Amendment(s).

INITIAL RATE GUARANTEE AND RATE CHANGES

Refer to the Rate Information Amendment(s).

WHEN IS PREMIUM DUE FOR THIS SUMMARY OF BENEFITS?

Premium Due Dates: Premium due dates are based on the Premium Due Dates shown in the Rate Information Amendment(s).

EMPLOYER-2 (7/1/2015)

The Employer must send all premiums to Unum on or before their respective due date. The premium must be paid in United States dollars.

WHEN ARE INCREASES OR DECREASES IN PREMIUM DUE?

Premium increases or decreases which take effect during an insurance month are adjusted and due on the next premium due date following the change. Changes will not be pro-rated daily.

If premiums are paid on other than a monthly basis, premiums for increases and decreases will result in a monthly pro-rated adjustment on the next premium due date.

Unum will only adjust premium for the current plan year and the prior plan year. In the case of fraud, premium adjustments will be made for all plan years.

WHAT INFORMATION DOES UNUM REQUIRE FROM THE EMPLOYER?

The Employer must provide Unum with the following on a regular basis:

- information about employees:

who are eligible to become insured;

whose amounts of coverage change; and/or whose coverage ends;

- occupational information and any other information that may be required to manage a claim; and

- any other information that may be reasonably required.

Employer records that, in Unum's opinion, have a bearing on this Summary of Benefits will be available for review by Unum at any reasonable time.

Clerical error or omission by Unum will not:

- prevent an employee from receiving coverage;

- affect the amount of an insured's coverage; or

- cause an employee's coverage to begin or continue when the coverage would not otherwise be effective.

WHO CAN CANCEL OR MODIFY THIS SUMMARY OF BENEFITS OR A PLAN

UNDER THIS SUMMARY OF BENEFITS?

This Summary of Benefits or a plan under this Summary of Benefits can be cancelled:

- by Unum; or

- by the Employer.

Unum may cancel or modify this Summary of Benefits or a plan if:

- there is less than 100% participation of those eligible employees for an Employer paid plan; or

- there is less than 75% participation of those eligible employees who pay all or part of the premium for a basic benefit plan; or

EMPLOYER-3 (7/1/2015)

- the number of employees insured for all contributory benefits is less than 15 lives or 25% of those eligible, whichever is greater; or

- the number of employees insured under a plan decreases by 25%; or

- the Employer does not promptly provide Unum with information that is reasonably required; or

- the Employer fails to perform any of its obligations that relate to this Summary of

Benefits; or

- fewer than 15 employees are insured under a plan; or

- the premium is not paid in accordance with the provisions of this Summary of

Benefits that specify whether the Employer, the employee, or both, pay the premiums; or

- the Employer does not promptly report to Unum the names of any employees who are added or deleted from the eligible group; or

- Unum determines that there is a significant change, in the size, occupation or age of the eligible group as a result of a corporate transaction such as a merger, divestiture, acquisition, sale, or reorganization of the Employer and/or its employees; or

- the Employer fails to pay any portion of the premium within the 60 day grace period.

If Unum cancels or modifies this Summary of Benefits or a plan, for reasons other than the Employer's failure to pay premium, a written notice will be delivered to the Employer at least 60 days prior to the cancellation date or modification date. The Employer may cancel this Summary of Benefits or a plan if the modifications are unacceptable.

If any portion of the premium is not paid during the grace period, Unum will either cancel or modify this Summary of Benefits or a plan automatically at the end of the grace period. The Employer is liable for premium for coverage during the grace period. The Employer must pay Unum all premium due for the full period each plan is in force.

The Employer may cancel this Summary of Benefits or a plan by written notice delivered to Unum at least 31 days prior to the cancellation date. When both the Employer and Unum agree, this Summary of Benefits or a plan can be cancelled on an earlier date. If Unum or the Employer cancels this Summary of Benefits or a plan, coverage will end at 12:00 midnight on the last day of coverage.

If this Summary of Benefits or a plan is cancelled, the cancellation will not affect a payable claim.

