Appendix_7.14_RFP%2031786-00186_161596%20MetLife%20LTD%20Certificate%20of%20Coverage%20Eff.%20Jan%202022.pdf

Certificate Number 26

YOUR BENEFIT PLAN

State of Tennessee

State Government Employees

Disability Income Insurance: Long Term Benefits

Certificate Date: January 1, 2022

1900 WRS Tennessee Tower 312 Rosa L. Parks Avenue Nashville, TN 37243

TO OUR EMPLOYEES:

All of us appreciate the protection and security insurance provides.

This certificate describes the benefits that are available to you. We urge you to read it carefully.

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Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166

CERTIFICATE OF INSURANCE

Metropolitan Life Insurance Company (“MetLife”), a stock company, certifies that You are insured for the benefits described in this certificate, subject to the provisions of this certificate. This certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY.

This certificate is part of the Group Policy. The Group Policy is a contract between MetLife and the Policyholder and may be changed or ended without Your consent or notice to You.

Policyholder: State of Tennessee

Group Policy Number:

161596-1-G

Type of Insurance: Disability Income Insurance: Long Term Benefits

MetLife Toll Free Number(s):

For Claim Information FOR DISABILITY INCOME CLAIMS: 1-855-700-8001

THIS CERTIFICATE ONLY DESCRIBES DISABILITY INSURANCE.

FOR CALIFORNIA RESIDENTS: REVIEW THIS CERTIFICATE CAREFULLY. IF YOU

ARE 65 OR OLDER ON YOUR EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY

RETURN IT TO US WITHIN 30 DAYS FROM THE DATE YOU RECEIVE IT AND WE

WILL REFUND ANY PREMIUM YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL

BE CONSIDERED TO NEVER HAVE BEEN ISSUED.

THE BENEFITS OF THE POLICY PROVIDING YOUR COVERAGE ARE GOVERNED PRIMARILY BY THE

LAW OF A STATE OTHER THAN FLORIDA.

THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED

IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS

REQUIRED BY MARYLAND LAW.

For Residents of North Dakota: If You are not satisfied with Your Certificate, You may return it to Us within 20 days after You receive it, unless a claim has previously been received by Us under Your Certificate. We will refund within 30 days of Our receipt of the returned Certificate any Premium that has been paid and the Certificate will then be considered to have never been issued. You should be aware that, if You elect to return the Certificate for a refund of premiums, losses which otherwise would have been covered under Your Certificate will not be covered.

For New Hampshire Residents: 30 Day Right to Examine Certificate.

Please read this Certificate. You may return the Certificate to Us within 30 days from the date You receive it.

If you return it within the 30 day period, the Certificate will be considered never to have been issued and We will refund any premium paid for insurance under this Certificate.

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WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE

AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S)

CAREFULLY.

NOTICE FOR RESIDENTS OF TEXAS

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Have a complaint or need help?

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

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

To get information or file a complaint with your insurance company or HMO:

Call: Corporate Consumer Relations Department at 1-800-438-6388

Toll-free: 1-800-438-6388

Email: Johnstown_Complaint_Referrals@metlife.com

Mail: Metropolitan Life Insurance Company

700 Quaker Lane 2nd Floor Warwick, RI 02886

The Texas Department of Insurance

To get help with an insurance question or file a complaint with the state:

Call with a question: 1-800-252-3439

File a complaint: www.tdi.texas.gov

Email: ConsumerProtection@tdi.texas.gov

Mail: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091

¿Tiene una queja o necesita ayuda?

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

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

Para obtener información o para presentar una queja ante su compañía de seguros o HMO:

Llame a: Departamento de Relaciones Corporativas del Consumidor al 1-800-438-6388

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Teléfono gratuito: 1-800-438-6388

Correo electrónico: Johnstown_Complaint_Referrals@metlife.com

Dirección postal: Metropolitan Life Insurance Company

700 Quaker Lane 2nd Floor Warwick, RI 02886

El Departamento de Seguros de Texas

Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una queja ante el estado:

Llame con sus preguntas al: 1-800-252-3439

Presente una queja en: www.tdi.texas.gov

Correo electrónico: ConsumerProtection@tdi.texas.gov

Dirección postal: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091 notice/wc/nw

NOTICE FOR RESIDENTS OF ALL STATES

WORKERS’ COMPENSATION

This certificate does not replace or affect any requirement for coverage by workers’ compensation insurance.

MANDATORY DISABILITY INCOME BENEFIT LAWS

For Residents of California, Hawaii, New Jersey, New York, Rhode Island and Puerto Rico This certificate does not affect any requirement for any government mandated temporary disability income benefits law.

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NOTICE FOR RESIDENTS OF ARKANSAS

If You have a question concerning Your coverage or a claim, first contact the Policyholder or group account administrator. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.

