44-I8 - Life Contract Rider 1.pdf

Symetra® is a registered service mark of Symetra Life Insurance Company.

LGC 13000 05/08 1

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, Washington 98004-5135

(An insurance company)

Incorporation Provision

Policy Rider Rider Number: 1 Policyholder: City of Burleson Policy Number: 01 017859 00

The Certificate(s) of Insurance, Rider(s), Policy change(s) and certificate change(s) are attached to, incorporated in and made a part of, The Policy. The Rider(s) do not vary, waive, alter or extend any of the terms, conditions or provisions of The Policy, except as stated herein.

Rider Effective Date of Incorporation Applicable to

1 Class 1, 2 and 3

Certificate of Insurance

October 12, 2020

Effective Date of Change

LGC 13500/TX-CERT 07/17 January 1, 2021

Certificate Change(s)

The following is amended:

Schedule of Insurance – Eligibility Waiting Period for Coverage

Certificate Page(s) Changed

LGC 13500/TX-SCH 07/17; Schedule of Insurance

The provisions found in the certificate(s) will control the benefit plan, period of coverage, exclusions, claims and other general policy provisions pertaining to state insurance law requirements.

In all other respects, The Policy and certificate(s) remain the same.

City of Burleson Symetra Life Insurance Company

By: By: Margaret Meister President

Title:

Date: Date: October 19, 2020

Instructions: (1) Sign and return to Symetra.

(2) Retain a copy with your policy.

Symetra® is a registered service mark of Symetra Life Insurance Company.

LG 13500 05/08 1

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, Washington 98004-5135

(An insurance company)

Certificate Rider

Rider Number: 1 Policyholder: City of Burleson Policy Number: 01 017859 00

The Rider(s) form a part of the Certificate of Insurance given in connection with The Policy. The Rider(s) do not vary, waive, alter or extend any of the terms, conditions or provisions of the Certificate of Insurance, except as stated herein.

Certificate of Insurance Applicable to

LGC 13500/TX-CERT 07/17

Effective Date of Change

January 1, 2021 Class 1

Certificate Change(s)

The following is amended:

Schedule of Insurance – Eligibility Waiting Period for Coverage

Certificate Page(s) Changed

LGC 13500/TX-SCH 07/17; Schedule of Insurance

The provisions found in the certificate will control the benefit plan, period of coverage, exclusions, claims and other general policy provisions pertaining to state insurance law requirements.

In all other respects, the certificate remains the same.

LG-12128 04/18

City of Burleson

Group Life Insurance Benefits Summary Plan Description

If you have questions regarding the Plan, please contact the Employer or Plan Administrator.

PLEASE READ THIS IMPORTANT NOTICE

The Employee Retirement Income Security Act of 1974 (ERISA) requires that the Plan Sponsor provide a Summary Plan Description to Plan Participants.

This document, together with the attached Certificate of Insurance (“Certificate”) issued by Symetra Life Insurance Company (“Symetra”) to the Plan Sponsor, is your Summary Plan Description. It provides you an overview of the Plan and addresses certain information that may not be included in the attached Certificate.

This document is not intended to give a Plan Participant any substantive rights to benefits that are not already provided by the attached Certificate. If the terms of this summary document conflict with the terms of the insurance contract, then the terms of the insurance contract will control, unless superseded by applicable law.

Plan Name City of Burleson Group Life Insurance Plan

Plan Effective Date January 1, 2019

Employer City of Burleson 141 W Renfro Street Burleson, Texas 76028

Plan Sponsor, EIN and Number City of Burleson Plan EIN: 75-6000475 Plan Number: 01 017859 00

Type of Plan Administration Symetra and Plan Administrator

Plan Administrator and Named Fiduciary City of Burleson 141 W Renfro Street Burleson, Texas 76028 Telephone Number: (817) 426-9644

Plan Year January 1 to December 31

Type of Plan Fully Insured Group Term Life Plan

Policy Number 01 017859 00

Insurance Company and Contact Information Symetra Life Insurance Company P. O. Box 2993 Hartford, CT 06104-2993 Toll Free Number: 1-800-943-2107 Fax Number: 1-860-392-3672

Claims Administrator Claims administration for life insurance benefits under your Plan is provided by Symetra Life Insurance Company (Symetra) according to the terms of a Group Life Insurance policy. The Plan Administrator has designated Symetra as a Named Fiduciary for benefit claims.

Agent for Service of Legal Process for the Plan Wanda Bullard 225 W. Renfro St Burleson, Texas 76028

Service of legal process may also be made on the Plan Administrator or a Plan Trustee, if any.

Trustees of the Plan Dale Cheatham, City Manager, 141 W Renfro St, Burleson, Texas 76028

Funding Medium and Type of Plan Administration The Plan is fully insured. Benefits are provided under the terms of a Group Life Insurance policy entered into between City of Burleson and Symetra. Claims for benefits are sent to the Insurance Company.

