60-J4 - Long-Term Disability Contract.pdf

Symetra Life Insurance Company is known as Symetra in this policy.

Symetra will pay the benefits provided in this policy.

This policy has been issued in consideration of the application and payment of the first premium.

This policy is a legal contract between the policyholder and Symetra.

Read this policy carefully. Signed for Symetra as of the policy effective date.

Michael Fry, Executive Vice President

Margaret Meister, President

Registrar

Policyholder

Policy Number

GROUP

INSURANCE

POLICY

GDC-4000 12/05 Symetra ® is a registered service mark of Symetra Life Insurance Company..

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

GDC-4000 12/05 1 ER-1 TX Rev 10/05

GROUP LONG TERM DISABILITY INSURANCE

Policyholder: City of Burleson

Policy Number: 01 017859 00

Policy Effective Date: January 1, 2019

Policy Anniversary Date: January 1, 2020

State of Policy Issue: Texas

Policy Insured By: Symetra Life Insurance Company, referred to as “the Company”, “we”, “us”, and “our”.

We will provide the benefits under this policy in consideration of the application and premium. In order for this policy to become effective, the first premium must be received within 90 days of the Policy Effective Date. We make this promise subject to all of the provisions of this policy.

Read this policy carefully and contact us promptly if you have questions. This policy is delivered and is governed by the laws of the state of policy issue and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments.

This policy consists of:

• all policy provisions and any amendments and/or attachments issued;

• the policyholder’s application, which will be attached to the policy upon issue;

• employees' signed applications, if any;

• the certificate of coverage.

This policy may be changed in whole or in part. Only an officer of ours can approve a change.

The approval must be in writing and endorsed on or attached to this policy. No other person, including any agent, may change this policy or waive any part of it.

THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER

DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY

PURCHASING THIS GROUP POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER,

THE EMPLOYER LOSES THOSE BENEFITS THAT WOULD OTHERWISE ACCRUE UNDER

THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE

WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE

REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

GDC-4000 12/05 2 ER-2

INTRODUCTION

This policy is divided into two sections:

• the employer section;

• the employee section.

Both sections together form the policy and include all of the benefits available under a plan.

Whenever we use the terms "you or your" in the employer section, we mean the employer.

GDC-4000 12/05 3 ER-3L TX Rev 3/99

LONG TERM DISABILITY

POLICY DETAILS

These are details concerning your policy:

Plan Effective Date:

January 1, 2019

Divisions, Subsidiaries or Affiliated Companies Include:

Name Location

None.

Initial Rate:

0.210% of total covered payroll.

Total covered payroll is the total amount of monthly earnings for which employees are insured under this plan, not to exceed the first $16,666.67 of their covered monthly earnings.

To calculate the initial monthly premium, multiply the Initial Rate by total covered payroll.

Rate Guarantee:

A change in the premium rate will not take effect prior to January 1, 2022, or 12 months following the policy effective date, whichever is later. However, the premium rate may change prior to this time for reasons that affect the insured risk, which includes:

• a change occurs in a plan of benefits;

• a division, subsidiary, or affiliated company is added or deleted;

• the number of employees insured by a plan changes by 10% or more;

• a new law or a change in any existing law is enacted which applies to a plan.

We will notify you in writing at least 60 days before a premium rate change is effective. A change may take effect on an earlier date if you agree to it.

GDC-4000 12/05 4 ER-4L

LONG TERM DISABILITY

POLICY DETAILS

(continued)

When do you need to pay premium?

Premium payments are due no later than 90 days following the Policy Effective Date, and the first day of each calendar month after the plan effective date.

We must receive all premiums on or before the date the premium is due. You must pay premium in United States dollars.

Waiver of Premium: Premium payments for coverage under this plan are suspended for an insured while benefits are payable to the insured under this long term disability plan.

GDC-4000 12/05 5 ER-5

EMPLOYER PROVISIONS

WHEN DO YOU MAKE PREMIUM CHANGES?