Policyholders have the right to file a complaint with the Arkansas Insurance Department (AID). You may call AID to request a complaint form at (800) 852-5494 or (501) 371-2640 or write the Department at:

Arkansas Insurance Department

Consumer Services Division

1 Commerce Way, Suite 102

Little Rock, Arkansas 72202

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NOTICE FOR RESIDENTS OF CALIFORNIA

IMPORTANT NOTICE

TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE

POLICYHOLDER OR METLIFE AT:

METROPOLITAN LIFE INSURANCE COMPANY

ATTN: CONSUMER RELATIONS DEPARTMENT

500 SCHOOLHOUSE ROAD

JOHNSTOWN, PA 15904

1-800-438-6388

IF, AFTER CONTACTING THE POLICYHOLDER AND/OR METLIFE, YOU FEEL THAT A SATISFACTORY

SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA

DEPARTMENT OF INSURANCE DEPARTMENT AT:

DEPARTMENT OF INSURANCE

CONSUMER SERVICES

300 SOUTH SPRING STREET

LOS ANGELES, CA 90013

WEBSITE: http://www.insurance.ca.gov/

1-800-927-4357 (within California)

1-213-897-8921 (outside California)

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NOTICE FOR RESIDENTS OF CONNECTICUT

MANDATORY REHABILITATION

This certificate contains a mandatory rehabilitation provision, which may require you to participate in vocational training or physical therapy when appropriate.

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NOTICE FOR RESIDENTS OF GEORGIA

The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence.

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NOTICE FOR RESIDENTS OF IDAHO

If You have a question concerning Your coverage or a claim, first contact the Policyholder. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.

If You are still concerned after contacting both the Policyholder and MetLife, You should feel free to contact:

Idaho Department of Insurance

Consumer Affairs

700 West State Street, 3rd Floor

PO Box 83720

Boise, Idaho 83720-0043

1-800-721-3272 (for calls placed within Idaho) or 208-334-4250 or www.DOI.Idaho.gov notice/il 11

NOTICE FOR RESIDENTS OF ILLINOIS

To make a complaint to MetLife, You may write to:

MetLife

200 Park Avenue New York, New York 10166

The address of the Illinois Department of Insurance is:

Illinois Department of Insurance

Public Services Division Springfield, Illinois 62767 notice/in 12

NOTICE FOR RESIDENTS OF INDIANA

Questions regarding your policy or coverage should be directed to:

If you (a) need the assistance of the government agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email:

State of Indiana Department of Insurance

Consumer Services Division

311 West Washington Street, Suite 300

Indianapolis, Indiana 46204

Consumer Hotline: (800) 622-4461; (317) 232-2395

Complaint can be filed electronically at www.in.gov/idoi

NOTICE FOR RESIDENTS OF MAINE

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You have the right to designate a third party to receive notice if Your insurance is in danger of lapsing due to a default on Your part, such as for nonpayment of a contribution that is due. The intent is to allow reinstatements where the default is due to the insured person’s suffering from cognitive impairment or functional incapacity. You may make this designation by completing a “Third-Party Notice Request Form” and sending it to MetLife. Once You have made a designation, You may cancel or change it by filling out a new Third-Party Notice Request Form and sending it to MetLife. The designation will be effective as of the date MetLife receives the form. Call MetLife at the toll-free telephone number shown on the face page of this certificate to obtain a Third-Party Notice Request Form. Within 90 days after cancellation of coverage for nonpayment of premium, You or any person authorized to act on Your behalf may request reinstatement of the certificate on the basis that You suffered from cognitive impairment or functional incapacity at the time of cancellation.

NOTICE FOR RESIDENTS OF MAINE

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NOTICE FOR MASSACHUSETTS RESIDENTS

CONTINUATION OF DISABILITY INCOME INSURANCE

1. If Your Disability Income Insurance ends due to a Plant Closing or Covered Partial Closing, such insurance will be continued for 90 days after the date it ends.

2. If Your Disability Income Insurance ends because:

You cease to be in an Eligible Class; or Your employment terminates;

for any reason other than a Plant Closing or Covered Partial Closing, such insurance will continue for 31 days after the date it ends.

Continuation of Your Disability Income Insurance under the CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT subsection will end before the end of continuation periods shown above if You become covered for similar benefits under another plan.

Plant Closing and Covered Partial Closing have the meaning set forth in Massachusetts Annotated Laws, Chapter 151A, Section 71A.

NOTICE FOR RESIDENTS OF MISSISSIPPI

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FILING A DISABILITY INCOME INSURANCE CLAIM

The Policyholder should have a supply of claim forms. Obtain a claim form from the Policyholder and fill it out carefully. Return the completed claim form with the required Proof to the Policyholder.

If You are unable to report for Active Work due to a Sickness or accidental injury, and You think that You may be Disabled, You should contact MetLife or Your benefits representative to initiate a claim. We recommend that You do so no later than:

14 days with respect to Disability Income Insurance: Short Term Benefits; and 12 weeks, with respect to Disability Income Insurance: Long Term Benefits after the first day You are unable to report for Active Work so that Your claim can be processed in a timely manner.

When a claimant files an initial claim for Disability Income Insurance benefits described in this certificate, the following should be sent to Us:

notice of claim within 30 days of the date of loss; and the required Proof within 90 days after the end of the Elimination Period.

