Appendix_1_–_City_of_Phoenix_Term_Policy_Certificate.pdf

MHC-96-13181.2 Minnesota Life 1

EdF82195 10-2014

Employee Group Term Life Certificate of Insurance

Minnesota Life Insurance Company - A Securian Company

400 Robert Street North • St. Paul, Minnesota 55101-2098

Policyholder: City of Phoenix

Policy Number: 34390-G

Read Your Certificate Carefully

You are insured under the group policy shown on the specifications page attached to this certificate. This certificate summarizes the principal provisions of the group policy that affect you. The provisions summarized in this certificate are subject in every respect to the group policy. You may examine the group policy at the principal office of the policyholder during regular working hours.

Right to Cancel

It is important to us that you are satisfied with this certificate after it is issued. If you are not satisfied with this certificate, you may cancel it by delivering or mailing a written notice or sending a telegram to Minnesota Life Insurance Company (Minnesota Life), 400 Robert Street North, St. Paul, Minnesota 55101-2098 and returning the certificate before midnight of the 30th day after you received this certificate.

Notice given by mail and return of the certificate by mail are effective on being postmarked, properly addressed, and postage prepaid. If you return this certificate, you will receive, within 10 days of the date we receive a notice of cancellation, a full refund of any premiums you have paid.

Upon cancellation of this certificate, it will be void as if it had never been issued.

Secretary President

TABLE OF CONTENTS

Definitions General Information Premiums Death Benefit

Termination Conversion Right Additional Information

GROUP TERM LIFE CERTIFICATE OF INSURANCE

Effective January 1, 2022

F. MHC-50303 A

CERTIFICATE SPECIFICATIONS PAGE

GENERAL INFORMATION

POLICYHOLDER:

City of Phoenix POLICY NO.: 34390-G

ASSOCIATED COMPANIES:

All subsidiaries and affiliates reported to Minnesota Life by the policyholder for inclusion in the policy.

POLICY SITUS:

The policy was issued and delivered in the state of Arizona.

POLICY EFFECTIVE DATE:

January 1, 2015. This specifications page represents the plan in effect as of

January 1, 2022.

This certificate and/or certificate specifications page replaces any and all certificates and/or certificate specifications pages previously issued to you under the group policy. Please replace any certificate and/or certificate specifications page previously issued to you with this new certificate and/or specifications page.

GROUP:

The group is composed of all active eligible full-time employees and certain eligible part-time employees in Unit 1 of the policyholder and its associated companies working in the United States in the following classes:

Note: As of July 1, 2016 all eligible part-time Unit 1 employees are eligible to enroll for all benefits eligible to a Class 1 employee.

Class 1 001 Field Unit 1

Class 2 002 Field Unit 2

Class 3 003 Office and Clerical Unit 3

Class 4 004 Police Officers Unit 4

Class 5 005 Firefighters Unit 5

Class 6 006 Police Supervisory and Professional Unit 6

Class 7 007 Supervisory and Professional Units 7

Class 8 008 Confidential Office and Clerical Unit 8

Class 9 009 Middle Managers

Class 10 010 Executives

Class 11 011 Mayor and City Council Unit 8

Class 12 012 Executive

Class 13 016 Middle Managers Police

Class 14 017 Middle Managers Fire

Class 15 018 Executives Police

Class 16 019 Executives Fire

Class 17 000 Police Reservists

Class 18 Arizona Municipal Water User’s Association - Removed from the policy 12/31/2016.

Class 19 Closed Disabled Group (grandfathered coverage)

ENROLLMENT PERIOD:

Not applicable for noncontributory insurance; 45 days from the first day of eligibility for contributory insurance.

WAITING PERIOD: None

MINIMUM HOURS: As determined by the policyholder per the employee’s class.

F. MHC-50303 B

PLAN OF INSURANCE

EMPLOYEE BENEFIT SCHEDULE

EMPLOYEE TERM LIFE INSURANCE:

Basic Life Insurance

Note: Multiples of base annual salary is rounded to the next higher multiple of $1,000 if not already a multiple thereof.

Eligible Class Amount of Basic Life Insurance

Class 1 001 Field Unit 1

$15,000

Class 2 002 Field Unit 2 The greater of one times base annual salary or $25,000

Class 3 003 Office and Clerical Unit 3 The greater of one times base annual salary or $25,000

Class 4 004 Police Officers Unit 4 $15,000

Class 5 005 Firefighters Unit 5 One times base annual salary

Class 6 006 Police Supervisory and Professional Unit 6 One times base annual salary

Class 7 007 Supervisory and Professional Units 7 The greater of one times base annual salary or $25,000

Class 8 008 Confidential Office and Clerical One and one-half times base annual salary

Class 9 009 Middle Managers One and one-half times base annual salary to a maximum of

$500,000

Class 10 010 Executives One and three-quarters times base annual salary to a maximum of $500,000

Class 11 011 Mayor and City Council One and three-quarters times base annual salary to a

Class 12 012 Executive Two times base annual salary to a maximum of $500,000

Class 13 016 Middle Managers Police One and one-half times base annual salary to a maximum of

Class 14 017 Middle Managers Fire One and one-half times base annual salary to a maximum of

Class 15 018 Executives Police One and three-quarters times base annual salary to a

Class 16 019 Executives Fire One and three-quarters times base annual salary to a

Class 17 000 Police Reservists None

Class 19 Closed Disabled Group None

F. MHC-50303 C

Optional Life Insurance

Eligible Class Amount of Optional Life Insurance

Classes 1-16

An amount elected by the employee in an increment of:

• $10,000 to a maximum of $250,000;

• thereafter, $50,000 to a maximum of $500,000.

