52-I1 - Accelerated Death Benefit Notice - Employers Version.pdf

LG 1138(h)/TX 07/17 Symetra ® is a registered service mark of Symetra Life Insurance Company.

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, Washington 98004-5135 (An insurance company) Telephone: 1-800-796-3872

EMPLOYEE ACCELERATED BENEFIT INSURANCE

WHAT YOU SHOULD KNOW

Death benefits will be reduced if an accelerated benefit is paid.

DISCLOSURE: The accelerated benefit offered under this policy may or may not qualify for favorable tax treatment under the Internal Revenue Code of 1986. Favorable tax treatment would allow the benefits to be excluded from your income subject to federal taxation, and would depend upon factors such as your life expectancy at the time benefits are accelerated or whether you use the benefits to pay for necessary long-term care expenses, such as nursing home care. Due to the complexity of tax laws, you are advised to consult with a qualified tax advisor about circumstances under which you could receive acceleration-of-life- insurance benefits excludable from income under federal law.

Receipt of accelerated benefits may affect your, your spouse’s or your family’s eligibility for public assistance programs such as medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), Supplemental Social Security Income (SSI), and drug assistance programs. You are advised to consult with a qualified tax advisor and with social service agencies concerning how receipt of such a payment will affect your, your spouse’s and your family’s eligibility for public assistance.

Symetra Life Insurance Company will pay the Accelerated Benefit subject to the terms of the Employee Accelerated Benefit Insurance provisions and all other provisions of the group policy. These provisions are in the Benefit Provisions of your Employee Certificate. Please read your Employee Certificate carefully.

Briefly, however, the Accelerated Benefit is available when you have given Symetra satisfactory evidence, including a licensed physician's certificate, you have 12 months or less to live. Symetra may require the physician's certificate to be from a physician that Symetra chooses. We reserve the right to require satisfactory Proof of Terminal Illness on an ongoing basis. Any diagnosis submitted must be provided by a Physician.

If You or Your Dependent do not submit proof of Terminal Illness satisfactory to Us, or if You or Your Dependent refuse to be examined by a Physician, as We may require, then We will not pay an Accelerated Benefit.

While a claim is pending, We have the right, at Our expense, to have the insured examined by a Physician when and as often as We reasonably require. If there are conflicting opinions between the insureds’ physician, and the company's physician, we may seek, at Our expense, a third medical opinion of a Licensed Health Care Practitioner that is mutually acceptable to the Insured and Us. Any additional diagnoses will be at the company's expense.

Payment of the Accelerated Benefit will affect the death benefit. Any Accelerated Benefit amount paid will be paid to you in a lump sum. The amount of insurance will be reduced by the amount of the lump sum payment.

For example:

For an employee with an amount of insurance of $50,000 who chooses the 50% accelerated benefit option:

$50,000 amount of insurance in force before accelerated benefit payment

- $25,000 amount of accelerated benefit payment $25,000 amount of insurance remaining after accelerated benefit payment