WHAT HAPPENS TO AN EMPLOYEE'S COVERAGE UNDER THIS SUMMARY OF

BENEFITS WHILE HE OR SHE IS ON A FAMILY AND MEDICAL LEAVE OF

ABSENCE?

We will continue the employee's coverage in accordance with the Employer's Human Resource policy on family and medical leaves of absence if premium payments continue and the Employer approved the employee's leave in writing.

Coverage will be continued until the end of the latest of:

- the leave period required by the federal Family and Medical Leave Act of 1993, and any amendments; or

- the leave period required by applicable state law; or

EMPLOYER-4 (7/1/2015)

- the leave period provided to the employee for injury or sickness.

If the Employer's Human Resource policy doesn't provide for continuation of a plan for an employee during a family and medical leave of absence, the employee's coverage will be reinstated when he or she returns to active employment.

We will not:

- apply a new waiting period; or

- require evidence of insurability.

DIVISIONS, SUBSIDIARIES OR AFFILIATED COMPANIES INCLUDE:

FOR LIFE INSURANCE:

NAME/LOCATION (CITY AND STATE)

None

FOR ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE:

NAME/LOCATION (CITY AND STATE)

None

CC.FP-1 (7/1/2015)

CERTIFICATE SECTION

Unum Life Insurance Company of America (referred to as Unum) welcomes you as a client.

This is your certificate of coverage as long as you are eligible for coverage and you become insured. You will want to read it carefully and keep it in a safe place.

Unum has written your certificate of coverage in plain English. However, a few terms and provisions are written as required by insurance law. If you have any questions about any of the terms and provisions, please consult Unum's claims paying office.

Unum will assist you in any way to help you understand your benefits.

If the terms and provisions of the certificate of coverage (issued to you) are different from the Summary of Benefits (issued to the Employer), the Summary of Benefits will govern. The Summary of Benefits may be changed in whole or in part. Only an officer or registrar of Unum can approve a change. The approval must be in writing and endorsed on or attached to the Summary of Benefits. Any other person, including an agent, may not change the Summary of Benefits or waive any part of it.

The Summary of Benefits is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments.

For purposes of effective dates and ending dates under the group Summary of Benefits, all days begin at 12:01 a.m. and end at 12:00 midnight at the Employer's address.

Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122

EMPLOYEE-1 (7/1/2015)

GENERAL PROVISIONS

WHAT IS THE CERTIFICATE OF COVERAGE?

This certificate of coverage is a written statement prepared by Unum and may include attachments. It tells you:

- the coverage for which you may be entitled;

- to whom Unum will make a payment; and

- the limitations, exclusions and requirements that apply within a plan.

WHEN ARE YOU ELIGIBLE FOR COVERAGE?

Groups 1, 2, 3 and 4 If you are working for your Employer in an eligible group, the date you are eligible for coverage is the later of:

- the plan effective date; or

- the day after you complete your waiting period.

Group 5 The date you are eligible for coverage is the later of:

- the plan effective date; or

- the date you retire.

WHEN DOES YOUR COVERAGE BEGIN?

Groups 1, 2, 3 and 4 This plan provides contributory benefits in addition to the basic benefit. When you first become eligible for coverage, you may apply for any number of benefit units, however, you cannot be covered for more than the maximum benefit available under the plan.

Evidence of insurability is required for any amount of life insurance over the amount shown in the LIFE INSURANCE "BENEFITS AT A GLANCE" page.

Your Employer pays 100% of the cost of your coverage under the basic benefit. You will automatically be covered under the basic benefit at 12:01 a.m. on the later of:

- the date you are eligible for coverage; or

- the date Unum approves your evidence of insurability form, if evidence of insurability is required.

You pay 100% of the cost for the contributory benefits. You will be covered at 12:01 a.m. on the latest of:

- the date you are eligible for coverage, if you apply for insurance on or before that date;

- the date you apply for insurance, if you apply within 31 days after your eligibility date; or

- the date Unum approves your evidence of insurability form, if evidence of insurability is required.