Class 17 None

Class 19 Amounts vary and are on file with the policyholder. Amounts of coverage range from $30,000 to $100,000.

EMPLOYEE ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE:

Basic and Optional AD&D Insurance

Eligible Class Amount of Basic and Optional AD&D Insurance

An amount equal to the amount of basic and/or optional life insurance for which the employee is insured under the group policy.

Classes 17 and 19 None

EMPLOYEE OCCUPATIONAL ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE:

Occupational AD&D Insurance

Eligible Class Amount of Occupational AD&D Insurance

Class 1 001 Field Unit 1 $75,000

Class 2 002 Field Unit 2 $75,000

Class 3 003 Office and Clerical Unit 3 $75,000

Class 4 004 Police Officers Unit 4 $100,000

Class 5 005 Firefighters Unit 5 $75,000

Class 6 006 Police Supervisory and Professional Unit 6 $100,000

Class 7 007 Supervisory and Professional Units 7 $75,000

Class 8 008 Confidential Office and Clerical $75,000

Class 9 009 Middle Managers $75,000

Class 10 010 Executives $75,000

Class 11 011 Mayor and City council $75,000

Class 12 012 Executive $75,000

Class 13 016 Middle Managers Police $100,000

Class 14 017 Middle Managers Fire $75,000

Class 15 018 Executives Police $100,000

Class 16 019 Executives Fire

$75,000

F. MHC-50303 D

Class 17 000 Police Reservists $25,000

Class 19 Closed Disabled Group None

EMPLOYEE COMMUTATION ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE:

Commutation AD&D Insurance

Eligible Class Amount of Commutation AD&D Insurance

Note: This benefit applies to all part time employees of the policyholder, including part time employees who are not insured under the group policy with life insurance.

$200,000

Class 17 and 19 None

AGGREGATE LIMIT: Total liability for all losses for any one accident under the commutation AD&D benefit will not exceed $3,000,000. If the total benefits otherwise payable would exceed this amount, the amount payable for each insured will be in the same proportion as the $3,000,000 bears to the total amount of insurance that would have otherwise been payable except for this provision.

GENERAL PROVISIONS FOR EMPLOYEE INSURANCE

AGE REDUCTIONS:

(applies only to optional life and optional AD&D including those insureds in Class 19)

The amount of optional life/AD&D insurance on an employee age 65 or older shall be a percentage of the amount otherwise provided by the plan of insurance applicable to such employee in accordance with the following table:

Age of Employee

70 - 74

75 -79

80 and older

Amount of Optional Life/AD&D Insurance

65%

45%

30%

Age reductions will apply the first day of the month following an insured employee's applicable birthday.

Note: The reduced coverage is rounded to the next higher $1,000 if not already a multiple thereof.

RETIREMENT REDUCTIONS: All insurance terminates at retirement, except as provided for under the portability provision.

CONTRIBUTORY/NONCONTRIBUTORY: Basic insurance is noncontributory insurance; optional insurance is contributory insurance.

GUARANTEED ISSUE AMOUNT: Guaranteed issue is the maximum amount of insurance an employee can receive without evidence of insurability when first eligible under the plan provided enrollment is made within the enrollment period. The amounts are as follows:

For basic insurance:

All basic insurance is guaranteed issue.

For optional insurance:

For employees in an eligible class immediately prior to the effective date of the group policy:

F. MHC-50303 E

An amount equal to the amount of contributory insurance for which the employee was insured under the prior carrier’s group policy on the day immediately preceding the effective date of the group policy.

For employees who first become eligible after the effective date of the group policy:

$150,000

EVIDENCE OF INSURABILITY: Evidence of insurability is required as stated in the policy and for an amount of insurance greater than the guaranteed issue amount.

EFFECTIVE DATE OF INCREASES

AND DECREASES DUE TO CHANGE

IN ELIGIBLE CLASS OR EARNINGS:

Increases and decreases due to a change in eligible class or earnings will become effective the first of the following month after the change in eligible class or earnings. Evidence of insurability will not be required for an increase in insurance due solely to an increase in earnings.

All increases are subject to the actively at work requirement.

DEPENDENTS BENEFIT SCHEDULE

DEPENDENTS TERM LIFE INSURANCE:

An employee does not need to be insured for optional life insurance in order to be insured for dependents life insurance.

Spouse/Qualified Domestic Partner insurance may not exceed the total amount of employee insurance.

Spouse/Qualified Domestic Partner Life Insurance

Eligible Class Amount of Spouse/Qualified Domestic Partner Life Insurance

An amount elected by the employee, in an increment of $10,000, subject to a plan maximum of $300,000.