Notice of claim and Proof for Disability Income Insurance may also be given to Us by following the steps set forth below:

Step 1 A claimant may give Us notice by calling Us at the toll-free number shown in the Certificate Face Page within 30 days of the date of a loss.

Step 2 We will send a claim form to the claimant and explain how to complete it. The claimant should receive the claim form within 15 days of giving Us notice of claim.

Step 3 When the claimant receives the claim form the claimant should fill it out as instructed and return it with the required Proof described in the claim form. If the claimant does not receive a claim form within 15 days after giving Us notice of claim, Proof may be sent using any form sufficient to provide Us with the required Proof.

Step 4 The claimant must give Us Proof not later than 90 days after the end of the Elimination Period.

If notice of claim or Proof is not given within the time limits described in this section, the delay will not cause a claim to be denied or reduced if such notice or Proof are given as soon as is reasonably possible; and, in no event, except in the absence of legal capacity, later than 1 year after the date Proof is otherwise required.

Subject to due Written Proof of loss, all accrued benefits for loss for which this certificate provides periodic payment will be paid as follows:

Weekly, with respect to Disability Income Insurance: Short Term Benefits;

Monthly, with respect to Disability Income Insurance: Long Term Benefits.

Any balance remaining unpaid upon the termination of liability will be paid within thirty (30) days after receipt of due Written Proof.

Any benefit due and not paid within 30 days of our receipt of Proof will accrue interest at the rate of three percent (3%) per month on the amount due, until the claim is finally settled or adjudicated.

Subject to the Time Limit on Legal Actions provision, if We do not pay benefits when due and payable You may bring an action to recover such benefits, any interest which has accrued with respect to such benefits, and any other damages which may be allowed by law. If it is determined in such action that We acted in bad faith as evidenced by a repeated or deliberate pattern of failing to pay benefits and/or claims when due, You

NOTICE FOR RESIDENTS OF MISSISSIPPI (continued)

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notice/ms dis claim or the health care provider shall be entitled to recover damages in an amount up to three (3) times the amount of the benefits that remain unpaid until the claim is finally settled or adjudicated.

Items to be Submitted for a Disability Income Insurance Claim

When submitting Proof on an initial or continuing claim for Disability Income insurance, the following items may be required:

documentation which must include, but is not limited to, the following information:

1. the date Your Disability started;

2. the cause of Your Disability;

3. the prognosis of Your Disability;

4. the continuity of Your Disability; and

Your application for:

Other Benefit Sources;

Federal Social Security disability benefits; and Workers compensation benefits or benefits under a similar law.

Written authorization for Us to obtain and release medical, employment and financial information and any other items We may reasonably require to document Your Disability or to determine Your receipt of or eligibility for Other Benefit Sources;

any and all medical information, including but not limited to:

1. x-ray films; and

2. photocopies of medical records, including:

a) histories,

b) physical, mental or diagnostic examinations; and

c) treatment notes; and the names and addresses of all:

1. physicians and medical practitioners who have provided You with diagnosis, treatment or consultation;

2. hospitals or other medical facilities which have provided You with diagnosis, treatment or consultation;

3. pharmacies which have filled Your prescriptions within the past three years; and additional proof elements as required and described within the additional plan provisions for which you are filing a claim for benefits.

Time Limit on Legal Actions. A legal action on a claim may only be brought against Us during a certain period. This period begins 60 days after the date Proof is filed and ends 3 years after the date such Proof is required.

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NOTICE FOR RESIDENTS OF TEXAS

THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF

WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO

DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION

SYSTEM.

NOTICE FOR RESIDENTS OF UTAH

GTY-NOTICE-UT-0710

Notice of Protection Provided by Utah Life and Health Insurance Guaranty Association

This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Utah law, which determines who and what is covered and the amounts of coverage.

The Association was established to provide protection in the unlikely event that your life, health, or annuity insurance company becomes financially unable to meet its obligations and is taken over by its insurance regulatory agency. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Utah law, with funding from assessments paid by other insurance companies.

The basic protections provided by the Association are:

Life Insurance o $500,000 in death benefits o $200,000 in cash surrender or withdrawal values

Health Insurance o $500,000 in hospital, medical and surgical insurance benefits o $500,000 in long-term care insurance benefits o $500,000 in disability income insurance benefits o $500,000 in other types of health insurance benefits

Annuities o $250,000 in withdrawal and cash values

The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $500,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits.

Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract.

Coverage is conditioned on residency in this state and there are substantial limitations and exclusions. For a complete description of coverage, consult Utah Code, Title 3 lA, Chapter 28.

Insurance companies and agents are prohibited by Utah law to use the existence of the Association or its coverage to encourage you to purchase insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between Utah law and this notice, Utah law will control.