If employee status changes occur during a policy month then you must report the changes on the next premium due date following the change. Any premium increase or decrease will be adjusted and will become due at this same time, but will not be pro-rated daily.

If you pay premium on other than a monthly basis, changes in premiums will result in a monthly pro-rated adjustment on the next premium due date.

We will adjust premiums for the current policy year and the prior policy year unless changes are the result of fraudulent information.

WHAT INFORMATION DO WE REQUIRE OF YOU?

You must give us the following on a regular basis:

• information about your employees:

– who are eligible to become insured;

– whose amounts of coverage changed, including salary increase and decrease information;

– whose coverage ends;

• occupational information and any other information that we may reasonably require.

Your records that we believe have a bearing on coverage under this plan are open for our review at any reasonable time.

Clerical error or omission will not:

• prevent an employee from receiving coverage;

• affect the amount of an insured's coverage;

• affect the amount of premium actually owed;

OR

• effect or continue an insured’s coverage if it should not be in effect or continue in effect.

If the amount of premium paid is incorrect due to clerical error, we will adjust premiums for the current policy year and, if applicable, the prior policy years.

GDC-4000 12/05 6 ER-6

WHEN CAN THIS POLICY OR A PLAN UNDER THIS POLICY BE CANCELED?

This policy or a plan under this policy can be canceled:

• by us; or

• by you.

We may cancel or offer to modify this policy or a plan, with at least 31 days written notice, when:

• the employees pay all or a part of the cost of their coverage and less than 75% of the employees eligible for coverage are participating in a plan;

• you are paying the full cost of coverage and less than 100% of the employees eligible for coverage are participating in a plan;

• you do not promptly provide us with information that we need;

• this policy has been in effect more than 36 months;

• you fail to perform any of your obligations that relate to this policy;

• fewer than 10 employees are insured for coverage under this policy or a plan.

If you fail to pay the premium during the 31 day grace period, this policy or plan will terminate automatically on the last day for which premium was paid. You are responsible for paying premium for coverage in effect during the grace period. You must pay us all premium due for the full period each plan is in effect.

Plan means a line of coverage under this policy.

Grace period means the period of time following the premium due date, except for the first premium, during which premium payment may be made.

We reserve the right to review and terminate all classes covered under a plan if any class(es) cease(s) to be covered.

You may cancel this policy or a plan by giving us written notice at least 31 days before you intend the policy or plan to end. Cancellation can occur on an earlier date, if we agree. If this policy or a plan is canceled, the cancellation will not affect a payable claim.

Payable claim means a claim for which we are liable under the terms of this policy.

If this policy or a plan is canceled, coverage will end at 12:01 a.m. on the last day of coverage.

GDC-4000 12/05 7 ER-7

CAN A PLAN BE CHANGED?

You must give us advance notice of a request to change a plan.

WHAT IF STATUTES IN THE STATE OF POLICY ISSUE CHANGE?

Any provision of this policy which, on or after the policy effective date, conflicts with the statutes of the state of policy issue or any federal statutes, is hereby amended to comply with the minimum requirements of such statute.

CAN THE VALIDITY OF THIS POLICY BE DISPUTED?

The validity of this policy shall not be disputed after the policy has been in effect for two years from the policy effective date, except in situations when:

• premium has not been paid;

OR

• for fraudulent misrepresentations.

Disputing the validity of this policy shall be prohibited if statements made by the applicant in applying for this policy do not appear in a written document signed by the person making the statement. A copy of the written document must be given to the person making the statement.

LG-12128 04/18

City of Burleson

Group Disability Income 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 Disability 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 Long Term Disability 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 disability income benefits under your Plan is provided by Symetra Life Insurance Company (Symetra) according to the terms of a Group Disability Income 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 by the Plan Sponsor out of its general assets.

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.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

LGC-10024/TX 1/12

Incorporation Provision

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

Rider Number: 1

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’re traveling alone and are likely to be hospitalized for seven consecutive days.

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, Washington 98004-5135 (An insurance company)

LGC-10024/TX 1/12

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.

