Appendix_B_-_Current_Insurance_Plan_Certificates_&_Policy_Documents.pdf

GRP-CRT-51 (4-17) 1 Over 51

17500 Chenal Pkwy | Little Rock, AR 72223 P.O. Box 1650 Little Rock, AR 72203 | (501) 375-7200 | (800) 370-5856 | www.usablelife.com

CERTIFICATE OF INSURANCE

GROUP TERM LIFE, DEPENDENT LIFE, ACCELERATED DEATH BENEFIT AND

ACCIDENTAL DEATH AND DISMEMBERMENT

Policyholder: CITY OF HOLLY HILL

Policy Number: 50037123

Effective Date: January 1, 2020

Class: 0001 - ALL ELIGIBLE MAYOR AND COMMISSIONERS

State of Issue: FLORIDA

This Certificate is a part of the Policy and replaces any other that We may have issued to the Policyholder. You are insured for the benefits described in this Certificate, subject to the provisions of this Certificate.

READ THE CERTIFICATE CAREFULLY. INSURANCE BENEFITS MAY BE SUBJECT TO

CERTAIN REQUIREMENTS, REDUCTIONS, LIMITATIONS AND EXCLUSIONS. IF AN

ACCELERATED DEATH BENEFIT IS PAID, THE DEATH BENEFIT AND ANY APPLICABLE

PREMIUM PAYMENTS WILL BE REDUCED.

If the terms and provisions of the Certificate differ from the Policy, the Policy will govern. Your coverage may be canceled or changed in whole or in part under the terms and provisions of the Policy but shall not be less than those stated in this Certificate. You may inspect a copy of the Policy upon request to Your Employer.

The Policy is delivered in and is governed by the laws of the state of issue shown above, and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments.

For purposes of Effective Dates and ending dates under the Policy, all days begin at 12:00 A.M.

and end at 12:00 A.M., local time, at the Policyholder’s place of business in the state or jurisdiction where the Policy is issued.

If You have any questions about this coverage, need claims assistance, or need assistance in resolving complaints, please call Us at 1-800-370-5856.

NON-PARTICIPATING

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Table of Contents

Your Certificate of Insurance is divided into the following sections:

SCHEDULE OF INSURANCE

DEFINITIONS

ELIGIBILITY

ENROLLMENT FOR COVERAGE

EFFECTIVE DATE

DEFERRED EFFECTIVE DATE

CONTINUITY OF COVERAGE: TAKEOVER PROVISION

CHANGES IN COVERAGE

TERMINATION OF INSURANCE

WAIVER OF PREMIUM

CONTINUATION OF COVERAGE

REINSTATEMENT

EMPLOYEE LIFE INSURANCE

DEPENDENT LIFE INSURANCE

ACCELERATED DEATH BENEFIT

CONVERSION PRIVILEGE

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT

COMA BENEFIT

SAFETY EQUIPMENT BENEFIT

REPATRIATION BENEFIT

EXPOSURE AND DISAPPEARANCE BENEFIT

GENERAL INFORMATION

CLAIM INFORMATION

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THIS CERTIFICATE PROVIDES INSURANCE FOR THE EMPLOYEES AND

DEPENDENTS, IF APPLICABLE, OF:

CITY OF HOLLY HILL

1065 RIDGEWOOD AVE

HOLLY HILL, FL 32117

Policy Number: 50037123

THE EMPLOYEE SHALL BE GIVEN A COPY OF THE GROUP ENROLLMENT

APPLICATION. THE BENEFITS ARE PAYABLE TO THE BENEFICIARIES OF

RECORD DESIGNATED BY THE EMPLOYEE.

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SCHEDULE OF INSURANCE

This is a brief overview of Your benefits in the event of Your death or any other covered loss.

These benefits are described further in the Certificate, along with other important information about Your coverage.

Defined terms are capitalized when used throughout the Certificate and can be located in the Definitions section of the Certificate.