To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.utlifega.org or contact:

Utah Life and Health Insurance Guaranty Assoc. Utah Insurance Department 60 East South Temple, Suite 500 3110 State Office Building Salt Lake City UT 84111 Salt Lake City UT 84114-6901

(801) 320-9955 (801) 538-3800

A written complaint about misuse of this Notice or the improper use of the existence of the Association may be filed with the Utah Insurance Department at the above address.

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NOTICE FOR RESIDENTS OF THE STATE OF VERMONT

Vermont law provides that the following apply to Your certificate:

Domestic Partner means each of two people, one of whom is an Employee of the Policyholder, who have registered as each other’s domestic partner, civil union partner or reciprocal beneficiary with a government agency where such registration is available.

Wherever the term "Spouse" appears in this certificate it shall, unless otherwise specified, be read to include Your Domestic Partner.

Wherever the term "step-child" appears in this certificate it shall be read to include the children of Your Domestic Partner.

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NOTICE FOR RESIDENTS OF VIRGINIA

IMPORTANT INFORMATION REGARDING YOUR INSURANCE

In the event You need to contact someone about this insurance for any reason please contact Your agent. If no agent was involved in the sale of this insurance, or if You have additional questions You may contact the insurance company issuing this insurance at the following address and telephone number:

200 Park Avenue

Attn: Corporate Consumer Relations Department

To phone in a claim related question, You may call Claims Customer Service at:

1-800-275-4638

If You have been unable to contact or obtain satisfaction from the company or the agent, You may contact the Virginia State Corporation Commission’s Bureau of Insurance at:

Bureau of Insurance Life and Health Division

P.O. Box 1157 Richmond, VA 23218-1157

1-804-371-9691 - phone 1-877-310-6560 - toll-free

1-804-371-9944 - fax www.scc.virginia.gov - web address

BureauOfInsurance@scc.virginia.gov - email

Written correspondence is preferable so that a record of Your inquiry is maintained. When contacting Your agent, company or the Bureau of Insurance, have Your policy number available.

http://www.scc.virginia.gov/

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NOTICE FOR RESIDENTS OF THE STATE OF WASHINGTON

Washington law provides that the following apply to Your certificate:

Wherever the term "Spouse" appears in this certificate it shall, unless otherwise specified, be read to include Your Domestic Partner.

Domestic Partner means each of two people, one of whom is an Employee of the Policyholder, who have registered as each other’s domestic partner, civil union partner or reciprocal beneficiary with a government agency where such registration is available.

Wherever the term "step-child" appears in this certificate it shall be read to include the children of Your Domestic Partner.

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NOTICE FOR RESIDENTS OF WEST VIRGINIA

FREE LOOK PERIOD:

If You are not satisfied with Your certificate, You may return it to Us within 10 days after You receive it, unless a claim has previously been received by Us under Your certificate. We will refund within 10 days of our receipt of the returned certificate any Premium that has been paid and the certificate will then be considered to have never been issued. You should be aware that, if You elect to return the certificate for a refund of premiums, losses which otherwise would have been covered under Your certificate will not be covered.

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NOTICE FOR RESIDENTS OF WISCONSIN

KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS

PROBLEMS WITH YOUR INSURANCE? - If You are having problems with Your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve Your problem.

Attn: Corporate Consumer Relations Department

200 Park Avenue

You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin’s insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting:

Office of the Commissioner of Insurance Complaints Department

P.O. Box 7873 Madison, WI 53707-7873

1-800-236-8517 outside of Madison or 608-266-0103 in Madison.

TABLE OF CONTENTS

Section Page toc 24

CERTIFICATE FACE PAGE

NOTICES

SCHEDULE OF BENEFITS

DEFINITIONS

ELIGIBILITY PROVISIONS: INSURANCE FOR YOU

Eligible Classes

Date You Are Eligible for Insurance

Enrollment Process

Date Your Insurance Takes Effect

Date Your Insurance Ends

CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT

For Family And Medical Leave

At The Policyholder's Option

EVIDENCE OF INSURABILITY

DISABILITY INCOME INSURANCE: LONG TERM BENEFITS

DISABILITY INCOME INSURANCE: INCOME WHICH WILL REDUCE YOUR DISABILITY BENEFIT

DISABILITY INCOME INSURANCE: INCOME WHICH WILL NOT REDUCE YOUR DISABILITY BENEFIT 47

DISABILITY INCOME INSURANCE: DATE BENEFIT PAYMENTS END

DISABILITY INCOME INSURANCE: CONVERSION PRIVILEGE

DISABILITY INCOME INSURANCE

ADDITIONAL LONG TERM BENEFIT: SINGLE SUM PAYMENT IN THE EVENT OF YOUR DEATH

ADDITIONAL LONG TERM BENEFIT: ALTERNATIVE BENEFIT PAYMENT OFFER, AT OUR OPTION 52

DISABILITY INCOME INSURANCE: PRE-EXISTING CONDITIONS

DISABILITY INCOME INSURANCE: LIMITED DISABILITY BENEFITS

DISABILITY INCOME INSURANCE: EXCLUSIONS

GENERAL PROVISIONS

Assignment

TABLE OF CONTENTS (continued)

Section Page toc 25

Disability Income Benefit Payments: Who We Will Pay

Entire Contract

Incontestability: Statements Made by You

Misstatement of Age

Conformity with Law

Physical Exams

Autopsy

Overpayments for Disability Income Insurance

Lien and Repayment

SCHEDULE OF BENEFITS

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This schedule shows the benefits that are available under the Group Policy. You will only be insured for the benefits:

for which You become and remain eligible;

which You elect, if subject to election; and which are in effect.