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 employees, 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.

Symetra Life Insurance Company

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

GDC-4500 12/05 TX Notice

TEXAS TOLL-FREE TELEPHONE NUMBER AND INFORMATION

AND COMPLAINT NOTICES

IMPORTANT NOTICE AVISO IMPORTANTE

To obtain information or make a complaint: Para obtener informacion o para someter una queja:

You may call Symetra’s toll-free Usted puede llamar al numero de telephone number for information or to telefono gratis de Symetra para make a complaint at informacion o para someter una queja al 1-800-426-7784 1-800-426-7784

You may contact the Texas Department Puede comunicarse con el Departmento of Insurance to obtain information on de Sequros de Texas para obtener companies, coverages, rights or informacion acerca de companias, complaints at coberturas, derechos o quejas al 1-800-252-3439 1-800-252-3439

You may write the Texas Department Puede escribir al Departamento de of Insurance Seguros de Texas P.O. Box 149104 P.O. Box 149104 Austin TX 78714-9104 Austin TX 78714-9104

FAX # (512) 475-1771 FAX # (512) 475-1771

PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRE PRIMAS O RECLAMOS:

Should you have a dispute concerning Si tiene una disputa concerniente a your premium or about a claim you should su prima o a un reclamo, debe comunicarse contact the Company first. If the con el la compania primero. Si no se dispute is not resolved, you may contact resuelve la disputa, puede entonces the Texas Department of Insurance. comunicarse con el departamento (TDI).

ATTACH THIS NOTICE TO YOUR POLICY: UNA ESTE AVISO A SU POLIZA:

This notice is for information only and does Este aviso es solo para proposito de not become a part or condition of the informacion y no se convierte en parte attached document. o condicion del documento adjunto.

GDC-4500 12/05 Symetra ® is a registered service mark of Symetra Life Insurance Company.

LONG TERM DISABILITY INCOME INSURANCE

CLASS 1

Employee Benefits

Insurance Certificate

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

Symetra Life Insurance Company is known as Symetra in this certificate.

"You" and "your" refer to the insured employee in this certificate.

This certificate summarizes the major parts of the policy under which you are insured. Your insurance is subject to all the terms of the policy. This certificate replaces all others previously issued.

Signed for Symetra as of the policy effective date.

READ THIS CERTIFICATE CAREFULLY

Michael Fry, Margaret Meister, Executive Vice President President

GDC-4500 12/05 1 C-1

GROUP LONG TERM DISABILITY INSURANCE

CERTIFICATE OF COVERAGE

Policy Effective Date: January 1, 2019

Symetra Life Insurance Company (referred to as “the Company”, "we", "us", or "our") welcomes you as a client.

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

Your certificate of coverage is written in plain English. There are a few terms and provisions written as required by insurance law. If you have any questions about any of the terms and provisions, please consult our claims paying office. We will assist you in understanding your benefits.

If the terms and provisions of the certificate of coverage (issued to you) differ from the policy (issued to the Policyholder), the policy will govern. Your coverage may be canceled or changed in whole or in part under the terms and provisions of the policy.

The policy is delivered in and is governed by the laws of Texas and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments. When making a benefit determination under the policy, we have discretionary authority to determine your eligibility for benefits and to interpret the terms and provisions of the policy.

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

GDC-4500 12/05 2 C-2

TABLE OF CONTENTS

Your certificate is divided into the following sections:

SECTION 1 - HIGHLIGHTS OF YOUR PLAN

SECTION 2 - GENERAL INFORMATION

SECTION 3 - ELIGIBILITY FOR COVERAGE

SECTION 4 - BENEFIT SPECIFICS

• disability defined

• details on calculating benefit payments

• exclusions and limitations that may apply

SECTION 5 - CLAIM INFORMATION

SECTION 6 - ADDITIONS TO YOUR LTD PLAN

For your ease in finding information in your certificate, we:

• Start each section with a summary of the contents and the terms we define in the section.

• Shade all of the defined terms within a section.