Policyholder: CITY OF HOLLY HILL

Policyholder Address: 1065 RIDGEWOOD AVE

HOLLY HILL, FL 32117

Policyholder Telephone Number: (386) 248-9440

Policyholder Email Address: DCOLE@HOLLYHILLFL.ORG

Policy Number: 50037123

Policy Effective Date: January 1, 2020

Eligible Class: Class 0001 - ALL ELIGIBLE MAYOR AND

COMMISSIONERS

Full-Time Employment Requirements:

Non-Contributory Benefits: 30 hours weekly

Contributory Benefits: 30 hours weekly

Waiting Period:

Employees Active before the Policy Effective Date If You are in an Eligible Class on or before the Policy Effective Date, You will be eligible for coverage on the first day of the Policy Month following the date You complete 30 days of Active Work.

Employees Active after the Policy Effective Date If You enter an Eligible Class after the Policy Effective Date, You will be eligible for coverage on the first day of the Policy Month following the date You complete 30 days of Active Work.

Policy Benefits:

Non-Contributory: Group Term Life, Accidental Death and Dismemberment

Contributory: Dependent Life

Non-Contributory Benefit

Benefit Amount Benefit Reduction Schedule

Employee Basic Life $20,000 Reduces to 50% at the first policy anniversary following age 75.

Employee Basic Accidental Death & Dismemberment

$20,000 Reduces to 50% at the first policy anniversary following age 75.

Contributory Benefit Benefit Amount Benefit Reduction Schedule

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Dependent Life Spouse Amount Children Amount

$5,000 $1,000 - age live birth to 6 months $2,500 – age 6 months and over

Benefits do not reduce.

If a Covered Person is eligible for any amount in excess of the Guaranteed Issue amount shown below, the Employee must furnish Evidence of Insurability, which is subject to Our approval.

Benefit Guaranteed Issue Amounts

Employee Basic Life $20,000

Employee Basic Accidental Death & Dismemberment

$20,000

Dependent Life Spouse Amount Children Amount

$5,000 $2,500

Group Term Life Features

Features Benefit Feature Amount

Accelerated Death Benefits:

For You and Your Dependents

75% up to $500,000

Conversion Option:

For You and Your Dependents

Basic Life

Group Accidental Death and Dismemberment Features

Feature Benefit Feature Amount

AD&D Coma Benefit:

For You

3% per month for 12 months

AD&D Safety Equipment Benefit:

For You

Seat Belt: 10% up to $10,000 Air Bag: 10% up to $10,000 Helmet: 10% up to $10,000

AD&D Repatriation Benefit:

For You

10% up to $5,000

AD&D Exposure & Disappearance Benefit:

For You

AD&D benefit payable after 1 year of accidental disappearance

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DEFINITIONS

The following terms are used throughout the Certificate. Defined terms are capitalized throughout the Certificate. The terms listed, if used, will have these meanings:

Accident is an unforeseen occurrence which results in an Accidental Bodily Injury and occurs while this Certificate is in force and is not excluded in the Certificate.

Accidental Bodily Injury means an Injury or Injuries for which Treatment is received. The Injury or Injuries must be sustained by a Covered Person and must be the direct cause of the loss, independent of disease or bodily infirmity. All such Injuries, with any complications and any recurrences of complications arising from any one Accident, will be deemed to be a single Injury. Such Injury or Injuries must occur while the Certificate is in force.

Actively at Work or Active Work means You are performing all of the usual and customary duties of Your Job on a Full-Time basis for earnings. This may 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.

If You are not working on a day Your coverage would otherwise take effect, You will be considered to be at Active Work on that day if:

1. when that work day begins, it would be reasonable to expect that You would be physically and mentally able to complete a Full-Time week of work in Your Occupation;

and

2. You are not disabled; and

3. Your contract of employment, if applicable, remains active; and

4. You are not on an unapproved, administrative or disciplinary leave.

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

Annual Enrollment means the event where You may enroll in voluntary coverage if You have completed the Waiting Period, the Policy changed to include Your class, or if You became a member of an Eligible Class for coverage. Any amounts exceeding the inforce Guaranteed Issue amount will be subject to satisfactory Evidence of Insurability.

If You did not apply for coverage during the first Annual Enrollment Period following Your eligibility date, You will be required to submit satisfactory Evidence of Insurability.

Annual Salary or Annual Earnings for Active Employees means Your annual base rate of pay from the Employer before any reductions including deductions made for pre-tax contributions to a qualified deferred compensation Plan, Section 125 Plan, flexible spending account, overtime pay, Bonuses or any other extra pay.

If Your pay includes Commissions, Your Annual Salary will be based on Your average Commissions, for the prior 12 month(s) or over the number of calendar month(s) of employment if less than this period.