Spouse/QDP insurance terminates upon the Spouse’s/QDP’s attainment of age

70.

Class 19 Grandfathered amounts as on file with the policyholder.

Child Life Insurance

Eligible Class Amount of Child Life Insurance

$10,000, $15,000, $20,000 or $25,000 as elected by the employee.

An employee’s first eligible newborn child is automatically covered for $10,000 for 45 days from the child’s live birth. To continue coverage on the first child, the employee must elect child coverage within those 45 days; otherwise the coverage shall terminate at the end of the 45-day period.

Class 19 Grandfathered amounts as on file with the policyholder.

F. MHC-50303 F

GENERAL PROVISIONS FOR DEPENDENTS INSURANCE

CONTRIBUTORY/NONCONTRIBUTORY: Dependents insurance is contributory insurance.

GUARANTEED ISSUE AMOUNT: Guaranteed issue is the maximum amount of insurance an eligible dependent can receive without evidence of insurability when first eligible under the plan provided enrollment is made within the enrollment period. The amounts are as follows:

For employees with eligible dependents immediately prior to the effective date of the group policy, the guaranteed issue amount is equal to the amount of dependents insurance for which they were insured under the prior group policy.

For employees who first become eligible for dependents insurance after the effective date of the group policy, the guaranteed issue amount is as follows:

For spouse/qualified domestic partner insurance: $50,000

For child insurance: All child life insurance is guaranteed issue regardless of when elected.

EVIDENCE OF INSURABILITY: Evidence of insurability is required as stated in the policy and for an amount of insurance greater than the guaranteed issue amount. As an exception child life insurance will never require evidence of insurability.

EFFECT OF EMPLOYEE’S RETIREMENT: All dependents insurance terminates upon the employee’s retirement except as provided under the portability provision.

ADDITIONAL INFORMATION

BENEFICIARY ELECTION CHANGES: As an exception to the policy, an employee will manage beneficiary designations by using the eCHRIS electronic administration system used by the policyholder.

SUICIDE EXCLUSION: The suicide exclusion applies to employee optional life and spouse/qualified domestic partner life insurance under the group policy. Exclusions for AD&D, Occupational AD&D and Commutation AD&D insurance, including a suicide exclusion, are listed on the applicable policy rider.

ACCELERATED DEATH BENEFIT

APPLICATION:

The accelerated death benefit applies to basic and optional employee life insurance and spouse/qualified domestic partner life insurance.

Specified Disease Benefit and Permanent Institutional Confinement Benefit applies to employee optional life insurance and spouse/qualified domestic partner life insurance.

WAIVER OF PREMIUM APPLICATION: Applies to contributory employee insurance.

REINSTATEMENT: There is no reinstatement of coverage under the group policy, unless termination is contested and the Civil Service Board requires the City of

Phoenix to rehire and reinstate coverage to prior amount. Employee will be required to remit back premium if coverage is reinstated.

ONE TIME OPEN ENROLLMENT (applies to classes 1 – 16)

The policyholder will hold a one-time open enrollment October – November

2021. During this enrollment, the following elections will not require evidence of insurability:

• An employee may elect for the first time or increase existing supplemental life insurance by up to 5 $10,000 increments ($50,000 total) provided the resulting amount of insurance does not exceed the guaranteed issue amount of $150,000.

Coverage will be effective January 1, 2022, subject to the actively at work requirement.

F. MHC-50303 G

ANNUAL OPEN ENROLLMENTS:

(beginning with the 2016 plan year)

During the policyholder’s annual open enrollment, the following election changes can be made without providing evidence of insurability:

• An employee may elect or increase optional life insurance up to two

$10,000 increments provided the resulting amount of insurance does not exceed the guaranteed issue amount of $150,000. This offer is provided to both current optional life participants and those electing optional life insurance for the first time.

• An employee may increase spouse life insurance up to two $10,000 increments provided the resulting amount of insurance does not exceed the guaranteed issue amount of $50,000. This offer is provided to current spouse life participants only.

• An employee may elect any child life amount.

Coverage will be effective on the January 1 following the annual enrollment, subject to the actively at work requirement for employees and the hospitalization/confinement clause for dependents.

QUALIFIED STATUS CHANGES:

An employee who experiences one of the Qualified Status Changes listed below may make the following election changes without providing evidence of insurability, provided enrollment is made within 31 days of the status change:

• An employee may increase his or her optional life coverage by two

$10,000 increments, provided the resulting amount of insurance does not exceed $150,000. This offer is provided to both current optional life participants and those electing optional life insurance for the first time.

• An employee may increase spouse/qualified domestic partner life insurance up to two $10,000 increments provided the resulting amount of insurance does not exceed the guaranteed issue amount of $50,000.

This offer is provided to current spouse life participants only.

• An employee may elect any child life amount

Coverage will be effective on the date of the election, subject to the actively at work requirement for employees and the hospitalization/confinement clause for dependents.

Qualified Status Change for this purpose means:

• Birth or adoption or otherwise acquiring a newly eligible child

• Death of a dependent (spouse, qualified domestic partner or child)

• Divorce, legal separation or annulment

• Dissolution of a domestic partnership

• Marriage or creation of domestic partnership (an employee may increase his or her supplemental life insurance due to marriage or creation of domestic partnership).