BENEFIT BENEFIT AMOUNT AND HIGHLIGHTS

Disability Income Insurance For You: Long Term Benefits

OPTION 1:

Monthly Benefit………………………………..

60% of the first $12,500 of Your Predisability Salary, subject to the INCOME WHICH WILL REDUCE YOUR DISABILITY BENEFIT section

Maximum Monthly Benefit…………………… $7,500

Minimum Monthly Benefit…………………….

10% of the Monthly Benefit before reductions for Other Income Benefits or $100, whichever is greater, subject to the Overpayments and Rehabilitation Incentive subsections of this certificate

Note: The Minimum Monthly Benefit will not apply if You are receiving 100% of Your Predisability Salary under the Policyholder’s paid leave policy.

Elimination Period…………………………….

The greater of the Short Term Disability Maximum Benefit Period or 90 Days

Maximum Benefit Period*

Age on Date of Your Disability

Benefit Period

Less than 65 The greater of Your Normal Retirement Age or 12 months

65 24 months 66 21 months 67 18 months 68 15 months 69 and over 12 months

*The Maximum Benefit Period is subject to the LIMITED DISABILITY BENEFITS and DATE BENEFIT PAYMENTS END sections.

Rehabilitation Incentives……………………. Yes

Additional Benefits:

Cost of Living Adjustment…………………… No

Single Sum Payment in the Event of Your Death………………………

Yes

Alternative Benefit Payment, At Our Option…………………………………

Conversion .................................................... Yes

SCHEDULE OF BENEFITS (continued)

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OPTION 2:

60% of the first $12,500 of Your Predisability Salary, Maximum Monthly Benefit…………………… $7,500

Benefit Period or 180 Days

Maximum Benefit Period*

Age on Date of Your Disability

Benefit Period

Less than 65 The greater of Your Normal Retirement Age or 12 months

65 24 months 66 21 months 67 18 months

Cost of Living Adjustment…………………… No

OPTION 3:

63% of the first $15,873.02 of Your Predisability Salary, Maximum Monthly Benefit…………………… $10,000

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Benefit Period or 90 Days

Maximum Benefit Period*

Age on Date of Your Disability

Benefit Period

Less than 65 The greater of Your Normal Retirement Age or 12 months

65 24 months 66 21 months 67 18 months

Cost of Living Adjustment…………………… Yes

OPTION 4:

63% of the first $15,873.02 of Your Predisability Salary, Maximum Monthly Benefit…………………… $10,000

Benefit Period or 180 Days

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Maximum Benefit Period*

Age on Date of Your Disability

Benefit Period

Less than 65 The greater of Your Normal Retirement Age or 12 months

65 24 months 66 21 months 67 18 months

Cost of Living Adjustment…………………… Yes

DEFINITIONS

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As used in this certificate, the terms listed below will have the meanings set forth below. When defined terms are used in this certificate, they will appear with initial capitalization. The plural use of a term defined in the singular will share the same meaning.

Actively at Work or Active Work means that You are performing all of the usual and customary duties of Your job. This must be done at:

the Policyholder’s place of business;

an alternate place approved by the Policyholder; or a place to which the Policyholder’s business requires You to travel.

You will be deemed to be Actively at Work during weekends or Policyholder approved vacations, holidays or business closures if You were Actively at Work on the last scheduled work day preceding such time off.

Appropriate Care and Treatment means medical care and treatment that is:

given by a Physician whose medical training and clinical specialty are appropriate for treating Your

Disability;

consistent in type, frequency and duration of treatment with relevant guidelines of national medical research, health care coverage organizations and governmental agencies;

consistent with a Physician’s diagnosis of Your Disability; and intended to maximize Your medical and functional improvement.

Beneficiary means the person(s) to whom We will pay insurance as determined in accordance with the GENERAL PROVISIONS section.

Consumer Price Index means the CPI-W, the Consumer Price Index for Urban Wage Earners and Clerical Workers published by the U.S. Department of Labor. If the CPI-W is discontinued or replaced, We reserve the right to substitute any other comparable index.

Contributory Insurance means insurance for which the Policyholder requires You to pay any part of the premium.

Contributory Insurance includes: Disability Income Insurance: Long Term Benefits.

Definition of Disabled or Disability for Employees who elect Option 1 or Option 2:

Disabled or Disability means that, due to Sickness or as a direct result of accidental injury:

during the Elimination Period and the next 24 months of Sickness or accidental injury;

You are unable to perform the duties of Your Own Occupation and You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; or

You are unable to earn more than 80% of Your Predisability Salary at Your Own Occupation and You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment.

