APPENDIX_3.pdf

Certificate of Insurance

Hartford, Connecticut

County of Orange

ADD-S07154

January 1, 2009

We have issued a policy to the Policyholder. Our name, the Policyholder name and the Policy Number are shown above. The provisions of the policy which are important to you are summarized in this Certificate; consisting of this Certificate and any additional forms which have been made a part of this Certificate. This Certificate replaces all certificates which may hav been given to you earlier for the policy. The policy alone is the only contract under which payment will be made. Any difference between the policy and this Certificate will be settled according to the provisions of the policy.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

Policyholder:

Policy Number:

Policy Effective Date:

Form PA-5427 A2 (S07154)(1) Printed in U.S.A.

Richard G. Costello, John C. Walters, Secretary President

SCHEDULE

Becoming Insured:

Definition of Member

Eligible Persons:

Eligibility Waiting Period

Eligibility Effective Date

Non-Contributory Plan – Basic AD&D

Principal Sum Amount

Contributory Plan – Voluntary AD&D

Principal Sum Amount

Eligible Dependents:

To become insured you must:

(a) Be a Member;

(b) Complete your Eligibility Waiting Period; and

(c) Meet the requirements in Eligibility Effective Date.

: You are a Member if you are one of the following:

An Active Full-time Employee of the Executive Management Unit, Probation Executive Management, Elected Official, Superior Court Commissioner, Court Administrator, Superior Court Executive Officer or Superior Court Judge who is regularly working throughout the entire duration of the Employer's work week at least 40 hours.

You are not a Member if you are:

1. A temporary or seasonal employee; or

2. A full time member of the armed forces of any country.

Executive Management Unit Members, Elected Officials, Court Executive Management, Probation Executive Management and Judges

: You are eligible on one of the following dates, but not before the Group Policy Effective Date:

1. If you are a Member on the Group Policy Effective Date, you are eligible on the first day of the calendar month following 30 consecutive days as a Member.

2. If you become a Member after the Group Policy Effective Date, you are eligible on the first day of the calendar month following 30 consecutive days as a Member.

See the section entitled to determine the effective date of your coverage.

$125,000

The Principal Sum applicable to you is the amount for which:

a) you are eligible to request as determined below;

b) you have given us a Written Request; and

c) the required premium is paid.

$20,000, $40,000, $60,000, $80,000, $100,000, $150,000, $200,000 or $250,000, as elected by You

Non-Contributory Coverage (Basic AD&D): None Contributory Coverage (Voluntary AD&D): Eligible Person's Spouse and Child(ren)

Policy Age Limit:

Change in Class:

Principal Sum for Each of Your Eligible Dependents (Please see Accidental Death and Dismemberment Benefit)

Seat Belt and Air Bag Coverage

Education Benefit

Spouse Education Benefit

Felonious Assault Benefit

Day Care Benefit

DEFINITIONS

We us our

You, your Insured Person

Covered Person

Injury

On, Civil Public Aircraft

Airworthiness Certificate

Military Transport Aircraft

Insured Person - None Spouse - None

If you enter a new Class, described in the Schedule, the insurance applica you is:

a) determined on the basis of the provisions for the new Class; and

b) effective on the Premium Due Date on or next following the date you enter the new Class.

Seat Belt Benefit Amount: the lesser of (1) $10,000, or (2) the Principal Sum payable for loss of life Air Bag Benefit Amount: 5% Maximum Amount: $10,000

An amount equal to the tuition expenses incurred per C years after the date of your death at an accredited institution of higher education, exclusive of room and board, but not to exceed $5,000 per year, or the cumulative total of $20,000 or 25% of the Principal Sum, whichever is less.

The tuition expenses, not to exceed the lesser of $5,0 0 per year or the cumulative total of $10,000 or 25% of the Principal Sum

Percentage of Principal Sum: 5% Maximum Amount: $25,000

The total child care expense incurred within 36 months after the date of your death for all Children under age 13, but not to exceed $5,000 per year, or the cumulative total of $10,000 or 25% of the Principal Sum, whichever is less.

, or means the insurance company named on the face page.

or means an Eligible Person or Member while he or she is covered under the policy.

means you, or your Eligible Dependent while you, he or she is covered under the policy.

means bodily injury resulting directly and independently of all other causes from an accident which occurs while the Covered Person is covered under the policy. Loss resulting from:

a) sickness or disease, except a pus-forming infection which occurs through an accidental wound; or

b) medical or surgical treatment of a sickness or disease;

is not considered as resulting from Injury.

when used with reference to any conveyance (land, water or air), means in or on, boarding or alighting from the conveyance.

or means an aircraft which:

a) has a current and valid Airworthiness Certificate;

b) is piloted by a person who has a valid and current certificate of competency of rating which authorizes him or her to pilot the aircraft; and

c) is not operated by the militia or armed forces of any state, national government or international authority.

means:

a) the "Standard" Airworthiness Certificate issued by the United States Federal Aviation Administration; or

b) a foreign equivalent issued by the governmental authority with jurisdiction over civil aviation in the country of its registry.

means a transport aircraft operated by:

a) the United States Air Mobility Command (AMC); or

b) a national military air transport service of any country.

means any form provided by us for the particular request.