• Loss of spouse/qualified domestic partner employment

SUPPLEMENT(S) TO THE CERTIFICATE

Accelerated Benefits

Accidental Death and Dismemberment Benefits

Commutation AD&D Benefits

Dependents Term Life Benefits

Occupational AD&D Benefits

Portability Benefits

Waiver of Premium Benefits

MHC-96-13181.2 Minnesota Life 2

Definitions age

Attained age as of most recent birthday.

application

Your application for insurance under the group policy and, if required, your evidence of insurability application.

associated company

Any company which is a subsidiary or affiliate of the policyholder which is designated by the policyholder and agreed to by us to participate under the group policy.

certificate effective date

The date your coverage under this certificate becomes effective.

contributory insurance

Insurance for which you are required to make premium contributions.

earnings

Your basic rate of compensation not including commissions, overtime or premium pay, bonuses, or any other additional compensation.

employee

An individual who is employed by the policyholder or by an associated company. A sole proprietor will be considered the employee of the proprietorship. A partner in a partnership will be considered an employee so long as the partner’s principal work is the conduct of the partnership’s business. The term employee does not include temporary employees nor corporate directors who are not otherwise employees.

employer

The policyholder or any designated associated companies.

evidence of insurability

Evidence satisfactory to us of the good health of the prospective insured and any other underwriting information we require.

insured

A person who is eligible for and becomes insured according to the terms of this certificate.

non-work day

A day on which you are not regularly scheduled to work, including scheduled time off for vacations, personal holidays, weekends and holidays, and approved leaves of absence for non-medical reasons.

Non-work day does not include time off for medical leave of absence, temporary layoff, employer suspension of operations in total or in part, strike, and any time off due to sickness or injury including sick days, short-term disability, or long-term disability.

noncontributory insurance

Insurance for which you are not required to make premium contributions.

policyholder

The owner of the group policy as shown on the specifications page attached to this certificate.

specifications page

The outline which summarizes your coverage under the policyholder’s plan of insurance.

waiting period

The period, if any, of continuous employment with the employer required prior to becoming eligible for coverage under this certificate. The waiting period is shown on the specifications page attached to this certificate.

we, our, us

Minnesota Life Insurance Company.

you, your, certificate holder

An insured employee.

General Information

What is your agreement with us?

You are insured under the group policy shown on the specifications page attached to this certificate. Your application as defined under this certificate is attached and is a part of this certificate. This certificate summarizes the principal provisions of the group policy that affect your life insurance coverage. The provisions summarized in this certificate are subject in every respect to the group policy.

Any statements made in your application as defined in this certificate will be considered representations and not warranties. Also, any statement made will not be used to void your insurance nor defend against a claim unless the statement is contained in the application attached to your certificate and a copy has been provided to you or your beneficiary.

This certificate is issued in consideration of your application and the payment of the required premium.

Can this certificate be amended?

Yes. We retain the right to amend this certificate at any time without your consent. Any amendment will be

MHC-96-13181.2 Minnesota Life 3 without prejudice to any claim incurred for benefits prior to the date of the amendment.

Who is eligible for insurance?

You are eligible if you:

(1) are a member of the group and of an eligible class as defined in the group policy; and

(2) work for the employer for at least the number of hours per week shown as the minimum hours per week requirement on the specifications page attached to this certificate; and

(3) have satisfied the waiting period as shown on the specifications page attached to this certificate;

and

(4) meet the actively at work requirement as shown in the section entitled “What is the actively at work requirement?”.

Are retired employees eligible for insurance?

If the policyholder’s plan of insurance, as reflected in the specifications page attached to this certificate, does not specifically provide insurance for retired employees, a retired employee shall not be eligible to become insured, nor have his or her insurance continued. If the policyholder’s plan of insurance specifically provides insurance for retired employees, the minimum hours per week and actively at work requirements will not apply to such persons.

What is the actively at work requirement?

To be eligible to become insured or to receive an increase in the amount of insurance, you must be actively at work, fully performing your customary duties for your regularly scheduled number of hours at the employer’s normal place of business, or at other places the employer’s business requires you to travel.

If you are not actively at work on the date coverage would otherwise begin, or on the date an increase in your amount of insurance would otherwise be effective, you will not be eligible for the coverage or increase until you return to active work. However, if the absence is on a non-work day, coverage will not be delayed provided you were actively at work on the work day immediately preceding the non-work day.

Except as otherwise provided for in this certificate, you are eligible to continue to be insured only while you remain actively at work.

When will we require evidence of insurability?

Evidence of insurability will be required if:

(1) the specifications page attached to this certificate states that evidence of insurability is required; or

(2) the insurance is contributory and you do not enroll within the enrollment period shown on the specifications page attached to this certificate; or

(3) the insurance for which you previously enrolled did not go into effect or was terminated because you failed to make a required premium contribution; or

(4) during a previous period of eligibility, you failed to submit required evidence of insurability or that which was submitted was not satisfactory to us; or

(5) you are insured by an individual policy issued under the terms of the conversion right section.