Symetra (not City of Burleson) is responsible for paying benefits. City of Burleson is the Plan Administrator.

As the Plan Administrator, City of Burleson is responsible for satisfying certain legal requirements under ERISA with respect to the Plan (for example, distributing SPDs and filing an annual report about the Plan with the U.S. Department of Labor).

Insurance premiums for covered individuals are paid in part by the Plan Sponsor out of its general assets, and in part by employee payroll deductions..

City of Burleson provides a schedule of the applicable premiums; contact the Human Resources Manager of City of Burleson if you need another copy.

Plan Interpretation The Plan Administrator has delegated to Symetra the exclusive right, power, and authority, in its sole and absolute discretion, to interpret the Plan (including the terms of the Plan set forth in the attached Certificate) including (but not limited to) the sole and absolute discretionary authority to take all actions and make all decisions regarding questions of coverage, eligibility, and entitlement to benefits, and benefit amounts, and to process and approve or deny all claims for benefits.

Amendment or Termination City of Burleson, as the sponsor of the Plan, has the general right to amend or terminate the Plan or any component benefit program under the Plan at any time. The Plan may be amended or terminated by a written instrument duly adopted by the City of Burleson or any of its delegates who are authorized to amend or terminate the Plan.

No Contract of Employment The Plan is not intended to be, and may not be construed as constituting, a contract or other arrangement between you and City of Burleson to the effect that you will be employed for any specific period of time.

Information in Attached Certificate of Insurance Benefits under the Plan are described in the attached Certificate issued by Symetra to the Plan Sponsor.

The Certificate contains important information about your coverage, including:

Eligibility and Participation Requirements Termination Provisions Enrollment Requirements Continuation of Coverage Description of Benefits Effective Date of Coverage Definitions Benefit Reductions, Exclusions and

Limitations

In order to understand your benefits under the Plan, you must read the attached Certificate.

Claims Procedures

The Plan’s claims procedures are set forth in the attached certificate of insurance, as supplemented by the Symetra Disability Plan Claim Procedures and Symetra Non-Disability Plan Claim Procedures (including Group Life Claims). The Symetra Disability Plan Claim Procedures and Symetra Non-Disability Plan Claim Procedures (including Group Life Claims) are being furnished to you automatically, without charge, as a separate document accompanying this Summary Plan Description.

Statement of ERISA Rights

Your Rights As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:

Receive Information About Your Plan and Benefits Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites, all documents governing the Plan, including insurance contracts, and a copy of the latest annual report (Form 5500 Series), if any, filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.

Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and updated summary plan description (SPD). The Plan Administrator may make a reasonable charge for the copies.

Receive a summary of the Plan's annual Form 5500, if any is required by ERISA to be prepared, in which case the Plan Administrator, is required by law to furnish each participant with a copy of this summary annual report.

Prudent Actions by Plan Fiduciaries In addition for creating rights for Plan Participants, ERISA imposes duties upon the people who are responsible for the employee welfare benefit plan. The people who operate your plan, called “fiduciaries,” have a duty to do so prudently in the interest of you and other plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you from obtaining a welfare benefit or exercising your rights under ERISA.

Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps that you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report (Form 5500), if any, from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator, to provide the materials and pay you up to $110 per day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored in whole or in part, and if you have exhausted the claims procedures available to you under the Plan, you may file suit in a state or federal court.

If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance With Your Questions If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor (listed in your telephone directory), or contact the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S.

Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

Your Certificate of Insurance, issued by Symetra Life Insurance Company, is attached.

This Certificate is furnished to you automatically without charge.

LG-12128 04/18 1

Symetra Disability Plan Claim Procedures

Symetra’s Disability Plan Claim Procedures are set forth in the attached certificate of insurance, as supplemented by the procedures set forth below. The Disability Plan Claim Procedures are followed by Symetra Life Insurance Company and First Symetra National Life Insurance Company of New York when processing group short term disability claims, group long term disability claims, and waiver of premium claims under a group life insurance plan.

These Disability Plan Claim Procedures are being furnished to you automatically, without charge, as a separate document accompanying the Summary Plan Description.

What you should do and what you should expect if you have a disability claim?

To claim benefits under the Plan, you* must first apply for the benefit according to Symetra’s requirements.

Claims can be submitted telephonically, electronically, or via paper application. You may request the claim form from Symetra by calling (877) 377-6773 or from the Plan Administrator by contacting your benefits coordinator. If Symetra’s claim form or instructions for completing it are not available, you must submit to Symetra a written statement of the reasons you are entitled to benefits, and you must include your name, address and contact information, and your employer’s name, address and contact information. After you have completed the claim form or written statement, you must submit it to Symetra at the following address:

Symetra Claims Department P.O. Box 1230

Enfield, CT 06083

For purposes of the Plan’s claims procedures, you will be considered to have filed your claim under the Plan when your claim form or written statement is received at this address.

