47-I11 - Life Contract.pdf

Symetra Life Insurance Company

LG-12042/CON 10/12

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

Group Life Insurance

CONTRACT

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

LGC 13000/TX 07/17 1

Name of Policyholder: City of Burleson

Policy Number: Effective Date: Place of Delivery:

01 017859 00 January 1, 2019 Texas

Anniversary Date: Premium Due Dates:

January first of each year beginning in 2020

No later than 90 days following the Policy Effective Date, and the first day of each calendar month after the plan effective date.

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200

Bellevue, Washington, 98004-5135 (An insurance company, herein called The Company) will pay benefits according to the terms and conditions of The Policy.

Signed for The Company

Michael Fry, Executive Vice President Margaret Meister, President

Table of Contents Premium Provisions Premium Schedule Policy Provisions

Incorporation Provision

LGC 13000/TX 07/17 2

The Schedule(s) of Insurance for The Policy benefits listed below are shown in the certificate(s), as incorporated into The Policy:

1) Basic Life Insurance;

2) Basic Accidental Death and Dismemberment Insurance;

3) Basic Dependent Life Insurance;

4) Supplemental Life Insurance;

5) Supplemental Accidental Death and Dismemberment Insurance;

6) Supplemental Dependent Life Insurance; and

7) Supplemental Dependent Accidental Death and Dismemberment Insurance.

The Schedule(s) of Insurance will control the:

1) benefit amounts and maximum limits;

2) eligibility and effective date requirements; and

3) other schedule amounts and limits;

which apply to the employees of the Policyholder.

Initial Monthly Premium Rates:

The initial monthly premium rates to be charged for employee coverage and/or child/Spouse coverage, if applicable, are shown on the following page(s).

The first premium is due and payable no later than 90 days following the effective date of The Policy.

Subject to The Policy's grace period provision, all premiums after the first must be paid when or before they are due.

Premiums are based on the employee’s age on his or her effective date and thereafter on the Policy Anniversary following the date of change.

The Initial Monthly Premium Rates may be converted as follows:

To Convert Rates to: Use a Conversion Factor of:

- annual rates 11.8227

- semi-annual rates 5.9557

- quarterly rates 2.9852

Grace Period:

The Company will allow the Policyholder a 31 day grace period for the payment of all premiums after the first. During this 31 day period, The Policy will stay in force. If the owed premium is not paid by the 31st day, The Policy will automatically terminate. If the Policyholder gives The Company written advance notice of an earlier cancellation date, The Policy will terminate on the earlier date. Premium is due for each day The Policy is in force.

Monthly Premium Rate Guarantee:

Initial Monthly Premium rates are guaranteed as follows:

Benefit Rate Guarantee Period

Basic Life Insurance 36 months Basic Accidental Death and Dismemberment Insurance 36 months Basic Dependent Life Insurance 36 months Supplemental Life Insurance 36 months Supplemental Accidental Death and Dismemberment Insurance 36 months Supplemental Dependent Life Insurance 36 months Supplemental Dependent Accidental Death and Dismemberment Insurance

36 months

LGC 13000/TX 07/17 3

Subject to the Rate Guarantee period shown above, The Company has the right to change premium rates on any premium due date if:

1) written notice is delivered to the Policyholder's last address on record; and

2) the change is effective at least 31 days after the date of notice.

The Rate Guarantee supersedes only those provisions appearing elsewhere in The Policy which give The Company the right to change the premium rates, and then, only for the period of time for which the rates are guaranteed. However, The Company may change the premium rates during the Rate Guarantee period if there is a 10% change in lives and/or volume in The Policy or if the Policyholder adds or deletes a subsidiary or affiliated business entity. The Company may also change the premium rates during the Guarantee Period if there has been a material misstatement in the reported experience during the pre-sale process. The Rate Guarantee in no way affects, amends or supersedes any other provision in The Policy.

Calculation:

Premiums may be calculated by multiplying the rate times the applicable number of units of coverage.

If any insurance is added, increased or becomes effective after The Policy is in force, the premium charges will begin on:

1) the day the coverage is effective, if it is also the first day of a policy month; or

2) the first day of the next policy month.

For insurance which is terminated, premium charges will stop as of the first day of the next policy month.