When does insurance become effective?

Insurance becomes effective on the date that all of the following conditions have been met:

(1) you meet all eligibility requirements; and

(2) if required, you apply for the insurance on forms which are approved by us; and

(3) we are satisfied with your evidence of insurability, if we require evidence; and

(4) we receive the required premium.

Can your coverage be continued during sickness, injury, leave of absence or temporary layoff?

Yes. The employer may continue your noncontributory insurance or allow you to continue your contributory insurance when you are absent from work due to sickness, injury, leave of absence, or temporary layoff.

Continuation of your insurance is subject to certain time limits and conditions as stated in the group policy. If you stop active work for any reason, you should discuss with the employer what arrangements may be made to continue your insurance.

Premiums

When and how often are your premium contributions due?

Unless the policyholder and we have agreed to some other premium payment procedure, any premium contributions you are required to make for contributory insurance are to be paid by you to the policyholder on a monthly basis. We apply premiums consecutively to keep the insurance in force.

How is the premium determined?

The premium will be the premium rate multiplied by the number of $1,000 units of insurance in force on the date premiums are due. The premium may also be computed by any other method on which the policyholder and we agree.

We may change the premium rate:

(1) on any premium due date following the expiration of any rate guarantee period, or following the date that the amount of insurance in force for any one coverage changes by more than 15% from that which was used to determine the current rates (active employee coverage and retiree coverage

MHC-96-13181.2 Minnesota Life 4 are considered separate coverages, as are basic life, supplemental life, spouse life, child life and AD&D) or

(2) anytime, if the policy terms are amended or the total amount of insurance in force changes by 15% from the volume that was used to determine the current rates or more.

Death Benefit

What is the amount of the death benefit?

The amount of the death benefit is the amount of insurance shown on the specifications page attached to this certificate. The amount of insurance for each insured dependent shall not exceed your amount of insurance.

Can you request a change in the amount of your contributory insurance?

Yes. If the policyholder’s plan of insurance, as reflected in the specifications page attached to the group policy, allows for a choice of amounts of insurance for your class, you can request an increase or a decrease in the amount of your contributory insurance within the limitations of the policyholder’s plan of insurance, including any limitations on when and how often such requests may be made.

If you request an increase in the amount of your contributory insurance, we will require evidence of insurability, unless otherwise noted on the specifications page.

When will changes in your coverage amount be effective?

Requested increases in the amount of your contributory insurance, if approved, are effective on the date we approve the increase. Requested decreases in the amount of your contributory insurance are effective on the first day of the month following receipt of your request for a decrease or if different, according to the administrative practices of the employer.

Requests for a change made during a special enrollment period offered by the employer will not become effective prior to the general effective date of elections made during that enrollment.

Increases and decreases in insurance amounts which result from a change in your eligible class or earnings will be effective as shown on the specifications page attached to this certificate.

All increases in the amount of insurance are subject to the actively at work requirement.

When will the death benefit be payable?

We will pay the death benefit upon receipt at our home office of written proof satisfactory to us that you died while insured under this certificate. All payments by us are payable from our home office.

The death benefit will be paid in a single sum or by any other method agreeable to us and the beneficiary. We will pay interest on the death benefit from the date of your death until the date of payment. Interest will be at an annual rate determined by us, but never less than 0.1% per year compounded annually, or the minimum required by state law, whichever is greater.

Payment of the death benefit will extinguish our liability under the certificate for which the death benefit has been paid.

To whom will we pay the death benefit?

We will pay the death benefit to the beneficiary or beneficiaries. A beneficiary is named by you to receive the death benefit to be paid at your death. You may name one or more beneficiaries. You cannot name the policyholder or an associated company of the policyholder as a beneficiary.

You may also choose to name a beneficiary that you cannot change without the beneficiary’s consent. This is called an irrevocable beneficiary.

If there is more than one beneficiary, each will receive an equal share, unless you have requested another method in writing. To receive the death benefit, a beneficiary must be living on the date of your death. In the event a beneficiary is not living on the date of your death, that beneficiary’s portion of the death benefit shall be equally distributed to the remaining surviving beneficiaries. In the event of the simultaneous deaths of you and a beneficiary, the death benefit will be paid as if you survived the beneficiary.

If there is no eligible beneficiary, or if you do not name one, we will pay the death benefit to:

(1) your lawful spouse if living, otherwise;

(2) your natural or legally adopted child (children) in equal shares, if living, otherwise;

(3) your parents in equal shares, if living, otherwise;

(4) your siblings in equal shares, if living, otherwise;

(5) the personal representative of your estate.

Can you add or change beneficiaries?

Yes. You can add or change beneficiaries if all of the following are true:

(1) your coverage is in force; and

(2) we have written consent of all irrevocable beneficiaries; and

(3) you have not assigned the ownership of your insurance.

A request to add or change a beneficiary must be made in writing. All requests are subject to our approval. A change will take effect as of the date it is signed, but will not affect any payment we make or action we take before receiving your notice.

MHC-96-13181.2 Minnesota Life 5

Termination

When does your coverage terminate?