The Plan Administrator has appointed Symetra as the claims administrator of the Plan for adjudicating claims for benefits under the Plan and for deciding any appeals of denied claims. Symetra shall have the authority, at its discretion, to interpret the terms of the Plan, to decide questions of eligibility for coverage or benefits under the Plan, and to make any related findings of fact. All benefits decisions made by Symetra shall be final and binding to the full extent permitted by law.

Symetra has 45 days from the date your claim is filed to determine whether or not benefits are payable to you in accordance with the terms and provisions of the Plan, and, if so, the amount of benefits. If more time is needed to review your claim due to circumstances beyond the Plan’s control, Symetra must notify you in writing that the review period has been extended. The extension notice will describe the circumstances requiring the extension, the expected date of a decision, the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on your claim, and the additional information needed to resolve those issues. This extension may be for up to 30 days beyond the end of the normal 45-day review period. A second 30-day extension may apply if, for reasons beyond the Plan’s control, additional time, beyond the first 30-day extension, is needed to review your claim. In this case, Symetra will notify you in writing that the review period has been further extended. Symetra will provide the same information required in the first notice of extension.

If an extension of the review period is made because you must furnish additional information in order for Symetra to decide your claim, Symetra will specify the additional information that is needed in the extension notice. You will have at least 45 days to return the specified information to Symetra. Until you return that information (or the time to provide the information expires), the review period will be “tolled,” further extending the review period beyond the normal 45-day period or the extended 75- or 105-day period. For example, if Symetra advises you on the 20th day after your claim was filed that your claim is incomplete because it lacks a physician’s statement regarding your ability to perform various tasks, the number of days from the date of Symetra’s request for the physician’s statement until you provide the physician’s statement will not count as part of the review period. In this example, the day you provided the physician’s statement will be treated as the 21st day of the review period.

LG-12128 04/18 2

If needed in order to decide your claim, Symetra may require you to submit to a medical examination, at Symetra’s expense. If a medical examination is required, Symetra will notify you of the date and time of the examination and the physician’s name and location. This will be treated as a request for additional information, as described above, and the review period will be tolled until Symetra receives the results of the examination. It is important that you keep any appointments made for you by Symetra, since rescheduling examinations will delay the claim process.

If your claim is approved, you will receive the appropriate benefit from Symetra.

If your claim is denied, in whole or in part, you will receive a written notice from Symetra within the review period. The written notice of claim denial must include the following information:

1. The specific reason(s) the claim was denied, including an explanation of the basis for disagreeing with or not following:

• the views that you presented to Symetra of health care professionals that treated you and vocational professionals that evaluated you;

• the views of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the claim denial, without regard to whether Symetra relied upon the advice in denying your claim; and

• the disability determination made by the Social Security Administration, if you presented such a disability determination to Symetra.

2. Specific reference to the Policy provision(s) on which the denial was based.

3. A description of any additional material or information necessary to perfect your claim, and the reason this material or information is necessary.

4. If your claim was denied based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request.

5. Either the specific internal rules, guidelines, protocols, standards or other similar criteria of the Plan relied upon in denying your claim or, alternatively, a statement that in denying your claim, Symetra did not rely upon any specific internal rules, guidelines, protocols, standards or other similar criteria of the Plan in existence.

6. A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim.

7. A statement informing you of your right to appeal the decision, and an explanation of the appeal procedure, as outlined below.

Appeal procedure for denied disability claims

Whenever a claim is denied in whole or in part, you have the right to appeal the decision. You (or your duly authorized representative) must make a written request to appeal Symetra’s decision within 180 days from the date you receive the denial. If you do not make this request within that time, you will have waived your right to appeal. This request for review should be directed to Symetra at the address given above for claims submissions. When requesting a review, you should state the reasons you believe the claim denial was improper, and you should submit any additional information, material, or comments which you consider appropriate. You may also review and, upon request, obtain copies of any documents that have a bearing on the claim, including the documents which establish and control the Plan.

LG-12128 04/18 3

Once your request has been received by Symetra, a full and fair review of your claim must take place. This review will give no deference to the original claim decision and will not be made by the person who made the initial claim decision, nor a subordinate of that person. Any medical or vocational experts consulted by Symetra in reviewing your claim will be identified. If your claim was denied in whole or in part based on a medical judgment, Symetra, in deciding your appeal of that determination, will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. In no case will such health care professional be an individual who was consulted in connection with the original claim decision. In conducting the review, Symetra will take into account all comments, documents, and other information that you submit, whether or not it was submitted at the time of the initial claim decision.

In conducting the review, Symetra will provide you, free of charge, with any new or additional evidence considered, relied upon, or generated by Symetra (or at the direction of Symetra) in connection with your claim. Symetra will provide you with this evidence as soon as possible and sufficiently in advance of the date on which the review period expires, as further described below, in order to give you a reasonable opportunity to respond to the new or additional evidence prior to that date.