: If you are incapable of Active Work because of Sick Injury or Pregnancy on the day before the scheduled effective date of your insurance or an increase in your insurance, the insurance or increase will not become effective until the day after you complete one full day of Activ Work as an eligible Member.

Active Work and Actively At Work mean performing the material duties of your own occupation at your Employer's usual place of business.

You will also meet the Active Work requirement if:

1. you were absent from Active Work because of a regularly scheduled day off, holiday, or vacation day;

2. you were Actively At Work on your last scheduled work day before the date of your absence; and

3. you were capable of Active Work on the day before the sche e date of your insurance or increase in your insurance.

: Subject to the Active Work Provisions, you, if an Eligible Person or Member, become an Insured Person for Non-Contributory Benefits on the later of:

1. the Policy Effective Date; or

2. the first day of the calendar month following 30 consecutive days as a Member.

Subject to the Active Work Provisions, if you are eligible for Contributory Benefits and apply in writing for coverage, you become an Insured Person on the later of:

1. the Policy Effective Date; or

2. the first day of the month on or next following:

a) the date you apply if you apply within 30 consecutive days after you become a Member; or

b) the date you apply if you become a Member and apply within 30 consecutive days following the date you receive your enrollment information.

: Coverage of you, as an Insured Person, terminates on the earlier of:

1. the date this policy is terminated; or

2. the date your employment terminates;

3. the date you fail to pay any required premium contribution; or

4. the date you cease to be a Member. However, if you cease to be a Member because you are not working the required minimum number of hours, your coverage wi11 be continued with payment of premium, during a leave of absence which is required by the federal or a state-mandated family or medical leave act or law, unless it ends under 1 through 3 above.

1. Waiver Of Active Work Requirement If you were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy, you can become insured on the effective your Employer's coverage without meeting the Active Work requirement. See

2. Payment Of Benefit The benefits payable before you meet the Active Work requirement will be:

a) The benefits which would have been payable under the terms of the Prior Plan if it had remained in force; reduced by

b) Any benefits payable under the Prior Plan.

Insurance may be continued for up to 6 months while you are absent from performing the material duties of your own occupation at your Employer's usual place usiness because of a strike, lockout or other general work stoppage caused by a labor dispute. Rules 1 through 4 below will apply.

1. When your compensation is suspended or terminated because of a work stoppage, your Employer wi11 immediately notify you in writing of your rights under this provision. The Employer will mail the notice to you at your last address on record with the Employer.

2. You must pay the entire premium for your Insurance, including the Employer's share, if any, to your Employer on or before each Premium Due Date.

Written Request

INSURED PERSONS PERIOD OF COVERAGE

Active Work Provisions

Eligibility Effective Date

Termination

Continuity of Coverage

Active Work Provisions.

Strike Continuation:

3. The premiums for your Insurance during the work s ll equal a percentage of the premium rate in effect on the date the work stoppage began (see Coverage Features). We may change premium rates during the work stoppage according to the terms of the Group Policy.

4. Insurance continued under this provision will end on the earliest of:

a) Any Premium Due Date you fail to make the required premium contribution to your Employer on or before that date.

b) The date you have been absent from performing the material duties of your own occupation at your Employer's usual place of business for 6 months.

c) On the date you begin full-time employment with another employer.

d) At our option, on any Premium Due Date if less than 7 5 % of the Members eligible to continue Insurance under this provision make the required premium payment to the Employer.

: If you give us a Written Request for a change in your coverage, and if you:

1. are not eligible for the coverage requested, the change will not become effective;

2. are eligible for the coverage requested, the change will become effective on the first of the month on or next following the date we receive the request.

If your insurance ends, you may become insured again as a new Member. However, the following will apply.

1. If your insurance ends because you cease to be a Member, and if you become a Member again within 90 days, the Eligibility Waiting Period will be waived.

2. If your insurance ends because you are on a federal or state mandated family or medical leave of absence, and you become a Member again immediately following the period allowed, your insurance will be reinstated pursuant to the federal or state-mandated family or medical leave act or law.

You are insured with Dependents Coverage if it is indicated on the Enrollment Form on file with the Policyholder.

Eligible Dependents are defined below. In any event, not an Eligible Dependent.

1 means your spouse unless:

a) you and your spouse are legally separated or divorced; or

b) your spouse has attained the Policy Age Limit, if any, shown in the Schedule.

The term “spouse” used in this policy will include, with respect to California residents only, an individual who is in a registered domestic partnership with you in accordance with California law. Reference your marriage or divorce shall include your registered domestic partnership or dissolution of your registered domestic partnership.

2. or means your unmarried child, stepchild, legally adopted child, or foster child:

a) who is less than age 20 and primarily dependent on you for support and maintenance; or

b) who is at least age 20 but less than age 24 who:

1) regularly attends an institution of learning; and

2) is primarily dependent on you for support and maintena

Each Eligible Dependent will become covered under the on the later of:

a) the date you become an Insured Person;

b) the first day of the month on or next following the date we receive your Written Request for coverage of Dependents; or

c) the date the person qualifies as an Eligible Dependent.

Coverage of each Eligible Dependent terminates on the Premium Due Date on or next following the earlier of:

a) the date you cease to be an Insured Person; or

b) the date he or she ceases to qualify as an Eligible Dependent.