GDC-4500 12/05 3 EE-1L-1 Rev 10/05

SECTION 1: HIGHLIGHTS OF YOUR LTD PLAN

This is a brief overview of your plan of benefits. We refer to these terms often throughout this certificate. Whenever we use these terms in the certificate, they have the following meaning, unless we advise you otherwise.

Eligible Class 1 = All Active Full Time Employees.

You must be working at least 30 hours per week. Benefit Percentage = 60%

Maximum Payment Amount = $10,000*

* We may reduce the amount we pay to you by other income amounts and any income you earn or receive from any form of employment. Some disabilities may not be covered under this plan.

Minimum Payment Amount = $100

We may apply all payments to you toward overpayments.

Elimination Period = The later of: 90 days after the date disability begins or the date accumulated sick leave ends or the date salary continuation ends or all employer paid time off.

Pre-disability earnings means your gross monthly rate of earnings from the employer in effect on the policy anniversary just prior to the date disability begins, or in effect on your date of employment if you were not in employment on the previous policy anniversary. It does not include commissions, bonuses, overtime pay or other extra compensation.

If your disability begins while you are on a covered layoff or leave of absence, we will use your pre-disability earnings from the employer in effect on the policy anniversary just before the date your absence begins, or in effect on your date of employment if you were not in employment on the previous policy anniversary.

Our payments to you will be based on the amount of your pre-disability earnings covered by this plan and for which premium has been paid.

GDC-4500 12/05 4 EE-1L-2 Rev 10/05

SECTION 1: HIGHLIGHTS OF YOUR LTD PLAN

(continued)

Maximum Payment Duration

Social Security Normal Retirement Age

Age When Disability Begins Maximum Payment Duration

Less than age 60 To Social Security Normal Retirement Age (SSNRA) 60 60 months or to SSNRA, whichever is greater 61 48 months or to SSNRA, whichever is greater 62 42 months or to SSNRA, whichever is greater 63 36 months or to SSNRA, whichever is greater 64 30 months or to SSNRA, whichever is greater 65 24 months 66 21 months 67 18 months 68 15 months 69 and over 12 months

Social Security Normal Retirement Age (SSNRA) means the age at which you are eligible for Social Security full retirement benefits.

Waiting Period:

If you are in an eligible class on or before the plan effective date: The first of the month following 30 days of continuous employment.

If you are entering an eligible class after the plan effective date: The first of the month following 30 days of continuous employment.

If your employment ends and you are rehired by the same employer within 90 days, we will apply your previous employment in an eligible class toward completing the waiting period.

All other provisions of this plan apply.

Cost of Coverage:

The employer pays the cost of your coverage.

Waiver of Premium: The cost of your coverage will be suspended for any period of time during which you are disabled under this plan and eligible to receive a monthly payment from us. If you return to active employment with the employer, and want your coverage to continue, the cost of your coverage must begin to be paid again.

GDC-4500 12/05 5 EE-2-Summary

SUMMARY OF THE GENERAL INFORMATION SECTION 2

What will you find in this section?

• information we have access to

• how we use statements made in applying for coverage

• insurance fraud

• time limits for legal proceedings

What terms do we define in this section?

• you

• we

• us

• our

• employee

• employer

• insured

• plan

GDC-4500 12/05 6 EE-2-1 Rev 5/98

SECTION 2: GENERAL INFORMATION

WHAT IS THE CERTIFICATE OF COVERAGE?

This certificate of coverage is a written statement prepared by us and may include attachments.

It tells you:

• the coverage to which you may be entitled

• to whom we make payments

AND

• the limitations, exclusions and requirements applying to a plan.

You means an employee who is eligible for the coverage of this plan.

We, us and our means the Insurance Company named on the first page of your Certificate of Coverage.

Employee means a person who is a citizen or permanent resident of the United States in active employment with the employer unless we advise you otherwise.

This plan excludes temporary and seasonal workers from coverage.

Employer means individual, company or corporation where you are in active employment, and includes any division, subsidiary or affiliated company named in the policy.