Before Symetra can deny your appeal based on a new or additional rationale, Symetra must provide you, free of charge, with the new or additional rationale. Symetra will provide you with the new or additional rationale as soon as possible and sufficiently in advance of the date on which the review period expires, as further described below, in order to give you a reasonable opportunity to respond to the new or additional rationale prior to that date.

Symetra has 45 days from the date it receives your appeal to review the original claim decision for your claim and notify you of its decision. Under special circumstances, Symetra may require more time to review your claim. If this should happen, Symetra must notify you, in writing, that its appeal review period has been extended for an additional 45 days, noting the special circumstances requiring the extension and the date by which a decision on the appeal is expected.

If an extension of the appeal review period is made because you must furnish additional information in order for Symetra to decide your appeal, Symetra will specify the additional information that is needed in the extension notice. You will have at least 45 days to return the specified information to Symetra. Until you return that information (or the time to provide the information expires), the review period will be “tolled,” further extending the review period beyond the normal 45-day period.

Once its review is complete, Symetra must notify you, in writing, of the results of the review and must include in its notice the following information:

1. The specific reason(s) the appeal was denied, including an explanation of the basis for disagreeing with or not following:

• the views that you presented to Symetra of health care professionals that treated you and vocational professionals that evaluated you;

• the views of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the claim denial, without regard to whether Symetra relied upon the advice in denying your claim; and

• the disability determination made by the Social Security Administration, if you presented such a disability determination to Symetra.

2. Specific reference to the Policy provision(s) on which the denial was based.

3. A statement that you are entitled to receive, upon request and free of charge, all documents, records, and copies of all documents, records, and other information relevant to your claim for benefits under the Plan.

LG-12128 04/18 4

4. If your claim was denied based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request.

5. Either the specific internal rules, guidelines, protocols, standards or other similar criteria of the Plan relied upon in denying your claim or, alternatively, a statement that in denying your claim, Symetra did not rely upon any specific internal rules, guidelines, protocols, standards or other similar criteria of the Plan in existence.

6. The written notice will include a statement regarding your right to file suit in federal or state court to recover benefits under the terms of the Plan, including pursuant to ERISA Section 502(a) as applicable, together with a description of any applicable contractual limitations period that applies to your right to bring such an action, including the calendar date on which the contractual limitations period expires for your claim.

* You may have an authorized representative, such as a guardian or an individual having a valid power of attorney, act on your behalf in pursuing a claim for benefits under this Plan. The Plan will take reasonable steps to determine whether an individual claiming to be acting on your behalf is, in fact, validly empowered to do so under the circumstances. Throughout this description of the Plan’s claims and appeals procedures, the word “you” is used to refer to you and/or any representative acting on your behalf in claiming benefits under the Plan.

LG-12128 04/18 1

Symetra Non-Disability Plan Claim Procedures (including Group Life Claims)

The Plan’s claims procedures are set forth in the attached certificate of insurance, as supplemented by the Symetra Non-Disability Claim Procedures set forth below. The Symetra Non-Disability Plan Claim Procedures are followed by Symetra Life Insurance Company and First Symetra National Life Insurance Company of New York when processing group life claims and any claims other than claims for group short term disability benefits, group long term disability benefits and group life waiver of premium benefits. These Symetra Non-Disability Plan Claim Procedures are being furnished to you automatically, without charge, as a separate document accompanying the Summary Plan Description.

What you should do and what you should expect if you have a non-disability claim, including a Group Life Claim

To claim benefits other than disability benefits under the Plan (including Group Life Claims), you must first complete Symetra’s claim form according to Symetra’s requirements. You may request the claim form from Symetra by calling (877) 377-6773 or from the Plan Administrator by contacting your benefits coordinator.

If Symetra’s claim form or instructions for completing it are not available, you must submit to Symetra a written statement of the reasons you are entitled to benefits, and you must include your name, address and contact information, and your employer’s name, address and contact information. After you have completed the claim form or written statement, you must submit it to Symetra at the following address:

Symetra Claims Department P.O. Box 1230

Enfield, CT 06083

For purposes of the Plan’s claims procedures, you will be considered to have filed your claim under the Plan when your claim form or written statement is received at this address.

Symetra has 90 days from the date your claim is filed to decide your claim. If more time is needed to review your claim due to circumstances beyond the Plan’s control, Symetra must notify you in writing that the review period has been extended. The extension notice will describe the circumstances requiring the extension, the expected date of a decision, the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on your claim, and the additional information needed to resolve those issues. This extension may be for up to 90 days beyond the end of the normal 90-day review period.

If your claim is approved, you will receive the appropriate benefit from Symetra.