EMPLOYEE-2 (7/1/2015)

If you do not apply for contributory benefits on or before the 31st day after your eligibility date, you can only apply at the next annual enrollment period or within 30 days of a change in status. Evidence of insurability is required for any amount of insurance.

Coverage applied for during an annual enrollment period will begin at 12:01 a.m. on the later of:

- the first day of the next plan year; or

- the date Unum approves your evidence of insurability form.

Coverage applied for due to a change in status will begin at 12:01 a.m. on the date Unum approves your evidence of insurability form.

Group 5 Your Employer pays 100% of the cost of your coverage. You will be covered at 12:01 a.m. on the date you are eligible for coverage.

WHEN CAN YOU CHANGE YOUR COVERAGE?

Groups 1, 2, 3 and 4 You can change your coverage by applying for contributory benefit units only during an annual enrollment period or within 30 days of a change in status.

You can increase your coverage any number of benefit units up to the maximum benefit available under the plan or decrease your coverage by any number of benefit units.

Evidence of insurability is required if you increase your coverage by any number of benefit units or if you apply for any amount of life insurance over the amount shown in the LIFE INSURANCE "BENEFITS AT A GLANCE" page.

If you are not approved for the increase in your coverage, you will automatically remain at the same amount you had prior to applying for the increase.

Unum and your Employer determine when the annual enrollment period begins and ends. A change in coverage that is made during an annual enrollment period will begin at 12:01 a.m. on the later of:

- the first day of the next plan year; or

- the date Unum approves your evidence of insurability form, if evidence of insurability is required.

A change in coverage due to a change in status will begin at 12:01 a.m. on the latest of:

- the date of the change in status, if you apply on or before that date; or

- the date you apply, if you apply within 30 days after the date of the change in status; or

- the date Unum approves your evidence of insurability form, if evidence of insurability is required.

Changes in coverage must be consistent with the change in status.

EMPLOYEE-3 (7/1/2015)

If you end employment and are rehired within the same plan year, you may be insured on your eligibility date for the coverage that you had under the plan when you ended employment. You cannot change your coverage until the next annual enrollment period or change in status.

An evidence of insurability form can be obtained from your Employer.

WHAT IF YOU ARE ABSENT FROM WORK ON THE DATE YOUR COVERAGE

WOULD NORMALLY BEGIN?

Groups 1, 2, 3 and 4 If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will begin on the date you return to active employment.

ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE NOT WORKING

DUE TO INJURY OR SICKNESS?

Groups 1, 2, 3 and 4 If you are not working due to injury or sickness, and if premium is paid, you may continue to be covered up to your retirement date.

ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE TEMPORARILY

NOT WORKING?

Groups 1, 2, 3 and 4 If you are on a temporary layoff, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your temporary layoff begins.

Groups 1, 2, 3 and 4 If you are on a leave of absence, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your leave of absence begins.

WHEN WILL CHANGES TO YOUR COVERAGE TAKE EFFECT?

Groups 1, 2, 3 and 4 Once your coverage begins, any increased or additional coverage due to a change in your annual earnings or due to a plan change requested by your Employer will take effect immediately or on the date Unum approves your evidence of insurability form, if evidence of insurability is required. You must be in active employment or on a covered layoff or leave of absence.

If you are not in active employment due to injury or sickness, any increased or additional coverage due to a change in your annual earnings or due to a plan change will begin on the date you return to active employment.

Any decrease in coverage will take effect immediately but will not affect a payable claim that occurs prior to the decrease.

EMPLOYEE-4 (7/1/2015)

WHEN DOES YOUR COVERAGE END?

Groups 1, 2, 3 and 4 Your coverage under the Summary of Benefits or a plan ends on the earliest of:

- the date the Summary of Benefits or a plan is cancelled;

- the date you no longer are in an eligible group;

- the date your eligible group is no longer covered;

- the last day of the period for which you made any required contributions; or

- the last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness or due to retirement, as described in this certificate of coverage.