Coverage of a child who, on the date he or she reaches age 20 or 24, is:

a) covered under the policy;

b) mentally or physically incapable of earning his or her own living; and

c) unmarried and primarily dependent on you for support and maintenance;

will not terminate solely due to age.

However, you must give us written notice of the incapacity within 31 days of the termination date.

Request For Change In Coverage

Reinstatement of Insurance:

DEPENDENTS PERIOD OF COVERAGE

Eligibility:

Eligible Dependents:

. Spouse

Child Children

Effective Date:

Termination:

Incapacitated Child:

Coverage will continue as long as:

a) the incapacity continues; and

b) the required premium is paid.

We may, from time to time, require proof of continued incapacity and dependency. After the first two years, we cannot require proof more than once each year.

If you give us a Written Request for a change in the coverage of your Eligible Dependents, and if you:

a) are not eligible for the coverage requested, it will not become effective; or

b) are eligible for the coverage requested, the change will become effective on the first day of the month on or next following the date we receive the request.

The policy does not cover any loss resulting from:

1. intentionally self-inflicted Injury, suicide or attempted suicide, whether sane or insane;

2. war or act of war, whether declared or undeclared;

3. Injury sustained while full-time in the armed forces of any country or international authority;

4. Injury sustained while riding On any aircraft except a Civil or Public Aircraft, or Military Transport Aircraft;

5. Injury sustained while riding On any aircraft:

a) as a pilot, crewmember or student pilot;

b) as a flight instructor or examiner; or

c) if it is owned, operated or leased by or on behalf of the Policyholder, or any employer or organization whose eligible persons are covered under the policy;

6. Injury sustained while voluntarily taking drugs which federal law prohibits dispensing without a prescription, including sedatives, narcotics, barbiturates, amphetamines, or hallucinogens, unless the drug is taken as prescribed or administered by a licensed physician;

7. Injury sustained while committing or attempting to commit a felony;

8. Injury sustained as a result of being legally intoxicated from the use of alcohol.

If your Injury or your Covered Dependent’s injury results in any of the following losses, we will pa he sum shown opposite the loss. We will not pay more than the Principal Sum for all losses due to the same accident. Your amount of the Principal Sum is determined in the Enrollment Form on file with the Policyholder. The amount of Principal Sum for each of your Covered Dependents is shown below as a percent of your Principal Sum.

You with:* Spouse only 50% 0%

Spouse & Children 40 5 Children only 0 10

*As determined on the date of accident.

The Principal Sum for any one Child cannot exceed the lesser of the amount calculated above or $25,000.

For Loss of:

Life ................................…................................................ The Principal Sum Both Hands or Both Feet or Sight of Both Eyes….. ................................................The Principal Sum One Hand and One Foot .................................................. The Principal Sum Speech and Hearing ......................................................... The Principal Sum Either Hand or Foot and Sight of One Eye .....…........................................... The Principal Sum Movement of Both Upper and Lower Limbs (Quadriplegia)............................................................... The Principal Sum

Movement of Both Lower Limbs (Paraplegia) .................... Three-Quarters The Principal Sum

Request For Change In Coverage:

EXCLUSIONS

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT

Spouse Each Child

Movement of Three Limbs (Triplegia)… Three-Quarters The Principal Sum Movement of Both Upper and Lower Limbs of One Side of Body (Hemiplegia) ................ One-Half The Principal Sum

Either Hand or Foot ...................................... One-Half The Principal Sum Sight of One Eye ........................................... One-Half The Principal Sum Speech or Hearing ......................................... One-Half The Principal Sum Thumb and Index

Finger of Either Hand........................... One-Quarter The Principal Sum Uniplegia (Movement of One Limb)……. One-Quarter The Principal Sum means with regard to:

a) hands and feet, actual severance through or above wrist or ankle joints;

b) sight, speech or hearing, entire and irrecoverable loss thereof;

c) thumb and index finger, actual severance through or above the metacarpophalangeal joints;

d) movement of limbs, complete and irreversible paralysis of such limbs.

If you or your Dependent have an accident, including a ntal exposure to adverse weather conditions, while insured under the Group Policy and the accident results in a Loss, We will pay benefits according to the terms of the Group Policy after we receive Proof of Loss.

With respect to Loss of life, death will be presumed if you or your Dependent disappear and the disappearance:

1) Is caused solely and directly by an accident that reasonably e caused Loss of life; and

2) Continues for a period of 365 days after the date of the accident, despite reasonable search efforts.

If your Injury results in a covered Loss under the Accidental Death and Dismemberment Benefit while:

a) a passenger riding in; or

b) the licensed operator of;

an Automobile, and at the time of the accident you were properly wearing a Seat Belt as verified on the police report, then the amount of the Principal Sum will be increased by a Percentage of the Principal Sum, up to a Maximum Amount.