If your claim is denied, in whole or in part, you must receive a written notice from Symetra within the review period (which may have been extended beyond 90 days, as described above). The written notice of claim denial must include the following information:

1. The specific reason(s) the claim was denied.

2. Specific reference to the Policy provision(s) on which the denial was based.

3. A description of any additional material or information necessary to perfect your claim, and the reason this material or information is necessary.

4. A statement informing you of your right to appeal the decision, and an explanation of the appeal procedure, as outlined below.

LG-12128 04/18 2

Appeal procedure for denied non-disability claims (including Group Life Claims)

Whenever a claim is denied in whole or in part, you have the right to appeal the decision. You (or your duly authorized representative) must make a written request to appeal Symetra’s decision within 60 days from the date you receive the denial. If you do not make this request within that time, you will have waived your right to appeal. This request for review should be directed to Symetra at the address given above for claims submissions. When requesting a review, you should state the reasons you believe the claim denial was improper, and you should submit any additional information, material, or comments which you consider appropriate. You may also review and, upon request, obtain copies of any documents that have a bearing on the claim, including the documents which establish and control the Plan.

Once your request has been received by Symetra, a full and fair review of your claim must take place. This review will give no deference to the original claim decision and will not be made by the person who made the initial claim decision, nor a subordinate of that person.

Symetra has 60 days from the date it receives your request to review the original claim decision for your claim and notify you of its decision. Under special circumstances, Symetra may require more time to review your claim. If this should happen, Symetra must notify you, in writing, that its appeal review period has been extended for an additional 60 days, noting the special circumstances requiring the extension and the date by which a decision on the appeal is expected.

Once its review is complete, Symetra must notify you, in writing, of the results of the review and must include in its notice the following information:

1. The specific reason(s) the appeal was denied.

2. Specific reference to the Policy provision(s) on which the denial was based.

3. A statement that you are entitled to receive, upon request and free of charge, all documents, records, and copies of all documents, records, and other information relevant to your claim for benefits under the Plan.

4. The written notice will include a statement regarding your right to file suit in federal or state court to recover benefits due to you under the terms of the Plan, including pursuant to ERISA Section 502(a) as applicable.

Suit may be filed only after the plan’s review procedures described above have been exhausted and only if filed within the limitations set forth in the certificate of insurance.

Symetra Life Insurance Company

LG-12042/CER 10/12

Symetra® is a registered service mark of Symetra Life Insurance Company.

Group Life Insurance

CERTIFICATE

Rider #1, Effective January 1, 2021

Symetra ® is a registered service mark of Symetra Life Insurance Company.

LGC 13500/TX-CERT 07/17 1

CERTIFICATE OF INSURANCE

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, Washington 98004-5135

(An insurance company)

Policyholder: City of Burleson Policy Number: 01 017859 00 Policy Effective Date: January 1, 2019 Policy Anniversary Date: January first of each year beginning in 2020

We have issued The Policy to the Policyholder. Our name, the Policyholder's name and the Policy Number are shown above. The provisions of The Policy, which are important to You, are summarized in this certificate consisting of this form and any additional forms which have been made a part of this certificate. This certificate replaces any other certificate We may have given to You earlier under The Policy. The Policy alone is the only contract under which payment will be made. Any difference between The Policy and this certificate will be settled according to the provisions of The Policy on file with Us. The Policy may be inspected at the office of the Policyholder.

Signed for The Company

Jacqueline M. Veneziani, Secretary Margaret Meister, President

A note on capitalization in this certificate:

Capitalization of a term, not normally capitalized according to the rules of standard punctuation, indicates a word or phrase that is a defined term in The Policy or refers to a specific provision contained herein.

LGC 13500/TX-CERT 07/17 2

Table of Contents Certificate Face Page Schedule of Insurance

Definitions Eligibility and Enrollment

Period of Coverage Benefits

General Provisions

LGC 13500/TX-SCH 07/17 1

Schedule of Insurance

The benefits described herein are those in effect as of: January 1, 2021

Cost of Coverage:

Non-Contributory Coverage:

Basic Life Insurance Basic Accidental Death and Dismemberment Insurance

Contributory Coverage:

Basic Dependent Life Insurance Supplemental Life Insurance Supplemental Accidental Death and Dismemberment Insurance Supplemental Dependent Life Insurance Supplemental Dependent Accidental Death and Dismemberment Insurance

Eligible Class(es) for Coverage: All full-time Active Employees working a minimum of 30 hours each week who are citizens or legal residents of the United States, excluding temporary, leased or seasonal employees.

Class 1 All Eligible Employees electing Dependent Basic Life Plan Option 1

Annual Enrollment Period: As determined by Your Employer on a yearly basis.

Benefit increases may not exceed the policy’s guaranteed issue amount.

For newly enrolled:

Employees: up to 5 increments of $10,000.

For currently enrolled:

Employees: up to 5 increments of $10,000.

