57-I13 - E-Cert 17859 Life Class 1 04 rev 1-2-2026.pdf

Symetra Life Insurance Company Telephone: 1-800-SYMETRA or 1-800-796-3872 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135

Important information regarding your Certificate of Insurance:

This Certificate evidencing your insurance coverage is made available to you by your group insurance policyholder.

Symetra Life Insurance Company is only responsible for the accuracy of the Certificate which Symetra provides to the policyholder. The policyholder is solely responsible for the accuracy of the information contained herein.

From time to time your Certificate may be modified by Symetra, and an updated electronic Certificate will be made available to you by the policyholder. You are advised to periodically review your Certificate to ensure that you have the most current version.

You have the right to request a paper copy of your current Certificate at any time. If you wish to receive a paper copy of your Certificate you may obtain one by contacting the policyholder.

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

LG 13500 05/08 Symetra® is a registered service mark of Symetra Life Insurance Company.

Symetra Life Insurance Company

Bellevue, Washington 98004-5135

(An insurance company)

Certificate Rider

Rider Number: 4 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 Effective Date of Change Applicable to

LGC 13500/TX-CERT 07/17 January 1, 2024 Class 1 (Revised January 2, 2026)

Certificate Change(s)

The following are amended:

Schedule of Insurance – Cost of Coverage Schedule of Insurance – Eligible Class(es) for Coverage Schedule of Insurance – Life Insurance Benefit Schedule of Insurance – Accidental Death and Dismemberment Insurance Benefit (AD&D) Eligibility and Enrollment – Dependent Evidence of Insurability Requirements Period of Coverage – Effective Date for Changes in Coverage Period of Coverage – Continuation Provisions Benefits – Limitations

Certificate Page(s) Changed

LGC 13500/TX-SCH 07/17; Schedule of Insurance LGC 13500/TX-ELI 07/17; Eligibility and Enrollment LGC 13500/TX-COV 07/17; Period of Coverage LGC 13500/TX-BEN 07/17; Benefits

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.

LU-596 6/23

Have a complaint or need help?

If you have a problem with a claim or your premium, call your insurance company or HMO first. If you can't work out the issue, the Texas Department of Insurance may be able to help.

Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company or HMO. If you don't, you may lose your right to appeal.

Symetra Life Insurance Company To get information or file a complaint with your insurance company or HMO:

Call: Customer Service Representative at 425-256-8000 Toll-free: 1-800-796-3872 Online: www.symetra.com Email: https://www.symetra.com/customer-service/how-can-we-help-you/email-us/ Mail: PO Box 34690, Seattle, WA 98124-1690

The Texas Department of Insurance To get help with an insurance question or file a complaint with the state:

Call with a question: 1-800-252-3439 File a complaint: www.tdi.texas.gov Email: ConsumerProtection@tdi.texas.gov Mail: Consumer Protection, MC: CO-CP, Texas Department of Insurance, PO Box 12030, Austin, TX 78711-2030

¿Tiene una queja o necesita ayuda?

Si tiene un problema con una reclamación o con su prima de seguro, llame primero a su compañía de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department of Insurance, por su nombre en inglés) pueda ayudar.

Aun si usted presenta una queja ante el Departamento de Seguros de Texas, también debe presentar una queja a través del proceso de quejas o de apelaciones de su compañía de seguros o HMO. Si no lo hace, podría perder su derecho para apelar.

Symetra Life Insurance Company Para obtener información o para presentar una queja ante su compañía de seguros o HMO:

Llame a: Customer Service Representative al 425-256-8000 Teléfono gratuito: 1-800-796-3872 En línea: www.symetra.com Correo electrónico: https://www.symetra.com/customer-service/how-can-we-help-you/email-us/ Dirección postal: PO Box 34690, Seattle, WA 98124-1690

El Departamento de Seguros de Texas Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una queja ante el estado:

Llame con sus preguntas al: 1-800-252-3439 Presente una queja en: www.tdi.texas.gov Correo electrónico: ConsumerProtection@tdi.texas.gov Dirección postal: Consumer Protection, MC: CO-CP, Texas Department of Insurance, PO Box 12030, Austin, TX 78711-2030

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

777 108th Avenue NE, Suite 1200 Bellevue, Washington 98004-5135

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

LGC-10024/TX 1/12 1

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

Incorporation Provision

Beneficiary Companion, Travel Assistance and Identity Theft Resolution Services Policy Rider

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

The following provision is hereby added to the above-referenced Group Policy and Certificate of Insurance. This Rider does not vary, waive, alter or extend any of the terms, conditions or provisions of The Policy.