Insured means a person covered under this plan.

Plan means a line of coverage under the policy.

GDC-4500 12/05 7 EE-2-2 TX

(continued)

TO WHAT INFORMATION DO WE HAVE ACCESS?

The employer will give us information about you including:

• if you are eligible for coverage

• if your amount of coverage changes, including salary change information

• if your coverage terminates

• other information we may reasonably require.

The employer's records that we believe have a bearing on coverage under this plan are open for our inspection at any reasonable time.

Clerical error or omission will not:

• prevent you from receiving coverage

• affect the amount of your coverage

OR

• effect or continue your coverage if it should not be in effect or continue in effect.

HOW CAN WE USE STATEMENTS YOU OR THE EMPLOYER MADE IN APPLYING FOR

COVERAGE?

We consider any statements you or the employer made in a signed application for coverage a representation and not a warranty. If any of the statements you or the employer made are not complete and/or not true at the time they were made, we can:

• reduce or deny any claim

OR

• cancel your coverage back to the date your coverage became effective.

We will use only statements made in a signed application as a basis for doing this. You, your beneficiary, or your personal representative will receive a copy of the signed application.

GDC-4500 12/05 8 EE-2-3

(continued)

HOW WILL WE HANDLE INSURANCE FRAUD?

We promise to focus on all means necessary to support fraud detection, investigation, and prosecution. It is a crime if you or the employer knowingly, and with intent to injure, defraud or deceive us, file a claim containing any false, incomplete or misleading information. These actions, as well as submission of false information, will result in denial of your claim, and are subject to prosecution and punishment to the full extent under state and/or federal law. We will pursue all appropriate legal remedies in the event of insurance fraud.

WHAT IF FACTS ABOUT YOU ARE NOT ACCURATE?

If relevant facts about you were not accurate, then we will use accurate information to decide if your coverage should be in effect and what your amount of coverage should be. If the cost of your coverage is affected, we will make a fair adjustment in the cost.

DOES THE EMPLOYER ACT AS YOUR AGENT?

For all purposes of the policy, the employer acts on its own behalf or as your agent. The employer is not our agent.

WHAT ARE THE TIME LIMITS FOR LEGAL PROCEEDINGS?

You can start legal action regarding your claim 60 days after the date you sent us proof of claim.

You have up to three years after the date you sent us proof of claim to start legal action, unless otherwise provided by law.

DOES THIS PLAN REPLACE OR AFFECT ANY REQUIREMENT FOR WORKERS'

COMPENSATION OR STATE DISABILITY INSURANCE?

The plan does not replace or affect requirements for coverage by Workers’ Compensation Insurance or state disability insurance.

GDC-4500 12/05 9 EE-3-Summary

SUMMARY OF THE ELIGIBILITY FOR COVERAGE SECTION 3

What will you find in this section?

• eligibility for coverage

• waiting period

• when coverage becomes effective

• evidence of insurability requirements

• what happens to coverage during a layoff, leave of absence or a family or medical leave of absence

• when coverage under this plan ends

What terms do we define in this section?

• waiting period

• active employment

• work site

• evidence of insurability

• layoff

• leave of absence

• family or medical leave of absence

GDC-4500 12/05 10 EE-3-1

SECTION 3: ELIGIBILITY FOR COVERAGE

WHEN ARE YOU ELIGIBLE FOR COVERAGE?

If you are in an eligible class you may apply for coverage under this plan on the later of:

• the date the plan is effective;

OR

• the date you complete the waiting period.

WHAT IS YOUR WAITING PERIOD?

Your waiting period appears in the PLAN HIGHLIGHTS.

Waiting period is the number of days you must be in active employment in an eligible class before you may apply for coverage.

If you have been continuously employed by the employer but were not in an eligible class, we will apply any prior period of work with the employer toward the waiting period.

Active employment means you are:

• working for the employer at your work site for earnings the employer pays on a regular basis;

AND

• performing the material and substantial duties of your regular occupation.

Active employment includes normal non-work days such as…