After such period:

You are unable to perform the duties of any occupation for which You are reasonably qualified taking into account Your training, education and experience and You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; or

You are unable to earn more than 60% of Your Predisability Salary from any employer in Your Local Economy at any gainful occupation for which You are reasonably qualified taking into account Your

DEFINITIONS (continued) def 31 training, education and experience and You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment.

For purposes of determining whether a Disability is the direct result of an accidental injury, the Disability must have occurred within 90 days of the accidental injury and resulted from such injury independent of other causes.

Definition of Disabled or Disability for Employees who elect Option 3 or Option 4:

Disabled or Disability means that, due to Sickness or as a direct result of accidental injury:

during the Elimination Period and the next 36 months of Sickness or accidental injury;

You are unable to perform the duties of Your Own Occupation and You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; or

You are unable to earn more than 80% of Your Predisability Salary at Your Own Occupation and You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment.

After such period:

You are unable to perform the duties of any occupation for which You are reasonably qualified taking into account Your training, education and experience and You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; or

You are unable to earn more than 60% of Your Predisability Salary from any employer in Your Local

Economy at any gainful occupation for which You are reasonably qualified taking into account Your training, education and experience and You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment.

For purposes of determining whether a Disability is the direct result of an accidental injury, the Disability must have occurred within 90 days of the accidental injury and resulted from such injury independent of other causes.

If You are Disabled and have received a Monthly Benefit for 12 months, We will adjust Your Predisability Salary only for the purposes of determining whether You continue to be Disabled and for calculating the Return to Work Incentive, if any. We will make the initial adjustment as follows:

We will add to Your Predisability Salary an amount equal to the product of:

Your Predisability Salary times the lesser of:

7%; or the annual rate of increase in the Consumer Price Index for the prior calendar year.

Annually thereafter, We will add an amount to Your adjusted Predisability Salary calculated by the method set forth above but substituting Your adjusted Predisability Salary from the prior year for Your Predisability Salary.

This adjustment is not a cost of living benefit.

If Your occupation requires a license, the fact that You lose Your license for any reason will not, in itself, constitute Disability.

Elimination Period means the period of Your Disability during which We do not pay benefits. The Elimination Period begins on the day You become Disabled and continues for the period shown in the

SCHEDULE OF BENEFITS.

def 32

Local Economy means the geographic area:

within which You reside; and which offers suitable employment opportunities within a reasonable travel distance.

If You move on or after the date You become Disabled, We may consider both Your former and current residence to be Your Local Economy.

Own Occupation means the essential functions You regularly perform that provide Your primary source of earned income.

Physician means:

a person licensed to practice medicine in the jurisdiction where such services are performed; or any other person whose services, according to applicable law, must be treated as Physician’s services for purposes of the Group Policy. Each such person must be licensed in the jurisdiction where he performs the service and must act within the scope of that license. He must also be certified and/or registered if required by such jurisdiction.

The term does not include:

You;

Your Spouse; or any member of Your immediate family including Your and/or Your Spouse’s:

parents;

children (natural, step or adopted);

siblings;

grandparents; or grandchildren.

Policyholder's Retirement Plan means a plan which:

provides retirement benefits to employees; and is funded in whole or in part by Policyholder contributions.

profit sharing plans;

thrift or savings plans;

non-qualified plans of deferred compensation;

plans under IRC Section 401(k) or 457;

individual retirement accounts (IRA);

tax sheltered annuities (TSA) under IRC Section 403(b);

stock ownership plans; or

Keogh (HR-10) plans.

def 33

Predisability Salary means gross salary or wages as of September 1, effective October 1, You were earning from the Policyholder before Your Disability began. For purposes of benefit payment We calculate this amount on a monthly basis.

The term includes:

contributions You were making through a salary reduction agreement with the Policyholder to any of the following:

an Internal Revenue Code (IRC) Section 401(k), 403(b) or 457 deferred compensation arrangement;

an executive non-qualified deferred compensation arrangement; and

Your fringe benefits under an IRC Section 125 plan.

commissions;

awards and bonuses;

overtime pay;

the grant, award, sale, conversion and/or exercise of shares of stock or stock options;

the Policyholder’s contributions on Your behalf to any deferred compensation arrangement or pension plan; or any other compensation from the Policyholder.

Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When a claim is made for any benefit described in this certificate, Proof must establish:

the nature and extent of the loss or condition;

Our obligation to pay the claim; and the claimant’s right to receive payment.

Proof must be provided at the claimant's expense.

Rehabilitation Program means a program that has been approved by us for the purpose of helping You return to work. It may include, but is not limited to, Your participation in one or more of the following activities:

return to work on a modified basis with a goal of resuming employment for which You are reasonably qualified by training, education, experience and past earnings;

on-site job analysis;

job modification/accommodation;

training to improve job-seeking skills;

vocational assessment;

short-term skills enhancement;

vocational training; or restorative therapies to improve functional capacity to return to work.