Noninsurance Benefits We may agree with the Policyholder to offer or provide to you the value-added benefits and services listed below.

We have arranged for a third party service provider to give access to you to the services which relate to the line of insurance coverage the Policyholder has purchased. While we have arranged for this access, the third party service provider is liable to you for the provision of such services. We are not responsible for the provision of such services nor are we liable for the failure of the provision of the same. Further, we are not liable to you for the negligent provision of such services by this third party service provider. If you wish to initiate a complaint or are requesting an appeal, please contact the vendor by calling 1-877-823-5807 and you will be guided through the complaint resolution process by the vendor. Please note that if the vendor fails to provide or continue to provide the services listed below, then no services are available, since we are not responsible for providing these services.

Beneficiary Companion services:

• Issue of a Beneficiary Companion Guidebook

• Access to Beneficiary Assistance Coordinators any time, any day of the week

• Assistance if a deceased's identity is stolen

Dedicated Beneficiary Assistance Coordinators are available 24/7 to:

• Answer any questions

• Offer guidance on how to obtain death certificate copies

• Manage notifications, including:

• Social Security Administration

• Credit reporting agencies

• Credit card companies/financial institutions

• Third-party vendors

• Government agencies

Travel Assistance services:

• Help finding physicians, dentists and medical facilities.

• Free transportation under medical supervision to a hospital/treatment facility.

• Replacement of medication or eyeglasses.

• Monitoring during a medical emergency to determine if care is appropriate, or if evacuation is required.

• Arrangement for your traveling companion’s return home if previously made arrangements are lost due to your medical emergency.

• Free transportation home for dependent children under the age of 16 who were traveling with you and are left unattended because of your hospitalization.

A qualified escort will be arranged if necessary.

• Free round-trip transportation for one immediate family member or friend to visit you if you are traveling alone and are likely to be hospitalized for seven consecutive days.

Identity Theft Resolution services:

• Assistance completing an ID theft affidavit to submit to the proper authorities, credit bureaus and creditors.

• Help replacing credit, debit and membership cards.

• A credit report review with the beneficiary.

• Suppression of the deceased’s credit report or an offer to freeze/close the account with credit bureaus.

• Full-service resolution assistance if the deceased’s identity is stolen, including affidavit assistance, credit bureau and fraud department notification, help filing a police report, and creditor follow-up.

LGC-10024/TX 1/12 2

To obtain these benefits, contact Europ Assistance at 1-877-823-5807. You may obtain a complete description of these services in the additional materials given to you by the Policyholder.

As an insured employee, you and your family members have access to these programs at no additional charge.

Termination of these services will occur if your coverage under the group policy terminates for any reason, or in the event that the Policyholder chooses to discontinue these services.

The effective date of these changes is January 1, 2019 but will not be effective prior to an insured person’s effective date of coverage. All other terms and provisions of the policy will apply other than as stated in this amendment.

The provisions found in the Certificate(s) of Insurance 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) of Insurance remain the same.

By: Margaret Meister, President Instructions: Retain a copy with your policy.

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

LGC-13002 10/12

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

Incorporation Provision

Occupational Death Benefit

Rider Number: 3 Policyholder: City of Burleson Policy Number: 01 017859 00

The following provision is hereby added to the above-referenced Group Policy and Certificate of Insurance. This Rider does not vary, waive, alter or extend any of the terms, conditions or provisions of The Policy.

Occupational Death Benefit: When is the Occupational Death Benefit payable?

If You suffer a Loss of life as the result of a Covered Occupational Death, We will pay an Occupational Death Benefit if Your death occurs:

1) within 365 days after the date You were last Actively at Work; and

2) while You were covered under The Policy.