With respect to Dependent Life Insurance only, the premium rate per Dependent Unit or per $1,000 of insurance, whichever is applicable, will be based on actuarial assumptions, due to the difficulty in obtaining the ages of all Dependents who are covered under this benefit. The actuarial assumptions will produce, in the opinion of The Company, the same total amount of premium as would be obtained by the use of the actual ages of the Dependents covered.

Premiums may be calculated by any other method which both The Company and the Policyholder agree to in writing.

Premium Payments:

Premium payments are due and payable in full to a place designated by The Company or, with respect to the initial premium payment, premium payments may be made to an authorized agent of The Company.

Payment of premiums for a period before it is due will not guarantee the insurance for that period.

Premium Schedule

LGC 13000/TX 07/17 4

Coverage Monthly Rate

Basic Life Insurance $0.030 per $1,000

Basic Accidental Death and Dismemberment Insurance $0.030 per $1,000

Basic Dependent Life Insurance $2.000 per family unit

Supplemental Life Insurance step-rated*

Supplemental Accidental Death and Dismemberment Insurance $0.030 per $1,000

Supplemental Dependent Life Insurance Spouse step-rated*

Child $2.000 per family unit

Supplemental Dependent Accidental Death and Dismemberment Insurance

Spouse $0.030 per $1,000

Child $0.040 per $1,000

* Supplemental Life Insurance and Supplemental Spouse Life Insurance monthly step-rates are as follows: (Premiums for Supplemental Spouse Life Insurance are calculated based on the employee’s age.)

Age Per $1,000 of Insurance Age Per $1,000 of Insurance

Under 25 $0.070 50 through 54 $0.330 25 through 29 0.070 55 through 59 0.540 30 through 34 0.080 60 through 64 0.720 35 through 39 0.100 65 through 69 1.220 40 through 44 0.140 70 through 74 2.160 45 through 49 0.220 75 and over 8.180

Premium rate adjustments due to change in age are effective on the Policy Anniversary following the date of change.

LGC 13000/TX 07/17 5

Entire Contract:

The contract between the parties consists of:

1) The Policy;

2) any certificates incorporated and made a part of The Policy;

3) any riders issued in connection with such certificates;

4) the Policyholder’s application, if any, a copy of which is attached to and made a part of The

Policy when issued; and

5) any written medical insurability application submitted by the Eligible Person/Employee and accepted by The Company in connection with The Policy.

In the absence of fraud, all statements made by the Policyholder or persons insured under The Policy will be deemed representations and not warranties. No statement made to effect this insurance will be used in any contest unless it is in writing and a copy of it is given to the person who made it, or to his or her beneficiary.

Incontestability:

Except for non-payment of premium, the insurance provided by The Policy cannot be contested after such insurance has been in effect for a period of two years.

Changes:

The Company reserves the right to make changes in The Policy, after The Policy has been in force for 12 months. The Company will give the Policyholder 31 days advance written notice of any change. No agent has authority to change or waive any part of The Policy. To be valid, any change or waiver must be in writing, approved by one of Our officers and made a part of The Policy.

Clerical Error:

Clerical error (whether by the Policyholder, the Plan Administrator, or Us) in keeping the records having to do with The Policy, or delays in making entries on the records, will not void the insurance of any person if that insurance would otherwise have been in effect. A clerical error will not extend the insurance of any person if that insurance would otherwise have ended or been reduced as provided by The Policy. When a clerical error is found, premiums and benefits will be adjusted based on the true facts and The Policy.

Conformity with Law:

If any provision of The Policy is contrary to the law of the jurisdiction in which it is delivered, such provision is hereby amended to conform to that law. If any change to state or federal law, including but not limited to the Federal Social Security Act, affects The Company's liability under The Policy, The Company may change The Policy, the premiums or both. Such change:

1) will be effective as of the date of the change to the state or federal law; and

2) will not be made until The Company gives the Policyholder 31 days notice.

Termination of Policy:

The Company may terminate The Policy for the following reasons by giving the Policyholder 31 days written notice:

1) the Policyholder fails to furnish any information which The Company may reasonably require;

2) the Policyholder fails to perform any of his other obligations pertaining to The Policy;

3) less than 75% of the persons eligible for coverage on a Non-Contributory basis are insured;

4) less than 15% of the persons eligible for coverage on a Contributory basis are insured; or

5) fewer than ten persons are insured.

In addition, The Company may terminate The Policy on any premium due date after The Policy has been in force for 36 months by providing 31 days written notice.