If the above Seat Belt Benefit is payable, we will pay n additional Percentage of the Principal Sum, up to a Maximum Amount, as an Air Bag Benefit if:

a) you were positioned in a seat that was equipped with a factory-installed Air Bag;

b) you were properly strapped in the Seat Belt when the Air Bag inflated; and

c) the police report establishes that the Air Bag inflated properly upon impact.

means an inflatable, supplemental passive restraint s stem installed by the manufacturer of the Automobile, or proper replacement parts as required by the Automobile manufacturer’s specifications that inflates upon collision to protect an individual from Injury and death. An Air Bag is not considered a Seat Belt.

means a duly registered, four-wheeled, private passenger: car, pick-up truck, van, self-propelled motor home or sport utility vehicle which is not being used as a Common Carrier.

means a conveyance operated by a concern, other than t holder, organized and licensed for the transportation of passengers for hire and operated by employee of that concern.

means an unaltered belt, lap restraint, or lap and shoulder restraint installed by the manufacturer of the Automobile, or proper replacement parts as required by the Automobile manufacturer’s specifications.

This Seat Belt and Air Bag Benefit does not cover any loss if you are:

a) using any controlled substance, as defined in Title II of the Connecticut Comprehensive Drug Abuse Prevention and

Control Act of 1970, unless prescribed by a physician; d

b) operating the Automobile.

Loss

EXPOSURE

DISAPPEARANCE

SEAT BELT & AIR BAG BENEFIT

(Insured Member Only)

Air Bag

Automobile

Common Carrier

Seat Belt

Exclusions:

The Percentage of the Principal Sum and Maximum Amount for the Seat Belt and Air Bag Benefit are shown in the Schedule.

If:

a) your Spouse and Eligible Children are covered under the policy; and

b) a Principal Sum is payable under the Accidental Death and Dismemberment Benefit because of your death or your

Covered Spouse's death;

we will pay an Education Benefit to each Student as provided below.

A Student is a person for whom we receive proof that he or she:

a) is covered as your Eligible Dependent on the date of your death or your Covered Spouse's death; and

b) is a full-time post-high school student in a school for higher learning on the date of your death or your Covered Spouse's death; or

c) became a full-time post-high school student in a school for higher learning within 365 days after your death or your

Covered Spouse's death and was a student in the 12th grade on the date of your death or your Covered Spouse's death.

He or she is not considered to be a Student after the first to occur of:

a) our payment of the fourth Education Benefit to or on behalf of that person; or

b) the end of the 12th consecutive month during which we have not received proof that he or she is a Student.

The Education Benefit is an amount equal to the tuition expenses incurred per Child within 4 years after the date of your death or your Covered Spouse’s death at an accredited institution of higher education, exclusive of room and board, but not to exceed $5,000 per year, or the cumulative total of $20,000 or 25% of the Principal Sum, whichever is less.

We will not pay more than one Education Benefit to any one Student during any one school year.

The Education Benefit is payable to each person:

a) on the date; and

b) for whom;

we have received proof that he or she is a Student.

If he or she is a minor, we will pay the benefit to the Student's legal representative.

Your Principal Sum is determined in the Enrollment Form on file with the Policyholder. Your Covered Spouse's amount of Principal Sum is shown in the Accidental Death and Dismemberment section as a percentage of your Principal Sum. The Maximum Amount and Percentage of Principal Sum are shown in the Schedule.

If your Injury results in loss of life and:

a) your Eligible Dependents are covered under the policy; and

b) a Principal Sum is payable under the Accidental Death and Dismemberment Benefit;

we will pay an Education Benefit to your Surviving Covered Spouse as provided below.

Your Surviving Covered Spouse, to qualify for the Education Benefit, must enroll in an Occupational Training program:

a) for the purpose of obtaining an independent source of income;

b) within one (1) year of the date of your death.

The Education Benefit is an amount equal to the tuition expenses, not to exceed the lesser of $5,000 per year or the cumulative total of $10,000 or 25% of the Principal Sum

The expense must be incurred within three (3) years of the date of your death.

We will pay the Education Benefit due immediately after we receive proof that your Spouse has an Occupational Training program.

means any:

a) education;

EDUCATION BENEFIT

SPOUSE EDUCATION BENEFIT

Occupational Training

b) professional; or

c) trade training;

program which prepares your Spouse for an occupation for which he or she otherwise would not have been qualified.

means:

a) the actual tuition charged, exclusive of room and board; and

b) the actual cost of the materials needed;

for the Occupational Training program.

Your amount of the Principal Sum is determined in the Enrollment Form on file with the Policyholder.

The Maximum Amount and Percentage of Principal Sum are shown in the Schedule.

If your or your Covered Dependent’s Injury:

a) results in any loss payable under the policy; and

b) is a result of a Felonious Assault;

then we will pay an additional benefit equal to the lesser of:

a) a Percentage of your Principal Sum; or

b) the Maximum Amount;

as a Felonious Assault Benefit.

Your amount of Principal Sum is determined in the Enrollment Form on file with the Policyholder. Your Covered Dependent’s amount of Principal Sum is shown in the Accidental Death and Dismemberment section as a percentage of your Principal Sum.

The Percentage of Principal Sum and Maximum Amount are shown in the Schedule.

means:

a) a robbery, kidnapping or criminal assault; or

b) an attempt at any of the above.

The Felonious Assault Benefit will not pay for a Loss that results from a Felonious Assault committed by:

1) a member of the injured person’s family;

2) a member of the household in which the injured person lives; or

3) the injured person’s fellow employee.