Covered Occupational Death means a death caused by or resulting from an Injury sustained while You are Actively at Work as a Public Safety Officer, or in the case of a required period of work not coinciding with regular work hours, while in transit to or from work.

Public Safety Officer means an Active Employee whose primary job duties include controlling or reducing crime or juvenile delinquency, criminal law enforcement, or fire suppression. Public Safety Officer means police officers, firefighters, corrections officers, judicial officers, and officially recognized or designated volunteer firefighters, if they otherwise meet the definition of Public Safety Officer.

The Occupational Death Benefit will not be payable if Your death is caused or contributed by:

1) suicide or attempted suicide, whether sane or insane;

2) Injury sustained while committing or attempting to commit a felony; or

3) voluntary use or consumption of any poison, chemical compound or drug, including but not limited to prescription medications, unless as prescribed to You by or administered to You by a Physician.

The specific amounts for this Benefit are shown in the Schedule of Insurance.

The effective date of these changes is January 1, 2024, but will not be effective prior to an insured person’s effective date of coverage. All other terms and provisions of The Policy will apply other than as stated in this Rider.

The provisions found in the Certificate(s) of Insurance 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) of Insurance remain the same.

By: Margaret Meister, President Instructions: Retain a copy with your Policy.

LG-12042/CER 10/12

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

Group Life Insurance

CERTIFICATE

Rider #4, Effective January 1, 2024 (Revised January 2, 2026)

LGC 13500/TX-CERT 07/17 1

CERTIFICATE OF INSURANCE

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.

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, 2024 (Revised January 2, 2026)

Cost of Coverage:

Non-Contributory Coverage:

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

Contributory Coverage:

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 Active Full Time Employees

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 prior to January 1, 2021: The first of the month following 30 days of continuous employment.

If You start working 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.

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 2 x Earnings $300,000 $300,000

Supplemental

Amount

Benefit Maximum Amount

Guaranteed Issue Amount

Class 1 $10,000 to $500,000 in increments of $10,000 as selected by You on the enrollment card

$500,000, not to exceed 5 x Earnings

$150,000

Dependent

Benefit Benefit Maximum Guaranteed Issue Basic Amount Amount Amount Class 1 Spouse $10,000 $10,000 $10,000 Child birth to 26 years $10,000 $10,000 $10,000

Amount

Benefit Maximum Amount

Guaranteed Issue Amount

Class 1 Spouse $5,000 to $250,000 in increments of $5,000 as selected by You on the enrollment card

$250,000, not to exceed 100% of

Your Supplemental Life Benefit Amount

$50,000 birth to 26 years $20,000 $20,000 $20,000

Occupational Death Benefit Benefit Amount: $300,000 Maximum Amount: $300,000

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 2 x Earnings $300,000

LGC 13500/TX-SCH 07/17 3

Sum

Class 1 $10,000 to $500,000 in increments of

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

$500,000, not to exceed 5 x Earnings

Sum Class 1 Spouse $5,000 to $250,000 in increments of $5,000 as selected by You on the enrollment card

$250,000, not to exceed 100% of

Your Supplemental AD&D Principal Sum birth to 26 years $20,000 $20,000

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

LGC 13500/TX-SCH 07/17 4

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.

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 $20,000 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 of Insurability must be satisfactory to Us and may include, but will not be limited to:

1) a completed and signed application approved by Us;

2) a medical examination;

3) attending Physicians’ statement; and

4) any additional information We may require.

All Evidence of Insurability will be furnished at Your expense. We will then determine if You or Your Dependent are insurable for initial coverage or an increase in coverage under The Policy.

You will be notified in writing of Our determination of any Evidence of Insurability submission.

Change in Family Status: What constitutes a Change in Family Status?

A Change in Family Status occurs when:

1) You get married or You execute a domestic partner affidavit;

2) You and Your Spouse divorce or terminate a domestic partnership;

3) Your child is born or You adopt or become the legal guardian of a child;

4) Your Spouse or domestic partner dies;

5) Your child is no longer financially dependent on You or dies;

6) Your Spouse or domestic partner is no longer employed, which results in a loss of group insurance; or

7) You have a change in classification from part-time to full-time or from full-time to part-time.