Sickness means illness, disease or pregnancy, including complications of pregnancy.

def 34

Signed means any symbol or method executed or adopted by a person with the present intention to authenticate a record, which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law.

Spouse means Your lawful spouse.

We, Us and Our mean MetLife.

Written or Writing means a record which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law.

You and Your mean an employee who is insured under the Group Policy for the insurance described in this certificate.

ELIGIBILITY PROVISIONS: INSURANCE FOR YOU

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e/ee

ELIGIBLE CLASS(ES)

All Employees of the Policyholder employed by State Government who are:

regularly scheduled to work not less than 30 hours per week;

seasonal employees hired prior to July 1, 2015 with 24 months of service and certified by the appointing authority to work at least 1,450 hours per fiscal year (July-June); or deemed eligible by applicable federal law, state law, or action of the State Insurance Committee.

DATE YOU ARE ELIGIBLE FOR INSURANCE

You may only become eligible for the insurance available for Your eligible class as shown in the SCHEDULE

OF BENEFITS.

You will be eligible for the insurance described in this certificate on the later of:

1. January 1, 2022; and

2. the first day of the calendar month following the date You complete the Waiting Period of 1 full calendar month.

Waiting Period means the period of continuous membership in an eligible class that You must wait before You become eligible for insurance. This period begins on the date You enter an eligible class and ends on the date You complete the period(s) specified.

ENROLLMENT PROCESS

If You are eligible for insurance, You may enroll for such insurance by completing the required form. In addition, You must give evidence of Your Insurability satisfactory to Us if You are required to do so under the section entitled EVIDENCE OF INSURABILITY. If You enroll for Contributory Insurance, You must also give the Policyholder Written permission to deduct premiums from Your pay for such insurance. You will be notified by the Policyholder how much You will be required to contribute.

DATE YOUR INSURANCE TAKES EFFECT

Enrollment When First Eligible

If You complete the enrollment process within 30 days of becoming eligible for insurance, such insurance will take effect on the date You become eligible for such insurance if You are Actively at Work on that date.

If You do not complete the enrollment process within 30 days of becoming eligible, You will not be able to enroll for insurance until the next annual enrollment period, as determined by the Policyholder, following the date You first became eligible, unless You experience a Qualifying Event. At that time You will be able to enroll for insurance for which You are then eligible.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Enrollment During An Annual Enrollment Period

During any annual enrollment period as determined by the Policyholder, You may enroll for insurance for which You are eligible or choose a different option than the one for which You are currently enrolled. The insurance enrolled for or changes to Your insurance made during an annual enrollment period will take effect as follows:

for any amount for which You are not required to give evidence of Your insurability, such insurance will take effect on the first day of the calendar year following the annual enrollment period, if You are Actively at Work on that date.

ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued)

GCERT2000 36

for any amount for which You are required to give evidence of Your insurability and We determine that You are insurable, such insurance will take effect on the later of:

the first day of the calendar year following the annual enrollment period; or the first day of the calendar month following the date We state in Writing, if approved prior to the 15th day of the month and if You are Actively at Work on that date; or the first day of the second calendar month following the date We state in Writing, if approved on or after the

15th day of the month and if You are Actively at Work on that date.

If You are not Actively at Work on the date an amount of insurance would otherwise take effect, that amount of insurance will take effect on the day You resume Active Work.

Enrollment Due to a Qualifying Event

You may enroll for insurance for which You are eligible or change the amount of Your insurance between annual enrollment periods only if You have a Qualifying Event.

marriage; or the birth, adoption or placement for adoption or assumption of legal custody of a dependent child; or

Your loss of coverage under any group disability insurance plan.

If You have a Qualifying Event, You will have 60 days from the date of that change to make a request. This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for, or changes to Your insurance made as a result of a Qualifying Event will take effect as follows:

for any amount for which You are not required to give evidence of Your insurability, such insurance will take effect on the first day of the month following the date of Your request, if You are Actively at Work on that date.

for any amount for which You are required to give evidence of Your insurability and We determine that You are insurable, such insurance will take effect as follows:

the first day of the calendar month following the date We state in Writing, if approved prior to the 15th day of the month and if You are Actively at Work on that date; or the first day of the second calendar month following the date We state in Writing, if approved on or after the 15th day of the month and if You are Actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the first day of the calendar month following the date You resume Active Work.

DATE YOUR INSURANCE ENDS

Your insurance will end on the earliest of:

1. the date the Group Policy ends; or

2. the date insurance ends for Your class; or

3. the end of the period for which the last premium has been paid for You; or

4. the date You cease to be in an eligible class. You will cease to be in an eligible class on the date You cease Active Work in an eligible class, if You are not Disabled on that date; or

5. the last day of the calendar year following annual enrollment if You request to cancel Your coverage during annual enrollment, or

6. the date You specify, at least 30 days in advance, by written notification from You to the State to terminate Your coverage or on a later date specified in the notice; or

7. the date Your employment ends; or

GCERT2000 37

8. the date You retire in accordance with the date Your employment ends.

In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF

INSURANCE WITH PREMIUM PAYMENT.