This open enrollment does not apply to employees previously declined for amounts of coverage, or for those who were required to submit Evidence of Insurability but failed to do so. This open enrollment also does not apply to employees who have not satisfied the service waiting period.

Coverage enrolled for during this open enrollment period is effective January 1, 2019. However, any benefit amounts subject to Evidence of Insurability are not effective until approved in writing by Symetra.

Eligibility Waiting Period for Coverage:

If You are Actively at Work for the Employer before January 1, 2021: The first of the month following 30 days of continuous employment.

If You are Actively at Work for the Employer on or after January 1, 2021: None.

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a full-time Active Employee with the Employer under the Prior Policy.

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were a part-time or seasonal employee with the Employer.

The Eligibility Waiting Period for Coverage will be reduced by the period of time You were full-time Active Employee with the Employer if You are rehired or return to an eligible class within 90 days of the date Your coverage ended.

LGC 13500/TX-SCH 07/17 2

Life Insurance Benefit

Benefit Amounts are rounded to the next higher $1,000, if not already a multiple thereof.

Employee

Basic

Benefit Amount

Benefit Maximum Amount

Guaranteed Issue Amount

Class 1 1 x Earnings $250,000 $250,000

Supplemental

Amount

Benefit Maximum Amount

Guaranteed Issue Amount

Class 1 $10,000 to $300,000 in increments of $10,000 as selected by You on the enrollment card

$300,000, not to exceed 5 x Earnings

$100,000

Dependent

Benefit Benefit Maximum Guaranteed Issue Basic Amount Amount Amount Class 1 Spouse $5,000 $5,000 $5,000 Child birth to 26 years 2,500 $2,500 $2,500

Amount

Benefit Maximum Amount

Guaranteed Issue Amount

Class 1 Spouse $5,000 to $150,000 in increments of $5,000 as selected by You on the enrollment card

$150,000, not to exceed 100% of

Your Supplemental Life Benefit Amount

$25,000 birth to 26 years $10,000 $10,000 $10,000

Accidental Death and Dismemberment Insurance Benefit (AD&D)

Principal Sums are rounded to the next higher $1,000, if not already a multiple thereof.

Employee

Basic

Principal Sum Principal Maximum

Sum Class 1 1 x Earnings $250,000

Sum

Class 1 $10,000 to $300,000 in increments of

$10,000 as selected by You on the enrollment card

$300,000, not to exceed 5 x Earnings

LGC 13500/TX-SCH 07/17 3

Sum Class 1 Spouse $5,000 to $150,000 in increments of $5,000 as selected by You on the enrollment card

$150,000, not to exceed 100% of

Your Supplemental AD&D Principal Sum birth to 26 years $10,000 $10,000

Additional Accidental Death and Dismemberment Insurance Benefits

Seat Belt and Air Bag Coverage Seat Belt Benefit Amount: 10% of Basic and Supplemental AD&D Principal Sum Seat Belt Maximum Amount: $25,000 Seat Belt Minimum Amount: $1,000

Air Bag Benefit Amount: 10% of Basic and Supplemental AD&D Principal Sum Air Bag Maximum Amount: $25,000

Repatriation Benefit Benefit Amount: 5% of Basic and Supplemental AD&D Principal Sum Maximum Amount: $5,000

Child Education Benefit Benefit Amount: 5% of Basic and Supplemental AD&D Principal Sum Maximum Amount: $5,000 Minimum Amount: $2,500

Day Care Benefit Benefit Amount: 5% of Basic and Supplemental AD&D Principal Sum Maximum Amount: $5,000 Minimum Amount: $2,500

Spouse Education Benefit Benefit Amount: 3% of Basic and Supplemental AD&D Principal Sum Maximum Amount: $3,000 Minimum Amount: $1,250

Reduction in Amount of Life Insurance We will reduce the amount of Life Insurance for You and Your Dependent by any amount:

1) of individual Life Insurance issued in accordance with the Conversion Right;

2) that was continued under the Portability provision; or

3) of Life Insurance in force, paid or payable under the Prior Policy.

LGC 13500/TX-SCH 07/17 4

Reduction in Coverage Due to Age Applies to Basic Life Insurance, Basic Accidental Death and Dismemberment Insurance, Supplemental Life Insurance, Supplemental Accidental Death and Dismemberment Insurance and Supplemental Spouse Life Insurance:

We will reduce the Life Insurance Benefit and Principal Sum for You and Your Spouse to the percentage indicated in the table below. This reduction will be effective on the first of the month coincident with or following the date You attain the age shown below . These reductions also apply if:

1) You or Your Spouse become covered under The Policy; or

2) Your or Your Spouse’s coverage increases;

on or after the date You attain age 65.