Application means the document You or Your Employer completed to request the Plan of insurance applied for.

Beneficiary means the person or entity You choose to receive Your life insurance benefits at Your death in accordance with the Beneficiary provisions of the Certificate. You may not designate Your Employer as Your Beneficiary.

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Bonuses means supplemental compensation calculated as a monthly average paid to You by Your Employer over the past 12 month(s) or over the number of calendar month(s) of employment if less than this period.

Certificate means this document prepared by Us which describes the Covered Person’s benefits and rights under the Policy, and which includes any riders, endorsements, amendments, Applications, notices or other attachments to the Certificate.

Child or Dependent Child or Children means Your biological/natural Child, legally adopted Child, Child placed for adoption, stepchild, foster Child, Child to which You are a party in a suit to seek adoption or are the legal guardian of, and any other Child required to be covered under the civil union, Domestic Partnership, marriage or other Family or domestic relations laws of the state where the Policy is delivered or issued for delivery or other Children in whose lives the Employee or the Employee’s Spouse has an insurable interest who is under the age of 26.

Child also includes a disabled Child, as defined in the Continuation of Coverage for a Disabled Child section, insured under this Policy before reaching age 26.

Child does not include persons not born alive.

Child Care Center means a facility which:

1. is operated in a private home, school or other facility;

2. provides, and charges for, the care of Children; and

3. is licensed as a day care center or is operated by a licensed day care provider, if such licensing is required by the state or jurisdiction in which it is located; or

4. if licensing is not required, provides childcare on a daily basis for 12 months a year.

A Child Care Center does not include:

1. a Hospital;

2. a Child's home; or

3. care provided by any facility during normal school hours while a Child is attending grades one through twelve except in the case of a disabled Child if already covered under the Policy.

Civil Union Partner means a person who has entered into a legal Civil Union Partnership with You as recognized by Your state government.

Civil Union Partnership means a legal relationship between two people providing all of the legal obligations, responsibilities, protections and benefits that the laws of Your state grants to married couples.

Commission means incentive based compensation for products or services sold calculated as a monthly average paid to You by Your Employer over the past 12 month(s) or over the number of calendar month(s) of employment if less than this period.

Complications of Pregnancy mean:

1. any of the following conditions whose diagnoses are distinct from Pregnancy but are adversely affected by Pregnancy or are caused by Pregnancy, such as: acute nephritis, pyelitis of Pregnancy, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, Physician prescribed rest during the period of Pregnancy, morning sickness and similar conditions associated with the management of a difficult Pregnancy not constituting a condition which is medically classified as a distinct Complication of Pregnancy;

2. an extra-uterine Pregnancy;

3. a complication that requires intra-abdominal surgery after termination of Pregnancy;

4. a miscarriage;

5. a non-elective caesarean section;

6. an ectopic Pregnancy that is terminated;

7. a spontaneous termination of Pregnancy that occurs when a viable birth is not possible;

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8. placenta previa, placenta abruptio or premature rupture of membranes;

9. pernicious vomiting of Pregnancy (hyperemesis gravidarum); and/or

10. toxemia (eclampsia or pre-eclampsia).

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

Contributory means You pay part or all of the cost for Your and Your Dependent's coverage.

Covered Accident means an Accident occurring while this Policy is in force resulting in death or Injury subject to the Exclusions and Limitations of this Policy.

Covered Person means an eligible Employee or the Employee's Dependents as defined by Your Employer whose insurance coverage has become and remains effective under all the conditions and provisions of the Policy. Covered Persons do not include contract, temporary, seasonal, or part-time workers.

Dependent means an Eligible Person who is Your Spouse or Your Child.

A Dependent is not a Person:

1. also insured as an Employee of Your Employer;

2. also insured as a Dependent of another Employee of the Policy; or

3. on active Military Service of any country or international authority.

Active Military Service does not include weekend or summer training for the National Guard or Reserves of the United States.

Effective Date means the date the Policy provides coverage for members of an Eligible Class.

Eligibility Date means the date or dates an Employee in an Eligible Class become eligible for insurance under this Policy. Classes eligible for insurance are shown in the Schedule of Benefits.

Eligible Class means the group(s) of Employees who have met the criteria selected by the Employer for eligibility for coverage under the Policy.