LGC 13000/TX 07/17 6

The Company reserves the right to terminate Dependent Life Insurance Benefits on any premium due date on which:

1) there are fewer than ten persons insured for Dependent Coverage; or

2) less than 15% of the persons eligible for Dependent Coverage on a Contributory basis are insured.

The Company shall give the Policyholder 31 days notice of its intent to terminate the Dependent Life Insurance Benefit.

Cancellation:

The Policy may be cancelled at any time by written notice mailed or delivered by The Company to the Policyholder, or by the Policyholder to Us. If The Company cancels, The Company will mail or deliver the notice to the Policyholder at its last address shown in Our records. If The Company cancels, it becomes effective on the later of:

1) the date stated in the notice; or

2) the 31st day after The Company mails or delivers the notice.

If the Policyholder cancels, it becomes effective on the later of:

1) the date The Company receives the notice; or

2) the date stated in the notice.

In either event:

1) The Company will promptly return to the Policyholder any unearned premium; or

2) the Policyholder will promptly pay any earned premium which has not been paid.

Any earned or unearned premium will be determined on a pro-rata basis. Cancellation will be without prejudice to any claim which commenced prior to the effective date of the cancellation.

Certificates:

The Company will give individual certificates to:

1) the Policyholder; or

2) any other person according to a mutual agreement among the other person, the Policyholder, and Us;

for delivery to persons covered under The Policy and which will explain the important features of The Policy.

Data to be Furnished:

The Policyholder, or any other person designated by the Policyholder, will give The Company all information The Company needs regarding matters pertaining to the insurance. At any reasonable time while The Policy is in force and for 12 months after that, The Company may inspect any of the Policyholder's documents, books or records which may affect the insurance or premiums of The Policy.

The Policyholder will, upon Our request, give Us:

1) the names of all persons initially eligible for coverage;

2) the names of all additional persons who become eligible for coverage;

3) the names of all persons whose amount of insurance is to be changed;

4) the names of all persons whose eligibility or insurance is terminated; and

5) any data necessary to administer the insurance provided by The Policy.

If the Policyholder gives The Company any incorrect information, the relevant facts will be determined to establish if insurance is in effect and in what amount.

No person will be deprived of insurance to which he or she is otherwise entitled or have insurance to which he or she is not entitled, because of any misstatement of fact by the Policyholder. Any required adjustment may be made in premiums or benefits.

LGC 13000/TX 07/17 7

Right to Audit:

The Company reserves the right to audit, once every two years, the Policyholder’s billing records and premium accounting practices. If The Company discovers:

1) an underpayment of premium by the Policyholder, the Policyholder will be obligated to remit, in a timely manner, the underpayment amount; or

2) an overpayment of premium, The Company will return any overpayment amount in a timely manner;

for the previous two year period.

Not in Lieu of Workers' Compensation:

The Policy does not satisfy any requirement for Workers' Compensation insurance.

Time Period:

All periods begin and end at 12:01 A.M., standard time, at the Policyholder's address.

Incorporation Provision

LGC 13000/TX 07/17 8

The Certificate(s) of Insurance listed below are attached to, incorporated in and made a part of, The Policy.

Certificate of Insurance Applicable to Effective Date of

Incorporation LGC 13500/TX-CERT 07/17 Class 1 January 1, 2019 LGC 13500/TX-CERT 07/17 Class 2 January 1, 2019 LGC 13500/TX-CERT 07/17 Class 3 January 1, 2019

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.

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.

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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.

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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.

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.

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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.

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.

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 ® 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

Michael Fry, Executive Vice President 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.

Table of Contents Certificate Face Page Schedule of Insurance

Definitions Eligibility and Enrollment

Period of Coverage Benefits

General Provisions

Schedule of Insurance

LGC 13500/TX-SCH 07/17 1

The benefits described herein are those in effect as of: January 1, 2019

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 on the Policy Effective Date: The first of the month following 30 days of continuous employment.

If You start working for the Employer after the Policy Effective Date: The first of the month following 30 days of continuous employment.

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 Benefit 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

Supplemental Benefit 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

Child 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

Supplemental Principal Sum Principal Maximum

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

Dependent

Supplemental Principal Sum Principal Maximum

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

Child 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, Supplemental Spouse Life Insurance, and Supplemental Spouse Accidental Death and Dismemberment Insurance:

We will reduce the Life Insurance Benefit and Principal Sum for You and Your Spouse to the percentage indicated in the table below.