Period of Coverage

LGC 13500/TX-COV 07/17 1

Effective Date: When does my coverage start?

Non-Contributory Coverage, for which Evidence of Insurability is not required, will start on the date You become eligible.

Contributory Coverage, for which Evidence of Insurability is not required, will start on the latest to occur of:

1) the date You become eligible, if You enroll on or before that date;

2) the first of the month following the last day of any Annual Enrollment Period, if You enroll during an Annual Enrollment Period; or

3) the date You enroll, if You do so within 31 days from the date You are eligible.

Any coverage, for which Evidence of Insurability is required, will become effective on the later of:

1) the date You become eligible; or

2) the date We approve Your Evidence of Insurability.

However, all Effective Dates of coverage are subject to the Deferred Effective Date provision.

Deferred Effective Date: When will my effective date for coverage or a change in my coverage be deferred?

If, on the date You are to become covered:

1) under The Policy;

2) for increased benefits; or

3) for a new benefit;

You are not Actively at Work due to a physical or mental condition such coverage will not start until the date You are Actively at Work.

Continuity from a Prior Policy: Is there continuity of coverage from a Prior Policy?

Your initial coverage under The Policy will begin, and will not be deferred if, on the day before the Policy Effective Date, You were insured under the Prior Policy, but on the Policy Effective Date You were not Actively at Work and would otherwise meet the Eligibility requirements of The Policy. However, Your amount of Insurance will be the lesser of the amount of Life Insurance and Accidental Death and Dismemberment Principal Sum:

1) You had under the Prior Policy; or

2) shown in the Schedule of Insurance;

reduced by any coverage amount:

1) that is in force, paid or payable under the Prior Policy; or

2) that would have been so payable under the Prior Policy had timely election been made.

Such amount of insurance under this provision is subject to any reductions in The Policy and will not increase.

Coverage provided through this provision ends on the first to occur of:

1) the last day of a period of 12 consecutive months after the Policy Effective Date;

2) the date Your insurance terminates for any reason shown under the Termination provision;

3) the last day You would have been covered under the Prior Policy, had the Prior Policy not terminated; or

4) the date You are Actively at Work.

However, if the coverage provided through this provision ends because You are Actively at Work, You may be covered as an Active Employee under The Policy.

LGC 13500/TX-COV 07/17 2

Dependent Effective Date: When does Dependent coverage start?

Coverage, for which Evidence of Insurability is not required, will start on the latest to occur of:

1) the date You become eligible for Dependent coverage, if You have enrolled on or before that date;

2) the first of the month following the last day of any Annual Enrollment Period, if You enroll during an Annual Enrollment Period; or

3) the date You enroll, if You do so within 31 days from the date You are eligible for Dependent coverage.

Coverage, for which Evidence of Insurability is required, will become effective on the later of:

1) the date You become eligible for Dependent coverage; or

2) the date We approve Your Dependent Evidence of Insurability.

In no event will Dependent coverage become effective before You become insured.

Dependent Deferred Effective Date: When will the effective date for Dependent coverage or a change in coverage be deferred?

If, on the date Your Dependent, other than a newborn is to become covered:

1) under The Policy;

2) for increased benefits; or

3) for a new benefit;

he or she is:

1) confined in a hospital; or

2) Confined Elsewhere;

such coverage will not start until he or she:

1) is discharged from the hospital; or

2) is no longer Confined Elsewhere;

and has engaged in all the normal and customary activities of a person of like age and gender, in good health, for at least 15 consecutive days.

This Deferred Effective Date provision will not apply to Disabled children who qualify under the definition of Dependent Child.

Confined Elsewhere means Your Dependent is unable to perform, unaided, the normal functions of daily living, or leave home or other place of residence without assistance.

Dependent Continuity from a Prior Policy: Is there continuity of coverage from a Prior Policy for my Dependent?

If, on the day before the Policy Effective Date, You were covered with respect to Your Dependent under the Prior Policy, the Deferred Effective Date provision will not apply to initial coverage under The Policy for such Dependent. However, the Dependent amount of Insurance will be the lesser of the amount of Life Insurance and the Accidental Death and Dismemberment Principal Sum:

1) they had under the Prior Policy; or

2) shown in the Schedule of Insurance;

reduced by any coverage amount:

1) that is in force, paid or payable under the Prior Policy; or

2) that would have been so payable under the Prior Policy had timely election been made.