Eligible Person means a person who:

1. is a citizen of the United States or Canada who either:

a. resides in the United States or Canada; or

b. resides outside the U.S. or Canada for a period of less than 6 months per year; and

c. works for a United States company at a Job site in the United States; and

d. is not in active, Military Service; or

2. is a foreign national residing in the U.S. who:

a. is legally permitted to work in the U.S., or the Dependent of such a person if covered as a Dependent; and

b. participates in U.S. Social Security; and

c. is covered by Workers’ Compensation.

Employee means an Eligible Person who is:

1. directly employed in the normal business of the Employer; and

2. paid for services by the Employer; and

3. Actively at Work for the Employer.

Directors, officers, consultants, elected officials, appointed officials, proprietors, owners, partners, commissioners or other persons not Actively at Work on behalf of the Employer will not be considered an Employee.

Employer means a company, corporation, partnership, school, government, association, or organization where You are Actively at Work, and includes any division, subsidiary, or Affiliate named in the Policy.

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Enrollment Form means the paper, electronic or telephonic media used to enroll Your benefits under this Policy and which is consistent with applicable law and has been approved by Us.

Evidence of Insurability means a statement of health and medical history, which is used to determine approval for coverage or an increase in coverage.

Family and Medical Leave of Absence means a Leave of Absence for:

1. The birth, adoption or foster care of a Child;

2. The care of Your Child, Spouse or parent who has a serious health condition; or

3. Your own serious health condition.

As those terms are defined by the federal Family and Medical Leave Act of 1993 and any amendments, or by applicable state law.

Family or Family Member means a person who is a parent, Spouse, Child, sibling, grandparent, grandchild, step-child, step-parent, step-sister, step-brother, father-in-law, or mother-in-law of the Covered Person.

Full-Time means Actively at Work for Your Employer as indicated in the Schedule of Insurance for Full-Time employment.

Guaranteed Issue means the maximum amount of insurance available under this Policy without Evidence of Insurability.

Home Office means the principal office of USAble Life in Little Rock, Arkansas.

Hospital means a facility supervised by one or more Physicians and operated under state and local laws. It must have 24-hour nursing service by registered graduate nurses. It may specialize in treating alcoholism, drug addiction, chemical dependency, or mental disease, but it cannot be a rest home, convalescent home, or a home for the aged.

Hospital Confined and Hospital Confinement mean staying in a Hospital as a registered Inpatient for 24 hours a day.

Injury means bodily injury resulting from an Accident, independent of disease or Sickness, and not related to any other cause.

Inpatient means a person confined in a Hospital, for whom at least one day's room and board charge is made by the Hospital as a result of an Injury.

Intoxicated or Intoxication means the Covered Person’s normal capacity to act or reason is inhibited by alcohol or any drug, sedative, hallucinogen, controlled substance or narcotic, unless administered by a Physician and taken according to the Physician’s instructions and as determined by the laws of the jurisdiction in which the incident occurred. Conviction is not necessary for a determination of being Intoxicated.

Irrevocable Beneficiary means a named Beneficiary whose rights to the Employee’s life insurance proceeds are vested and whose rights cannot be cancelled by the Employee unless the Irrevocable Beneficiary consents.

Job or Jobs means the Job that a Covered Person was performing on the day prior to the Covered Person’s loss.

Layoff or Leave of Absence means a temporary absence from Active Work that has been agreed to and approved by the Employer for a specified period of time. Normal vacation time, weekends, holidays, and periods of disability are not considered a Layoff or Leave of Absence.

Material and Substantial Duties mean the sets of tasks or skills generally required by Employers from those engaged in an Occupation. We will consider one material and substantial duty of Your Occupation to be the ability to work for the Employer on a Full-Time basis as defined in the Policy.

Mental Illness or Mental Infirmity means disability caused or contributed to by psychiatric or psychological conditions, regardless of cause, and includes:

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1. Schizophrenia;

2. Depression;

3. Manic depressive or bipolar illness;

4. Anxiety;

5. Personality disorders;

6. Adjustment disorders; and

7. Other conditions usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs or other similar methods of Treatment.

Military Leave means a Leave of Absence that:

1. is subject to the Uniformed Services Employment and Reemployment Rights Act of 1994

(USERRA), and any amendments to it; and

2. is taken in accord with Your Employer’s leave Policy and the federal USERRA law; and

3. does not exceed the period required by that law.