Percentage to which the original amount of coverage will be reduced:

Your Age Benefit % You and Your Spouse Receive 65 65% 70 50% 75 35%

Applies to Supplemental Spouse Accidental Death and Dismemberment Insurance:

We will reduce the Principal Sum for Your Spouse to the percentage indicated in the table below. This reduction will be effective on the first of the month coincident with or following the date You attain the age shown below . These reductions also apply if:

1) Your Spouse becomes covered under The Policy; or

2) Your Spouse’s coverage increases;

on or after the date You attain age 35.

Percentage to which the original amount of coverage will be reduced:

Your Age Benefit % Your Spouse Receives 35 75% 50 70% 65 65%

Applies to Basic Spouse Life Insurance:

No reduction.

Definitions

LGC 13500/TX-DEF 07/17 1

Active Employee means an employee who works for the Employer on a regular basis in the usual course of the Employer's business. This must be at least the number of hours shown in the Schedule of Insurance.

Actively at Work means at work with Your Employer on a day that is one of Your Employer's scheduled workdays. On that day, You must be performing for wage or profit all of the regular duties of Your job:

1) in the usual way; and

2) for Your usual number of hours.

We will also consider You to be Actively At Work on any regularly scheduled vacation day or holiday, only if You were Actively At Work on the preceding scheduled work day.

Airworthiness Certificate means:

1) the “Standard” Airworthiness Certificate issued by the United States Federal Aviation Administration (FAA); or

2) a foreign equivalent issued by the governmental authority with jurisdiction over civil aviation in the country of its registry.

Civil or Public Aircraft means a Civil or Public Aircraft which:

1) has a current and valid Airworthiness Certificate;

2) is piloted by a person who has a valid and current certificate of competency of a rating which authorizes him or her to pilot the aircraft; and

3) is not operated by the militia, or armed forces of any state, national government or international authority.

Common Carrier means a conveyance operated by a concern, other than the Policyholder, organized and licensed for the transportation of passengers for hire and operated by that concern.

Common Carrier will not mean any such conveyance which is hired or used for a sport, gamesmanship, contest, sightseeing, observatory and/or recreational activity, regardless of whether such conveyance is licensed.

Contributory Coverage means coverage for which You are required to contribute toward the cost. Contributory Coverage is shown in the Schedule of Insurance.

Dependent Child means Your children, stepchildren, adopted children, grandchildren or adopted grandchildren provided such children are:

1) under age 26; or

2) age 26 or older and physically or mentally disabled and under the parents’ supervision.

LGC 13500/TX-DEF 07/17 2

means Your Spouse, Your same or opposite sex domestic partner as permitted or required to be recognized as a dependent under state or federal law and Your Dependent Child. A Dependent must be a citizen or legal resident of the United States. Any person who is in full-time military service cannot be a Dependent.

Earnings means Your regular annual rate of pay not counting commissions, bonuses, tips and tokens, overtime pay or any other fringe benefits or extra compensation, in effect on the most recent date immediately prior to the last Policy Anniversary Date.

Employer means the Policyholder.

FAA

means:

1) the Federal Aviation Administration of the United States; or

2) the equivalent aviation authority for the country of the aircraft's registry, if the governmental authority is recognized by the United States.

Guaranteed Issue Amount means the amount of Life Insurance for which We do not require Evidence of Insurability. The Guaranteed Issue Amount is shown in the Schedule of Insurance.

Injury means bodily Injury resulting:

1) directly from an accident; and

2) independently of all other causes;

which occurs while You or Your Dependent are covered under The Policy.

Loss resulting from:

1) sickness or disease, except a pus-forming infection which occurs through an accidental wound;

or

2) medical or surgical treatment of a sickness or disease;

is not considered as resulting from Injury.

Military Transport Aircraft means a transport aircraft operated by:

1) the United States Air Mobility Command (AMC); or

2) a national military air transport service of a governmental authority recognized by the United

States.

LGC 13500/TX-DEF 07/17 3

Motor Vehicle means a self-propelled, four or more wheeled:

1) private passenger: car, station wagon, van or sport utility vehicle;

2) motor home or camper; or

3) pick-up truck;

not being used as a Common Carrier.

A Motor Vehicle does not include farm equipment, snowmobiles, all-terrain vehicles, lawnmowers or any other type of equipment vehicles.

Non-Contributory Coverage means coverage for which You are not required to contribute toward the cost. Non-Contributory Coverage is shown in the Schedule of Insurance.

Normal Retirement Age means the Social Security Normal Retirement Age under the most recent amendments to the United States Social Security Act. It is determined by Your date of birth, as follows:

Year of Birth Normal Retirement Age Year of Birth Normal Retirement Age 1937 or before 65 1955 66 + 2 months 1938 65 + 2 months 1956 66 + 4 months 1939 65 + 4 months 1957 66 + 6 months 1940 65 + 6 months 1958 66 + 8 months 1941 65 + 8 months 1959 66 + 10 months 1942 65 + 10 months 1960 or after 67 1943 through 1954 66

On means, when used with reference to any conveyance (land, water or air), in or On, boarding or alighting from the conveyance.