We will pay a Day Care Benefit for each of your Eligible Dependents who are covered under the policy if:

a) a Principal Sum is payable under the Accidental Death and Dismemberment Benefit because of your death or your

Covered Spouse's death; and

b) such dependent is under age 13 at the time of the death; and

c) proof of enrollment in a Day Care Program is provided as described below.

Payment will be made to the person who has legal physical custody of the Eligible Dependent and who has primary responsibility for the Eligible Dependent's expenses. Payment will be made in accordance with the Claims provision of the Policy.

Proof of enrollment for each child in a Day Care Program may be in the form of, but will not be limited to, the following:

a) a copy of the child's approved enrollment application in a Day Care Program; or

b) cancelled check(s) evidencing payment to a Day Care facility or Day Care Provider; or

c) a letter from the Day Care facility or Day Care provider stating that the child:

1) is attending a Day Care Program; or

2) has been enrolled in a Day Care Program and will be attending within 365 days of the date of your death or your

Covered Spouse's death.

Proof of enrollment must be sent to us prior to the last day of the 12th month on or next following the date of your death or your Covered Spouse's death.

Expense Incurred

FELONIOUS ASSAULT BENEFIT

Felonious Assault

DAY CARE BENEFIT

One Day Care Benefit payment will be made each year, for a maximum of 3 Day Care Benefit payments, for each Eligible Dependent.

The Day Care Benefit is the total child care expense incurred within 36 months after the date of your death or your Covered Spouse’s death for all Children under age 13, but not to exceed $5,000 per year, or the cumulative total of $10,000 or 25% of the Principal Sum, whichever is less.

The Maximum Amount and Percent are shown in the Schedule.

Your amount of Principal Sum is determined in the Enrollment Form on file with the Policyholder. Your Covered Spouse's amount of Principal Sum is shown in the Accidental Death and Dismemberment section as a percentage of your Principal Sum.

means a program of child care which:

a) is operated in a private home, school or other facility; and

b) provides, and makes a charge for, the care of children and

c) is licensed as a Day Care center or is operated by a licensed Day Care provider, if such licensing is required by the state of jurisdiction in which it is located; or

d) if licensing is not required, provides child care on a daily basis for 12 months a year.

The person who has the right to claim benefits (the claimant or beneficiary) must give us written notice of a claim within 20 days after a covered loss begins. If not be given within that time, it must be given as soon as reasonably possible.

The notice should include your name and the policy number. Send it to our office in Hartford, Connecticut, or give it to our agent.

When we receive the notice of claim, we will send forms to the claimant for giving us proof of loss. The forms will be sent within 15 days after we receive the notice of claim.

If the forms are not received, the claimant will satisfy the proof of loss requirement if a written notice of the occurrence, character and nature of the loss is sent to us.

Proof of loss must be sent to us in writing within 90 days after:

a) the end of a period of our liability for periodic paym ; or

b) the date of the loss for all other claims.

If the claimant is not able to send it within that time, it may be sent as soon as reasonably possible without affecting the claim.

We will pay any daily, weekly or monthly benefit due:

a) on a monthly basis, after we receive the proof of loss, while the loss and our liability continue; or

b) immediately after we receive the proof of loss following the end of our liability.

We will pay any other benefit due immediately after we receive the proof of loss.

We will pay any benefit due for loss of your life:

a) according to the beneficiary designation in effect under the policy at the time of your death; or

b) to the survivors, in equal shares, in the first of the following classes to have a survivor at your death:

1) spouse,

2) children,

3) parents,

4) brothers and sisters.

If there is no survivor in these classes, payment will be made to your estate.

All other benefits due and not assigned will be paid to you, if living. Otherwise, the benefits will be paid according to the preceding paragraph.

If a benefit due is payable to:

a) your estate; or

b) you or any person who is either a minor or not competent to give a valid release for the payment;

Day Care Program

CLAIMS

Notice of Claim:

Claim Forms:

Proof of Loss:

Time of Claim Payment:

Payment of Claims:

we may pay up to $1,000 of the benefit due to some other person.

The other person will be someone related to the minor or incompetent person by blood or marriage who we believe is entitled to the payment. We will be relieved of further responsibility to the extent of any payment made in good faith.

Benefits will be paid into a checking account which will be owned by:

a) you; or

b) the beneficiary or beneficiaries named in writing by you.

The checking account owner may elect a lump sum payment by writing a check for the full amount in the checking account.

However, a checking account will not be established for a benefit payable to your estate or for a Principal Sum that is less than $10,000 or for any claim that the claim department determines is more appropriately adjudicated through the issuance of a lump sum.

If a claim for benefits is wholly or partially denied, notice of the decision shall be furnished to you. The written decision will:

a) give the specific reason or reasons for denial;

b) make specific reference to the policy provision on which the denial is based;

c) provide a description of any additional information necessary to prepare the claim and an explanation of why it is necessary; and

d) provide an explanation of the review procedure.

On any denied claim, you or your representative may appeal to us for a full and fair review. The claimant may:

a) request a review upon written application within 60 days of the rec nial;

b) review pertinent documents;

c) submit issues and comments in writing.

We will make a decision no more than 60 days after the receipt of the request for review, except in special circumstances (such as the need to hold a hearing), but in no case more th ys after we receive the request for review. The written decision will include specific reasons on which the decision is based.