Change in Coverage: When may I change my coverage or coverage for my Dependent?

After Your initial enrollment, You may increase or decrease coverage for You or Your Dependent or add a new Dependent to Your existing Dependent coverage:

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

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

LGC 13500/TX-COV 07/17 3

Effective Date for Changes in Coverage: When will changes in coverage become effective?

Any decrease in coverage will take effect on the date of the change.

Any increase in coverage will take effect on the latest of:

1) the date of the change;

2) the date requirements of the Deferred Effective Date provision are met;

3) the date Evidence of Insurability is approved, if required; or

4) the first of the month following the last day of any Annual Enrollment Period, except for an increase as a result of a Change in Family Status.

Increase in Amount of Life Insurance: If I request an increase in the amount of Life Insurance for myself or my Dependent, must we provide Evidence of Insurability?

If You or Your Dependent are:

1) already enrolled for an amount of Life Insurance under The Policy, then You and Your Dependent must provide Evidence of Insurability for any increase; or

2) not already enrolled for Life Insurance under The Policy, You and Your Dependent must provide Evidence of Insurability for any amount of coverage, including an initial amount of Life Insurance.

In any event, if the amount of Insurance You request is greater than the Guaranteed Issue Amount, You or Your Dependent, as applicable, must provide Evidence of Insurability.

If Your Evidence of Insurability is not satisfactory to Us, the amount of Insurance You had in effect on the date immediately prior to the date You requested the increase will not change.

If Your Dependent Evidence of Insurability is not satisfactory to Us, the amount of Insurance he or she had in effect on the date immediately prior to the date You requested the increase will not change.

Increase in Amount of Life Insurance: If my amount of Life Insurance increases because my Earnings increase, must I provide Evidence of Insurability?

If Your amount of Insurance is based on a multiple of Your Earnings, You must provide Evidence of Insurability if Your Earnings increase such that Your amount of Insurance is greater than the Guaranteed Issue Amount.

Additionally, once approved, We require Evidence of Insurability again if Your amount of Insurance:

1) is greater than the Guaranteed Issue Amount; and

2) would increase solely because Your Earnings increased more than $25,000:

a) during the last 12 consecutive month period; or

b) since Your Evidence of Insurability was last approved;

whichever occurs most recently.

However, if:

1) You do not submit Evidence of Insurability; or

2) Your Evidence of Insurability is not satisfactory to Us;

Your amount of Life Insurance:

1) will increase, but only up to the amount for which You were eligible without having to provide

Evidence of Insurability; and

2) will not increase again, or beyond that amount, until Your Evidence of Insurability is approved.

LGC 13500/TX-COV 07/17 4

Termination: When will my coverage end?

Your coverage will end on the earliest of the following:

1) the date The Policy terminates;

2) the first day of the month following the date You are no longer in a class eligible for coverage, or the class is cancelled;

3) the date the required premium is due but not paid;

4) the first day of the month You or Your Employer terminates Your employment; or

5) the first day of the month following the date You are no longer Actively at Work;

unless continued in accordance with one of the Continuation Provisions.

Reinstatement: Can my coverage be reinstated after it ends?

If:

1) Your coverage ends because You are no longer employed by the Employer or no longer in an eligible class; and

2) You are rehired or return to an eligible class within 12 months of the date Your coverage ended;

then coverage for You and Your previously covered Dependent may be reinstated, provided You request such reinstatement within 31 days of the date You return to work or to an eligible class.

The reinstated coverage will:

1) be the same coverage amounts in force on the date coverage ended;

2) not be subject to any Eligibility Waiting Period for Coverage or Evidence of Insurability; and

3) be subject to all the terms and provisions of The Policy.

We will not reinstate any amount of coverage which You or Your Dependent:

1) converted in accordance with the Conversion Right; or

2) continued under the Portability provision;

unless You cancel such coverage.

Dependent Termination: When does coverage for my Dependent end?