Reinstatement of Disability Income Insurance

If Your insurance ends, You may become insured again as follows:

1. If Your insurance ends because:

You cease to be in an eligible class; or Your employment ends; and

You become a member of an eligible class again within one full calendar month, insurance will be reinstated and coverage will continue as if Your insurance had remained in effect with no interruption, provided You meet the eligibility requirements; or

You become a member of an eligible class again after one full calendar month but:

within 6 months of the date Your insurance ended, You will not have to complete a new Waiting Period or provide evidence of Your insurability, however the limitation for Pre-Existing Conditions will be applied as if Your insurance had remained in effect with no interruption. Any time applied to the Pre-Existing Conditions limitation prior to the date Your leave of absence began will be applied toward satisfying the Pre-Existing Conditions limitation after You return to Active Work;

after 6 months but within 2 years from the date Your insurance ended, You will not have to complete a new Waiting Period or provide evidence of Your insurability, however the limitation for Pre-Existing Conditions will be applied beginning on the date You return to Active Work. Any time applied to the Pre-Existing Conditions limitation prior to the date Your leave of absence began will not be applied toward satisfying the Pre-Existing Conditions limitation after You return to Active Work.

2. If Your employment ends because You have retired, and You are under age 65 enrolled in the State’s medical insurance program, and You become a member of an eligible class again within 13 weeks to work a 120-day temporary assignment, insurance may be reinstated, provided You meet the eligibility requirements. You will not have to complete a new Waiting Period or provide evidence of Your insurability, however the limitation for Pre-Existing Conditions will be applied as if Your insurance had remained in effect with no interruption. Any time applied to the Pre-Existing Conditions limitation prior to the date Your leave of absence began will be applied toward satisfying the Pre-Existing Conditions limitation after You return to Active Work.

3. If Your insurance ends while on an approved Family and Medical Leave Act (FMLA) or other legally mandated leave of absence, and you become a member of an eligible class again:

within 6 months of the date Your insurance ended, You will not have to complete a new Waiting Period or provide evidence of Your insurability, however the limitation for Pre-Existing Conditions will be applied as if Your insurance had remained in effect with no interruption. Any time applied to the Pre-Existing Conditions limitation prior to the date Your leave of absence began will be applied toward satisfying the Pre-Existing Conditions limitation after You return to Active Work;

after 6 months but within 2 years from the date Your insurance ended, You will not have to complete a new Waiting Period or provide evidence of Your insurability, however the limitation for Pre-Existing Conditions will be applied beginning on the date You return to Active Work. Any time applied to the

4. If Your insurance ends while on a leave of absence, other than an approved Family and Medical

Leave Act (FMLA) or other legally mandated leave of absence, and you become a member of an eligible class:

GCERT2000 38

Period or provide evidence of Your insurability, however the limitation for Pre-Existing Conditions will be applied as if Your insurance had remained in effect with no interruption. Any time applied to the Pre-Existing Conditions limitation prior to the date Your leave of absence began will be applied toward satisfying the Pre-Existing Conditions limitation after You return to Active Work;

after 6 months but within 2 years from the date Your insurance ended, You will not have to complete a new Waiting Period or provide evidence of Your insurability, however the limitation for Pre-Existing Conditions will be applied beginning on the date You return to Active Work. Any time applied to the

5. If Your insurance ends due to active military duty, Your insurance may be reinstated on the earliest of:

The first day of the month which includes the date You are discharged from active military duty;

The first day of the month following the date You are discharged from active military duty;

The date You return to the Policyholder’s active payroll; or The first day of the month following Your return to the Policyholder’s active payroll.

You become a member of an eligible class again:

Period or provide evidence of Your insurability, however the limitation for Pre-Existing Conditions will be applied as if Your insurance had remained in effect with no interruption. Any time applied to the Pre-Existing Conditions limitation prior to the date Your leave of absence began will be applied toward satisfying the Pre-Existing Conditions limitation after You return to Active Work;

after 6 months but within 2 years from the date Your insurance ended, You will not have to complete a new Waiting Period or provide evidence of Your insurability, however the limitation for Pre-Existing Conditions will be applied beginning on the date You return to Active Work. Any time applied to the

6. In all other cases where Your insurance ends because the required premium for Your insurance has ceased to be paid, You will be required to provide evidence of Your insurability.

If Your insurance is being reinstated according to an order by the Board of Appeals, such reinstatement will be completed as outlined in the order. If the order does not specify a date for reinstatement of insurance, You will have the options outlined below:

(A) Your insurance will be reinstated and will continue as if Your insurance had remained in effect with no interruption with the requirement that You pay all past due premiums; or

(B) Your insurance will be reinstated on the first day of the month in which the order is signed or the first day of the following month, with Your written authorization.

CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT

GCERT2000 39

coi-eport

FOR FAMILY AND MEDICAL LEAVE

Certain leaves of absence may qualify for continuation of insurance under the Family and Medical Leave Act of 1993 (FMLA), or other legally mandated leave of absence or…