While a claim is pending we have the right at our expense:

a) to have the person who has a loss examined by a physician at reasonable intervals; and

b) to make an autopsy in case of death where it is not forbidden by law.

You cannot take legal action against us before 60 days following the d s or after 3 years following the date written proof of loss is due..

You may name a beneficiary or change a revocable named beneficiary by giving your Written Request to the Policyholder. Your request takes effect on the date you execute it, regardless of whether you are living when the Policyholder receives it. We will be relieved of further responsibility to the extent of any payment we made in good faith before the Policyholder received your request.

We will recognize any assignment you make under the policy, provided:

a) it is duly executed; and

b) a copy is on file with us.

We and the Policyholder assume no responsibility for the validity or effect of an assignment.

Appealing Denial of Claims:

Physical Examinations and Autopsy:

Legal Actions:

Naming a Beneficiary:

Assignment:

County of Orange

ADD-S07154

January 1, 2009

We have issued a policy to the Policyholder. Our name, the Policyholder name and the Policy Number are shown above. The provisions of the policy which are important to you are summarized in this Certificate; consisting of this Certificate and any additional forms which have been made a part of this Certificate. This Certificate replaces all certificates which may hav been given to you earlier for the policy. The policy alone is the only contract under which payment will be made. Any difference between the policy and this Certificate will be settled according to the provisions of the policy.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

Policyholder:

Policy Number:

Policy Effective Date:

Form PA-5427 A2 (S07154)(2)

Definition of Member

Eligible Persons:

Eligibility Waiting Period

Eligibility Effective Date

Non-Contributory Plan – Basic AD&D

Principal Sum Amount

Contributory Plan – Voluntary AD&D

Principal Sum Amount

Eligible Dependents:

Policy Age Limit:

Change in Class:

To become insured you must:

(a) Be a Member;

(b) Complete your Eligibility Waiting Period; and

(c) Meet the requirements in Eligibility Effective Date.

: You are a Member if you are one of the following:

An Active Full-time Employee of the Administrative Management Unit or Probation Administrative Management Unit who is regularly working throughout the entire duration of the Employer's work week at least 40 hours.

You are not a Member if you are:

1. A temporary or seasonal employee; or

2. A full time member of the armed forces of any country.

Administrative Management Unit Members, Probation Administrative Management Unit Members

: You are eligible on one of the following dates, but not before the Group Policy Effective Date:

1. If you are a Member on the Group Policy Effective Date, you are eligible on the first day of the calendar month following 30 consecutive days as a ber.

2. If you become a Member after the Group Policy Effective Date, you are eligible on the first day of the calendar month following 30 consecutive days as a Member.

See the section entitled to determine the effective date of your coverage.

$100,000

The Principal Sum applicable to you is the amount for which:

a) you are eligible to request as determined below;

b) you have given us a Written Request; and

c) the required premium is paid.

$20,000, $40,000, $60,000, $80,000, $100,000, $150,000, $200,000 or $250,000, as elected by the You

Non-Contributory Coverage (Basic AD&D): None Contributory Coverage (Voluntary AD&D): Eligible Person's Spouse and Child(ren)

Insured Person - None Spouse - None

If you enter a new Class, described in the Schedule, the insurance applicable to you is:

a) determined on the basis of the provisions for the new Class; and

b) effective on the Premium Due Date on or next following the date you enter the new Class.

Seat Belt Benefit Amount: the lesser of (1) $10,000, or (2) the Principal Sum p yable for loss of life Air Bag Benefit Amount: 5% Maximum Amount: $10,000

An amount equal to the tuition expenses incurred per C years after the date of your death at an accredited institution of higher education, exclusive of room and board, but not to exceed $5,000 per year, or the cumulative total of $20,000 or 25% of the Principal Sum, whichever is less.

The tuition expenses, not to exceed the lesser of $5,000 per year or the cumulative total of $10,000 or 25% of the Principal Sum

Percentage of Principal Sum: 5% Maximum Amount: $25,000

The total child care expense incurred within 36 months after the date of your death for all Children under age 13, but not to exceed $5,000 per year, or the cumulative total of 0,000 or 25% of the Principal Sum, whichever is less.

, or means the insurance company named on the face page.

or means an Eligible Person or Member while he or she is covered under the policy.

means you, or your Eligible Dependent while you, he or she is covered under the policy.

means bodily injury resulting directly and independently of all other causes from an accident which occurs while the Covered Person is covered under the policy. Loss resulting from:

a) sickness or disease, except a pus-forming infection which occurs through an accidental wound; or

b) medical or surgical treatment of a sickness or disease;

is not considered as resulting from Injury.

when used with reference to any conveyance (land, water or air), means in or on, boarding or alighting from the conveyance.

or means an aircraft which:

a) has a current and valid Airworthiness Certificate;

b) is piloted by a person who has a valid and current certificate of competency of a rating which authorizes him or her to pilot the aircraft; and

c) is not operated by the militia or armed forces of any state, national government or international authority.

means:

a) the "Standard" Airworthiness Certificate issued by the United States Federal Aviation Administration; or

b) a foreign equivalent issued by the governmental authority with jurisdiction over civil aviation in the country of its registry.

means a transport aircraft operated by:

a) the United States Air Mobility Command (AMC); or

b) a national military air transport service of any country.

means any form provided by us for the particular request.