Coverage for Your Dependent will end on the earliest to occur of:

1) the date Your coverage ends;

2) the date the required premium is due but not paid;

3) the date You are no longer eligible for Dependent coverage;

4) the date We or the Employer terminate Dependent coverage; or

5) the date the Dependent no longer meets the definition of Dependent;

unless continued in accordance with the Continuation Provisions.

Continuation Provisions: Can my coverage and my Dependent coverage be continued beyond the date it would otherwise terminate?

Coverage under The Policy may be continued, at Your Employer's option, beyond a date shown in the Termination provision, provided Your Employer provides a plan of continuation which applies to all employees the same way. Coverage may not be continued under more than one Continuation Provision.

The amount of continued coverage applicable to You or Your Dependent will be the amount of coverage in effect on the date immediately before coverage would otherwise have ended. Continued coverage:

1) is subject to any reductions in The Policy;

2) is subject to payment of premium;

3) may be continued up to the maximum time shown in the provisions; and

4) terminates if The Policy terminates.

In no event will the amount of insurance increase while coverage is continued in accordance with the following provisions.

In all other respects, the terms of Your and Your Dependent coverage remain unchanged.

LGC 13500/TX-COV 07/17 5

Leave of Absence: If You are on a documented leave of absence, other than Family and Medical Leave or Military Leave of Absence, all of Your coverage (including Dependent Life coverage) may be continued for up to 12 months following the date the leave of absence commenced. If the leave terminates prior to the agreed upon date, this continuation will cease immediately.

Military Leave of Absence: If You or Your Dependent enter active military service and are granted a military leave of absence in writing, all of Your coverage (including Dependent Life coverage) may be continued for up to 12 months following the month in which the leave of absence commenced. If the leave ends prior to the agreed upon date, this continuation will cease immediately.

Layoff: If You are temporarily laid off by the Employer due to lack of work, all of Your coverage (including Dependent Life coverage) may be continued for up to 12 months following the month in which the layoff commenced. If the layoff becomes permanent, this continuation will cease immediately.

Sickness or Injury: If You are not Actively at Work due to sickness or Injury, all of Your coverage (including Dependent Life coverage) may be continued:

1) for a period of 12 consecutive months from the date You were last Actively at Work; or

2) if such absence results in a leave of absence in accordance with state and/or federal family and medical leave laws, then the combined continuation period will not exceed 12 consecutive months.

Family and Medical Leave: If You are granted a leave of absence, in writing, according to the Family and Medical Leave Act of 1993, or other applicable state or local law, Your coverage (including Dependent Life coverage) may be continued for up to 12 weeks, or longer if required by other applicable law, following the date Your leave commenced. If the leave of absence ends prior to the agreed upon date, this continuation will cease immediately.

Continuation for Dependent Child with Disabilities: Will coverage for Dependent Child with Disabilities be continued?

If Your Dependent Child reaches the age at which they would otherwise cease to be a Dependent as defined, and they are:

1) age 26 or older;

2) Disabled; and

3) primarily dependent upon You for financial support;

then Dependent Child coverage will not terminate solely due to age. However:

1) You must submit proof satisfactory to Us of such Dependent Child's disability within 31 days of the date he or she reaches such age; and

2) such Dependent Child must have become Disabled before attaining age 26.

Coverage under The Policy will continue as long as:

1) You remain insured;

2) the child continues to meet the required conditions; and

3) any required premium is paid when due.

However, no increase in the amount of Life Insurance for such Dependent Child will be available.

We have the right to require proof, satisfactory to Us, as often as necessary during the first two years of continuation, that the child continues to meet these conditions. We will not require proof more often than once a year after that.

LGC 13500/TX-COV 07/17 6

Waiver of Premium: Does coverage continue if I am Disabled?

Waiver of Premium is a provision which allows You to continue Your and Your Dependent Life Insurance coverage without paying premium, while You are Disabled and qualify for Waiver of Premium.

If You qualify for Waiver of Premium, the amount of continued coverage:

1) will be the amount in force on the date You cease to be an Active Employee;

2) will be subject to any reductions provided by The Policy; and

3) will not increase.

Eligible Coverages: What coverages are eligible under this provision?

This provision applies only to:

1) Your Basic Life Insurance;

2) Your…