Unum will provide coverage for a payable claim which occurs while you are covered under the Summary of Benefits or plan.

Group 5 Your coverage under the Summary of Benefits or a plan ends on the earliest of:

- the date the Summary of Benefits or a plan is cancelled;

- the date you no longer are in an eligible group;

- the date your eligible group is no longer covered; or

- the last day of the period for which any required contributions are made.

Unum will provide coverage for a payable claim which occurs while you are covered under the Summary of Benefits or plan.

WHEN ARE YOU ELIGIBLE TO ELECT DEPENDENT LIFE COVERAGE?

Groups 1, 2, 3 and 4 If you elect coverage for yourself or are insured under the plan, you are eligible to elect dependent coverage for your spouse only, your dependent children only or both.

Group 5 If you are insured under the plan, you are eligible for dependent coverage for your spouse.

WHEN ARE YOUR DEPENDENTS ELIGIBLE FOR LIFE COVERAGE?

The date your dependents are eligible for coverage is the later of:

- the date your insurance begins; or

- the date you first acquire a dependent.

WHAT DEPENDENTS ARE ELIGIBLE FOR LIFE COVERAGE?

Groups 1, 2, 3 and 4 The following dependents are eligible for coverage under the plan:

- Your lawful spouse, including a legally separated spouse. You may not cover your spouse as a dependent if your spouse is enrolled for coverage as an employee.

EMPLOYEE-5 (7/1/2015)

- Your children from live birth but less than age 26. Stillborn children are not eligible for coverage.

- Your handicapped dependent children age 26 or over who became handicapped prior to the child's attainment of age 26.

Unum must receive proof within 31 days of the date the child is eligible for coverage under this Summary of Benefits, and as required during the first two years. After the first two years, Unum will ask for proof when needed, but not more than once a year.

Children include your own natural offspring, lawfully adopted children and stepchildren. They also include foster children. A child will be considered adopted on the date of placement in your home.

No child may be covered by more than one employee in the plan.

No child can be covered as both an employee and a dependent.

Group 5 The following dependents are eligible for coverage under the plan:

- Your lawful spouse, including a legally separated spouse. You may not cover your spouse as a dependent if your spouse is enrolled for coverage as an employee.

WHEN DOES YOUR DEPENDENT LIFE COVERAGE BEGIN?

Groups 1, 2, 3 and 4 This plan provides different benefit options for your dependents. When your dependents become eligible for coverage, you may apply for any dependent option.

However, your dependents cannot be covered under more than one option at a time.

You pay 100% of the cost of your dependent coverage for any option. Your dependents will be covered at 12:01 a.m. on the latest of:

- the date your dependents are eligible for coverage, if you apply for insurance on or before that date;

- the date you apply for dependent insurance, if you apply within 31 days after your dependent's eligibility date; or

- the date Unum approves your dependent's evidence of insurability form, if evidence of insurability is required.

Group 5 Your Employer pays 100% of the cost of your dependent coverage. Your dependent will be covered at 12:01 a.m. on the date your dependent is eligible for coverage.

WHEN CAN YOU APPLY FOR DEPENDENT LIFE COVERAGE IF YOU APPLY

MORE THAN 31 DAYS AFTER YOUR DEPENDENTS' ELIGIBILITY DATE? (Late Entrants)

Groups 1, 2, 3 and 4 You can apply for dependent coverage only during an annual enrollment period or within 30 days of a change in status. Evidence of insurability is required for any amount of dependent life insurance.

EMPLOYEE-6 (7/1/2015)

Unum and your Employer determine when the annual enrollment period begins and ends. Dependent coverage applied for during an annual enrollment period will begin at 12:01 a.m. on the later of:

- the first day of the next plan year; or

- the date Unum approves your dependent's evidence of insurability form.

Dependent coverage applied for due to a change in status will begin at 12:01 a.m.

on the date Unum approves your dependent's evidence of insurability form.

WHEN CAN YOU CHANGE YOUR DEPENDENT LIFE COVERAGE BY CHOOSING

ANOTHER…