Principal Sum for Each of Your Eligible Dependents (Please see Accidental Death and Dismemberment Benefit)

Seat Belt and Air Bag Coverage

Education Benefit

Spouse Education Benefit

Felonious Assault Benefit

Day Care Benefit

DEFINITIONS

We us our

You, your Insured Person

Covered Person

Injury

On, Civil Public Aircraft

Airworthiness Certificate

Military Transport Aircraft

Written Request

INSURED PERSONS PERIOD OF COVERAGE

Active Work Provisions

Eligibility Effective Date

Termination

Continuity of Coverage

Active Work Provisions.

Strike Continuation:

: If you are incapable of Active Work because of Sick Injury or Pregnancy on the day before the scheduled effective date of your insurance or an increase in your insurance, the insurance or increase will not become effective until the day after you complete one full day of Activ Work as an eligible Member.

Active Work and Actively At Work mean performing the material duties of your own occupation at your Employer's usual place of business.

You will also meet the Active Work requirement if:

1. you were absent from Active Work because of a regularly scheduled day off, holiday, or vacation day;

2. you were Actively At Work on your last scheduled work day before the date of your absence; and

3. you were capable of Active Work on the day before the scheduled effective date of your insurance or increase in your insurance.

: Subject to the Active Work Provisions, you, if an Eligible Person or Member, become an Insured Person for Non-Contributory Benefits on the later of:

1. the Policy Effective Date; or

2. the first day of the calendar month following 30 consecutive days as a Member.

Subject to the Active Work Provisions, if you are eligible for Contributory Benefits and apply in writing for coverage, you become an Insured Person on the later of:

1. the Policy Effective Date; or

2. the first day of the month on or next following:

a) the date you apply if you apply within 30 consecutive days after you become a Member; or

b) the date you apply if you become a Member and apply within 30 consecutive days following the date you receive your enrollment information.

: Coverage of you, as an Insured Person, terminates on the earlier of:

1. the date this policy is terminated; or

2. the date your employment terminates;

3. the date you fail to pay any required premium contribution; or

4. the date you cease to be a Member. However, if you cease to be a Member because you are not working the required minimum number of hours, your coverage wi11 be continued with payment of premium, during a leave of absence which is required by the federal or a state-mandated family or medical leave act or law, unless it ends under 1 through 3 above.

1. Waiver Of Active Work Requirement If you were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy, you can become insured on the effective date of your Employer's coverage without meeting the Active Work requirement. See

2. Payment Of Benefit The benefits payable before you meet the Active Work requirement will be:

a) The benefits which would have been payable under the terms of the Prior Plan if it had remained in force; reduced by

b) Any benefits payable under the Prior Plan.

Insurance may be continued for up to 6 months while you are absent from performing the material duties of your own occupation at your Employer's usual place usiness because of a strike, lockout or other general work stoppage caused by a labor dispute. Rules 1 through 4 below will apply.

1. When your compensation is suspended or terminated because of a work stoppage, your Employer wi11 immediately notify you in writing of your rights under this provis oyer will mail the notice to you at your last address on record with the Employer.

2. You must pay the entire premium for your Insurance, including the Employer's share, if any, to your Employer on or before each Premium Due Date.

3. The premiums for your Insurance during the work s ll equal a percentage of the premium rate in effect on the date the work stoppage began (see Coverage Features). We may change premium rates during the work stoppage according to the terms of the Group Policy.

4. Insurance continued under this provision will end on the earliest of:

a) Any Premium Due Date you fail to make the required premium contribution to your Employer on or before that date.

b) The date you have been absent from performing the material duties of your own occupation at your Employer's usual place of business for 6 months.

c) On the date you begin full-time employment with another employer.

d) At our option, on any Premium Due Date if less than 7 5 % of the Members eligible to continue Insurance under this provision make the required premium payment to the Employer.

: If you give us a Written Request for a change in your coverage, and if you:

1. are not eligible for the coverage requested, the chang effective;

2. are eligible for the coverage requested, the change will become effective on the first of the month on or next following the date we receive the request.

If your insurance ends, you may become insured again as a new Member. However, the following will apply.

1. If your insurance ends because you cease to be a Member, and if you become a Member again within 90 days, the Eligibility Waiting Period will be waived.

2. If your insurance ends because you are on a federal or state mandated family or medical leave of absence, and you become a Member again immediately following the period allowed, your insurance will be reinstated pursuant to the federal or state-mandated family or medical leave act or law.

You are insured with Dependents Coverage if it is indicated on the Enrollment Form on file with the Policyholder.

Eligible Dependents are defined below. In any event, not an Eligible Dependent.

1 means your spouse unless:

a) you and your spouse are legally separated or divorced; or

b) your spouse has attained the Policy Age Limit, if any, shown in the Schedule.

The term “spouse” used in this policy will include, with respect to California residents only, an individual who is in a registered domestic partnership with you in accordance with California law. Reference your marriage or divorce shall include your registered domestic partnership or dissolution of your registered domestic partnership.

2. or means your unmarried child, stepchild, legally adopted child, or foster child:

a) who is less than age 20 and primarily dependent on you for support and maintenance; or

b) who is at least age 20 but less than age 24 who:

1) regularly attends an institution of learning; and

2) is primarily dependent on you for support and maintenance.