Your coverage ends on the earliest of the following:

(1) the date the group policy ends; or

(2) the date you no longer meet the eligibility requirements; or

(3) the date the group policy is amended so you are no longer eligible; or

(4) 31 days (the grace period) after the due date of any premium contribution which is not paid; or

(5) the last day for which premium contributions have been paid following your written request to cease participation under this certificate.

If your coverage under the group policy terminates due to non-payment of premiums, your coverage may be reinstated if all premiums due are paid and received by us within 31 days of the date of termination and during your lifetime.

Can your insurance be reinstated after termination?

Yes. When your coverage terminates because you are no longer eligible, and you become eligible again within the time frame shown on the specifications page, your coverage may be reinstated.

Provided you are not then covered by an individual policy issued under the terms of the conversion right section, your coverage under the group policy shall be reinstated automatically, without evidence of insurability or satisfaction of any waiting period. Your amount of insurance will be that which applies to the classification to which you then belong, on the date you again become eligible. If the policyholder’s plan of insurance provides for contributory insurance under the group policy, your amount of contributory insurance will be limited to that for which you were insured immediately prior to the loss of coverage.

When does the group policy terminate?

The policyholder may terminate the group policy by giving us 31 days prior written notice. We reserve the right to terminate the group policy on the earliest of the following to occur:

(1) 31 days (the grace period) after the due date of any premiums which are not paid; or

(2) on any subsequent policy anniversary after the date the number of employees insured is less than any minimum established by us or as required by applicable state law; or

(3) 31 days after we provide the policyholder with notice of our intent to terminate the group policy.

Conversion Right

What is the conversion right?

You may be able to convert this insurance to a new individual life insurance policy if all or part of your life insurance under the group policy terminates.

You may convert up to the full amount of terminated insurance if termination occurs because you move from one existing eligible class to another, or you are no longer in an eligible class.

Limited conversion is available if, after you have been insured for at least five years, insurance is terminated because:

(1) the group policy is terminated; or

(2) the group policy is changed to reduce or terminate your insurance.

In such case, you may convert up to the full amount of terminated insurance, but not more than the maximum.

The maximum is the lesser of:

(a) $10,000; and

(b) the amount of life insurance which terminated minus any amount of group life insurance for which you become eligible under any group policy issued or reinstated by us or any other carrier within 31 days of the date the insurance terminated under the group policy.

Neither the conversion right nor the limited conversion right is available if your coverage under the group policy terminates due to failure to make, when due, required premium contributions.

Under both the conversion right and the limited conversion right, you may convert your insurance to any type of individual policy of life insurance then customarily issued by us for purposes of conversion, except term insurance.

The individual policy will not include any supplemental benefits, including, but not limited to, any disability benefits, accidental death and dismemberment benefits, or accelerated benefits.

How do you convert your insurance?

You convert your insurance by applying for an individual policy and paying the first premium within 31 days after your group insurance terminates. No evidence of insurability will be required.

If you do not receive written notice of the conversion right under this certificate at least 15 days prior to the end of the 31-day conversion period, you will have an additional period within which to exercise such right. This additional period will expire 15 days after you are given such notice, but in no event will such additional period be extended beyond 60 days after the end of the 31-day conversion period.

MHC-96-13181.2 Minnesota Life 6

Nothing contained herein will be construed to continue any insurance beyond the 31-day period provided in this certificate.

How is the premium for the individual policy determined?

We base the premium for the individual policy on the plan of insurance, your age, and the class of risk to which you belong on the date of the conversion.

When is the individual policy effective?

The individual policy takes effect 31 days after the group insurance provided under the group policy terminates.

What happens if you die during the 31-day period allowed for conversion?

If you die during the 31-day period allowed for conversion, we will pay a death benefit regardless of whether or not an application for coverage under an individual policy has been submitted. The death benefit will be the amount of insurance you would have been eligible to convert under the terms of the conversion right section.

We will return any premium you paid for an individual policy to your beneficiary named under the group policy.

In no event will we be liable under both the group policy and the individual policy.

Additional Information

What if your age has been misstated?

If your age has been misstated, the death benefit payable will be that amount to which you are entitled based on your correct age. A premium adjustment will be made so that the actual premium required at your correct age is paid.

Is there a suicide exclusion?

The specifications page attached to this certificate indicates what insurance, if any, is subject to the suicide exclusion outlined below.

When applicable, this suicide exclusion limits our liability to an amount equal to the premiums paid if you, whether sane or insane, die by suicide within two years of the effective date of your insurance.

If there has been an increase in your amount of insurance for which you were required to apply or for which we required evidence of insurability, and if you die by suicide within two years of the effective date of the increase, our liability with respect to that increase will be limited to the premiums paid and attributable to such increase.

When does your insurance become incontestable?

Except for the non-payment of premiums, after your insurance has been in force during your lifetime for two years from the effective date of your coverage, we cannot contest your coverage. However, if there has been an increase in the amount of insurance for which you were required to apply or for which we required evidence of insurability, then, to the extent of the increase, any loss which occurs within two years of the effective date of the increase will be contestable.

Any statements you make in your application as defined under this certificate will be considered representations and not warranties. Also, any statement you make will not be used to void your insurance, nor defend against a claim, unless the statement is contained in the application attached to your certificate and a copy has been provided to you or your beneficiary.