Physician means a legally qualified Physician or surgeon other than a Physician or surgeon who is Related to You by blood or marriage.

Prior Policy means, if applicable, the group life insurance policy carried by the Employer on the day before the Policy Effective Date.

Related means Your Spouse or other adult living with You, sibling, parent, step-parent, grandparent, aunt, uncle, niece, nephew, son, daughter or grandchild.

Scheduled Aircraft means a Civil or Public Aircraft operated by a scheduled airline which:

1) is licensed by the FAA for the transportation of passengers for hire; and

2) publishes its flight schedules and fares for regular passenger service.

LGC 13500/TX-DEF 07/17 4

Spouse means Your Spouse who is not legally separated or divorced from You. Spouse will include Your domestic partner, provided You have executed a domestic partner affidavit satisfactory to Us, establishing that You and Your partner are domestic partners for purposes of The Policy. You will continue to be considered domestic partners provided You continue to meet the requirements described in the domestic partner affidavit.

The Policy means The Policy which We issued to the Policyholder under the Policy Number shown on the face page.

We, Us or Our means the insurance company named on the face page of The Policy.

You or Your means the person to whom this certificate is issued. This person owns the certificate and is entitled to exercise all rights and privileges under the certificate.

Eligibility and Enrollment

LGC 13500/TX-ELI 07/17 1

Eligible Persons: Who is eligible for coverage?

All persons in the class or classes shown in the Schedule of Insurance will be considered Eligible Persons.

Eligibility for Coverage: When will I become eligible?

You will become eligible for coverage on the latest of:

1) the Policy Effective Date;

2) the date on which You complete the Eligibility Waiting Period for Coverage; or

3) the date You become a member of an Eligible Class.

Eligibility for Dependent Coverage: When will I become eligible for Dependent Coverage?

You will become eligible for Dependent coverage on the later of:

1) the date You become insured for employee coverage; or

2) the date You acquire Your first Dependent.

You may not elect coverage for Your Dependent if such Dependent is covered as an employee under The Policy. No person can be insured as a Dependent of more than one employee under The Policy.

Enrollment: How do I enroll for coverage for myself and my Dependents?

For Non-Contributory Coverage, Your Employer will automatically enroll You. However, You will need to complete a beneficiary designation form.

To enroll for Contributory Coverage, You must:

1) complete and sign a group insurance enrollment form, satisfactory to Us; and

2) deliver it to Your Employer.

If You do not enroll within 31 days after becoming eligible under The Policy, or if You were eligible to enroll under the Prior Policy and did not do so, and later choose to enroll, You may only enroll:

1) during an Annual Enrollment Period if designated by the Policyholder; or

2) within 31 days of the date You have a Change in Family Status.

Any enrollment may be subject to the Evidence of Insurability Requirements provision.

Evidence of Insurability Requirements: When will I first be required to provide Evidence of Insurability?

We require Evidence of Insurability, satisfactory to Us, for initial coverage, if You:

1) enroll more than 31 days after the date You are first eligible to enroll, including electing initial coverage after a Change in Family Status;

2) enroll for an amount of Life Insurance greater than the Guaranteed Issue Amount, regardless of when You enroll for coverage; or

3) were eligible for any coverage under the Prior Policy, but did not enroll and later choose to enroll for that coverage under The Policy.

If Your Evidence of Insurability is not satisfactory to Us:

1) Your amount of Life Insurance will equal the amount for which You were eligible without providing Evidence of Insurability, provided You enrolled within 31 days of the date You were first eligible to enroll; or

2) You will not be covered under The Policy if You enrolled more than 31 days after the date You were first eligible to enroll.

Eligibility and Enrollment

LGC 13500/TX-ELI 07/17 2

Dependent Evidence of Insurability Requirements: When will my Dependent first be required to provide Evidence of Insurability?

We require Evidence of Insurability, satisfactory to Us, for initial coverage, if You:

1) enroll for Your Dependent coverage more than 31 days after the date You are first eligible to enroll, including electing initial coverage after a Change in Family Status;

2) enroll for an amount of Dependent Life Insurance greater than the Guaranteed Issue Amount, regardless of when You enroll for coverage; or

3) were eligible for any coverage under the Prior Policy, but did not enroll and later choose to enroll for that coverage under The Policy.

However, no Evidence of Insurability will be required if the amount of Life Insurance for Your Dependent Child is $15,000 or less.

If Your Dependent Evidence of Insurability is not satisfactory to Us:

1) the amount of Dependent Life Insurance will equal the amount for which Your Dependent was eligible without providing Evidence of Insurability, provided You enrolled within 31 days of the date You were first eligible to enroll; or

2) Your Dependent will not be covered under The Policy if You enrolled more than 31 days after the date You were first eligible to enroll.

Evidence of Insurability: What is Evidence of Insurability?

Evidence…