Each Eligible Dependent will become covered under the on the later of:

a) the date you become an Insured Person;

b) the first day of the month on or next following the date we receive your Written Request for coverage of Dependents; or

c) the date the person qualifies as an Eligible Dependent.

Coverage of each Eligible Dependent terminates on the Premium Due Date on or next following the earlier of:

a) the date you cease to be an Insured Person; or

b) the date he or she ceases to qualify as an Eligible Dependent.

Coverage of a child who, on the date he or she reaches age 20 or 24, is:

a) covered under the policy;

b) mentally or physically incapable of earning his or her own living; and

c) unmarried and primarily dependent on you for support and maintenance;

will not terminate solely due to age.

However, you must give us written notice of the incapacity within 31 days of the termination date.

Coverage will continue as long as:

a) the incapacity continues; and

b) the required premium is paid.

Request For Change In Coverage

Reinstatement of Insurance:

DEPENDENTS PERIOD OF COVERAGE

Eligibility:

Eligible Dependents:

. Spouse

Child Children

Effective Date:

We may, from time to time, require proof of continued incapacity and dependency. After the first two years, we cannot require proof more than once each year.

If you give us a Written Request for a change in the coverage of your Eligible Dependents, and if you:

a) are not eligible for the coverage requested, it will not become effective; or

b) are eligible for the coverage requested, the change will become effective on the first day of the month on or next following the date we receive the request.

The policy does not cover any loss resulting from:

1. intentionally self-inflicted Injury, suicide or attempted suicide, whether sane or insane;

2. war or act of war, whether declared or undeclared;

3. Injury sustained while full-time in the armed forces of any country or international authority;

4. Injury sustained while riding On any aircraft except a Civil or Public Aircraft, or Military Transport Aircraft;

5. Injury sustained while riding On any aircraft:

a) as a pilot, crewmember or student pilot;

b) as a flight instructor or examiner; or

c) if it is owned, operated or leased by or on behalf of the Policyholder, or any employer or organization whose eligible persons are covered under the policy;

6. Injury sustained while voluntarily taking drugs which federal law prohibits dispensing without a prescription, including sedatives, narcotics, barbiturates, amphetamines, or hallucinogens, unless the drug is taken as prescribed or administered by a licensed physician;

7. Injury sustained while committing or attempting to commit a felony;

8. Injury sustained as a result of being legally intoxicated from the use of alcohol.

If your Injury or your Covered Dependent’s injury results in any of the following losses, we will pay the sum shown opposite the loss. We will not pay more than the Principal Sum for all losses due to the same accident. Your amount of the Principal Sum is determined in the Enrollment Form on file with the Policyholder. The amount of Principal Sum for each of your Covered Dependents is shown below as a percent of your Principal Sum.

You with:* Spouse only 50% 0%

Spouse & Children 40 5 Children only 0 10

*As determined on the date of accident.

The Principal Sum for any one Child cannot exceed the lesser of the amount calculated above or $25,000.

For Loss of:

Life ................................…................................................ The Principal Sum Both Hands or Both Feet or Sight of Both Eyes….. ................................................The Principal Sum One Hand and One Foot .................................................. The Principal Sum Speech and Hearing ................................... ................. The Principal Sum Either Hand or Foot and Sight of One Eye .....…........................................... The Principal Sum Movement of Both Upper and Lower Limbs (Quadriplegia)............................................................... The Principal Sum

Movement of Both Lower Limbs (Paraplegia) .................... Three-Quarters The Principal Sum Movement of Three Limbs (Triplegia)… Three-Quarters The Principal Sum Movement of Both Upper and Lower Limbs of One Side of Body (Hemiplegia) ................ One-Half The Principal Sum

Either Hand or Foot ...................................... One-Half The Principal Sum

Request For Change In Coverage:

EXCLUSIONS

Sight of One Eye ........................................... One-Half The Principal Sum Speech or Hearing ......................................... One-Half The Principal Sum Thumb and Index

Finger of Either Hand........................... One-Quarter The Principal Sum Uniplegia (Movement of One Limb)……. One-Quarter The Principal Sum means with regard to:

a) hands and feet, actual severance through or above wrist or ankle joints;

b) sight, speech or hearing, entire and irrecoverable loss thereof;

c) thumb and index finger, actual severance through or above the metacarpophalangeal joints;

d) movement of limbs, complete and irreversible paralysis of such limbs.

If you or your Dependent have an accident, including accidental exposure to adverse weather conditions, while insured under the Group Policy and the accident results in a Loss, We will pay benefits according to the terms of the Group Policy after we receive Proof of Loss.

With respect to Loss of life, death will be presumed if you or your Dependent disappear and the disappearance:

1) Is caused solely and directly by an accident that reasonably could have caused Loss of life; and

2) Continues for a period of 365 days after the date of the accident, despite reasonable search efforts.

If your Injury results in a covered Loss under the Accidental Death and Dismemberment Benefit while:

a) a passenger riding in; or

b) the licensed operator of;

an Automobile, and at the time of the accident you were properly wearing a Seat Belt as verified on the police report, then the amount of the Principal Sum will be increased by a Percentage of the Principal Sum, up to…