Can your insurance be assigned?

Yes. However, we will not be bound by an assignment of the certificate or of any interest in it unless it is made as a written instrument, and you file the original instrument or a certified copy with us at our home office, and we send you an acknowledged copy.

We are not responsible for the validity of any assignment.

You are responsible for ensuring that the assignment is legal in your state and that it accomplishes your intended goals. If a claim is based on an assignment, we may require proof of interest of the claimant. A valid assignment will take precedence over any claim of a beneficiary.

Is the policyholder required to maintain records?

Yes. The policyholder is required to maintain adequate records of any information necessary for us to administer this certificate. We own the records relating to the insurance provided by this certificate, and can obtain them from the policyholder at any reasonable time.

If a clerical error is made in keeping records on the insurance under the group policy, it will not affect otherwise valid insurance. A clerical error does not continue insurance which is otherwise stopped. If an error causes a change in premium payment, we will make a fair adjustment.

Will the provisions of this certificate conform with state law?

Yes. If any provision in this certificate, or in the provisions of the group policy, is in conflict with the laws of the state governing the certificates or the group policy, the provision will be deemed to be amended to conform to such laws.

MHC-96-13185 Minnesota Life 1

EdF82199 10-2014

Accelerated Benefits Certificate Supplement

Minnesota Life Insurance Company - A Securian Company

400 Robert Street North • St. Paul, Minnesota 55101-2098

Benefits received under this Accelerated Benefits Certificate Supplement may be taxable. You should seek assistance from a personal tax advisor prior to requesting an accelerated payment of death benefits.

General Information

This supplement is subject to every term, condition, exclusion, limitation, and provision of the certificate unless otherwise expressly provided for herein.

What does this supplement provide?

This supplement provides for the accelerated payment of either the full or a partial amount of an insured’s death benefit provided under your certificate. If an insured has a terminal condition as defined in this supplement, you may request an accelerated payment of the applicable death benefit. An accelerated payment will not include any accidental death benefit payable under an Accidental Death and Dismemberment Certificate Supplement.

What is a terminal condition?

A terminal condition is a condition caused by sickness or accident which directly results in a life expectancy of 12 months or less. We must be given medical evidence that satisfies us that the insured has a terminal condition. That evidence must include certification by a physician. For purposes of this supplement, a physician is an individual who is licensed to practice medicine or treat illness in the state in which treatment is received. The physician cannot be you or your spouse/qualified domestic partner, children, parents, grandparents, grandchildren, brothers or sisters; or the spouse of any such individuals.

Accelerated Benefit

Who may request an accelerated payment of the death benefit?

You may request an accelerated payment of the insurance on your life or on the life of a spouse/qualified domestic partner insured under your certificate.

When can an accelerated benefit be requested?

An accelerated benefit can be requested any time, provided the following conditions are met:

(1) the insurance is in force and all premiums due are fully paid; and

(2) you are the sole owner of the certificate; and

(3) the certificate does not have an irrevocable beneficiary; and

(4) application is made in writing or through any other method made available by us under the group policy and in a form which is satisfactory to us.

Is there a minimum or maximum death benefit eligible for an accelerated benefit?

Yes. The minimum death benefit to be eligible for an accelerated benefit under this supplement is $10,000.

The maximum death benefit that can be accelerated is $1,000,000.

Is a partial accelerated benefit available?

Yes. You may choose to accelerate only a portion of an insured’s death benefit, providing the remaining amount of insurance is at least $25,000. This is called a partial accelerated benefit.

You may reapply for the payment of the remaining amount of insurance at any time. However, the total amount of the death benefit for all accelerated benefit payments for an insured cannot exceed $1,000,000. We may ask for further satisfactory evidence that the insured meets all requirements for the accelerated benefit.

When will we pay an accelerated benefit?

We will pay an accelerated benefit upon receipt at our home office of written proof satisfactory to us that the insured meets the requirements herein.

The accelerated benefit will be paid in a single sum or by any other method agreeable to you and us.

To whom will we pay accelerated benefits?

We will pay the accelerated benefit to you.

What is the effect on the insured’s coverage of the receipt of an accelerated benefit?

If you elect to accelerate the full amount of an insured’s death benefit, the insured’s coverage and all other benefits under the certificate and any certificate supplements for that insured will end. If it is your death benefit being accelerated, any dependent life insurance will terminate, though it may be converted to a policy of individual life insurance according to the conversion right section of the certificate.

If a partial accelerated benefit is chosen, coverage will remain in force and premiums will be reduced accordingly.

The remaining amount of insurance under the certificate will be the full amount of insurance minus the amount of insurance that was accelerated.

MHC-96-13185 Minnesota Life 2

Permanent Institutional Confinement Benefit

What is the Permanent Institutional Confinement Benefit?

We will pay a one-time permanent institutional confinement benefit to an insured if the insured submits medical evidence certified by a United States licensed physician and satisfactory to us that the insured requires permanent institutional confinement to a non-hospital care facility licensed in the United States which is medically necessary for the health and well-being of the insured.

The benefit payable shall be 50% of the insured’s inforce life insurance benefit, subject to a maximum benefit amount of $50,000.

Are there any limitations to the permanent institutional confinement benefit?

Yes, this benefit is not payable if the terminal illness benefit or specified disease benefit are payable to the insured. Additionally, this benefit will not be paid when the necessity for permanent institutional confinement has occurred prior to the date that the insured was first covered under this supplement or when confinement to a hospital is necessary.

Hospital means an institution that meets any one of the following criteria:

(1) It is licensed and maintains, on the premises, all facilities necessary for medical and surgical treatment; provides such treatment on an inpatient basis, for compensation, under the supervision of physicians; and provides 24 hour service by registered graduate nurses; or

(2) It qualifies as a hospital, a psychiatric hospital, or a tuberculosis hospital, and a provider of services under Medicare, if such institution is accredited as a hospital by the Joint Commission on the Accreditation of Hospitals; or

(3) It specializes in the treatment of mental illness, alcoholism, drug abuse, or other related illness;

provides residential treatment programs; and is licensed in accordance with the laws of the appropriate legally authorized agency; or It is a free-standing surgical facility.

Specified Disease Benefit

What is the specified disease benefit?

We will pay a one-time specified disease benefit to an insured if the insured submits medical evidence certified by a United States licensed physician and satisfactory to us that the insured has been diagnosed with a specified disease.

To be eligible for the benefit, the certificate holder or spouse/qualified domestic partner must have been insured for at least 24 months under this policy and any other group policy(ies) this policy replaced. A 12 month pre-existing condition limit applies.

The benefit payable shall be 25% of the insured’s inforce life insurance benefit, subject to a maximum benefit amount of $25,000.

How is specified disease determined?

For the purposes of determining the existence of a specified disease we will require the insured to submit the following proof:

(1) a written diagnosis and prognosis by a physician licensed to practice in the United States certifying the existence of a specified disease; and

(2) supportive evidence satisfactory to us , including but not limited to radiological, histological, or laboratory reports documenting the specified disease.

We may at our expense require an examination of the insured and a review of the documented evidence by a physician of our choice.

Pre-Existing Condition means a disease or condition for which the insured received medical treatment, care or advice; took prescribed drugs or medicines; or consulted a physician during the 12 months prior to the effective date of his or her coverage under this policy and any other group policy(ies) this policy replaced.

Specified Disease means a person has been diagnosed by a physician as having one of the following diseases or conditions:

(1) Life-Threatening Cancer: any malignant disease or neoplasm characterized by abnormal cells that grow and spread in an uncontrolled manner. The term Life-Threatening Cancer does not include pre-malignant lesions, carcinoma in situ, skin cancer other than malignant melanoma, carcinoid of the appendix, intraductal non-invasive carcinoma of the breast, stage 1 Hodgkin’s Disease, and stage 1 transitional carcinoma of the urinary bladder or diagnosis of cancer or malignant tumor must be based on criteria established by the American Board of Pathology and histopathologic or histocytologic study.

(2) Heart Attack: an acute myocardial infarction caused by coronary thrombosis or coronary occlusion diagnosed by a physician. Supporting evidence must include electrocardiographic studies (ECG) and appropriate blood and clinical findings. If such studies are not available at the time of the attack, subsequent studies, when available, must confirm the episode by the demonstration of changes compatible with a heart attack and that were not known to be present prior to the episode in question. The term Heart Attack does not include any other diseases or injuries that may be the cause or result of a heart attack;

or any other diseases or injuries.

MHC-96-13185 Minnesota Life 3

(3) Renal Failure: the end stage of chronic, irreversible failure of both kidneys to function, necessitating regular renal dialysis.

(4) Stroke: a condition of sudden onset resulting in permanent brain damage as a result of a subarachnoid hemorrhage, thrombosis, embolism or of a sudden occlusion or spontaneous rupture of a blood vessel in the head or neck, including apoplexy or cerebral vascular accident. The term Stroke does not include transient ischemic attacks (TIA), brief episodes of altered brain function due to inadequate blood flow to the brain from any cause nor other diseases or injuries involving the brain or that may be the cause or result of brain damage.

(5) Specified Organ Transplant: the replacement of a person’s heart, liver, or lungs with a corresponding organ from a human donor.

(6) Acquired Immune Deficiency Syndrome (AIDS) a person tested positive for human immunodeficiency virus (HIV) infection and has been diagnosed as having a disease indicative of AIDS by a physician using definitive diagnostic methods. The term AIDS does not include HIV encephalopathy (dementia) and HIV wasting syndrome.

Termination

When does an insured’s coverage under this rider terminate?

An insured’s Accelerated Benefits coverage terminates on the earliest of:

(1) the date the insured is no longer insured for life insurance under the certificate; or

(2) the date the Accelerated Benefits Policy Rider is terminated; or

(3) the date the group policy is terminated.

Additional Information

Is the request for an accelerated benefit voluntary?

Yes. An accelerated benefit will be made available on a voluntary basis only. An accelerated benefit under this rider is not intended to cause an involuntary reduction of the death benefit ultimately payable to the beneficiary.

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