Military Service means performance of duty on a voluntary or involuntary basis in a Uniformed Service including:

1. Active duty;

2. Active duty for training;

3. Initial active duty for training;

4. Inactive duty training;

5. Full-time National Guard duty;

6. Absence from work for an examination to determine a person’s fitness for any of the above types of duty;

7. Funeral honors duty performed by National Guard or reserve members; and

8. Duty performed by intermittent employees of the National Disaster Medical System

(NDMS), which is part of the Department of Homeland Security – Emergency Preparedness and Response Directorate (FEMA), when activated for a public health emergency, and approved training to prepare for such service.

Motor Vehicle or Motorized Vehicle means a vehicle (such as a car, truck, or motorcycle) that is powered by an engine.

Noncontributory means Your Employer pays all of the cost for Your and Your Dependent's coverage.

Occupation means a group of Jobs or related Jobs:

1. in which a common set of tasks is performed; or

2. which are related in terms of similar objectives and methodologies, and which may be related in terms of materials, products, worker actions, or worker characteristics.

Open Enrollment means the event where You may enroll in voluntary coverage if You have completed the Waiting Period, the Policy changed to include Your class, or You became a member of an Eligible Class for coverage.

Any amounts exceeding the Guaranteed Issue amount will be subject to Evidence of Insurability.

If You did not apply for coverage during the initial enrollment period following Your Eligibility Date, You will not be required to submit Evidence of Insurability up to the group’s inforce Guaranteed Issue. Any amount exceeding the inforce Guaranteed Issue will be subject to satisfactory Evidence of Insurability. If You were previously denied coverage, You will not be eligible for Open Enrollment.

Participation with respect to Riot or Act of Terrorism means promoting, inciting, conspiring to promote or incite, aiding, abetting, and all forms of taking part in such actions. It does not include actions taken in defense of public or private property, or actions taken in defense of the person of the Covered Person, if such actions of defense are not taken against persons seeking to maintain or restore law and order, including but not limited to police officers and firemen.

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Physician means a person acting within the scope of his or her license to practice medicine, prescribe drugs or perform surgery. This includes a person whom We are required to recognize as a Physician by the laws or regulations of the governing jurisdiction. However, neither You nor a Family Member will be considered a Physician.

Plan means the insurance provided for Covered Persons as outlined in the Policy and Certificates of Insurance.

Plan Administrator means the Employer that sponsors the Plan for the benefit of its Employees and eligible Dependents.

Policy means the instrument by which the benefits under the Plan are approved and issued to the Policyholder, including any riders, endorsements or amendments, notices or other attachments to the Policy.

Policy Anniversary means the specified period of time (such as one year) following the Effective Date of the Policy, and each subsequent period.

Policy Month means the month in which coverage became effective. The first Policy month begins on the Effective Date of the Policy. Subsequent Policy months will begin on the same day of each following calendar month.

Policyholder means the entity to which the Policy is issued.

Pregnancy means childbirth and Complications of Pregnancy.

Premium means the amount charged for insurance provided under the Policy.

Private Passenger Motor Vehicle or Motorized Vehicle means an individually owned Motor Vehicle that is not for hire, for rent, or used as public transportation.

Prior Plan means the Policyholder’s insurance Plan under which a Covered Person may have been insured on the day before the Effective Date of the Policy.

Proof of Loss means Written evidence satisfactory to Us that a Covered Person has satisfied the conditions and requirements for any benefit described in the Certificate. The Proof of Loss shall establish:

1. The nature and extent of the loss or condition;

2. Our obligation to pay the claim; and

3. The claimant’s right to receive payment.

Reciprocal Beneficiary means one of two persons who have taken the steps required to create a valid Reciprocal Beneficiary relationship formed by consenting adults who are legally prohibited from marrying one another and who are not presently married or in another Reciprocal Beneficiary relationship. In order to enter into a valid Reciprocal Beneficiary relationship, it shall be necessary that:

1. Each of the parties be at least eighteen years old; and

2. Neither of the parties be married, a party to another Reciprocal Beneficiary relationship, or a partner in a civil union; and

3. The parties be legally prohibited from marrying one another; and

4. Consent of either party to the Reciprocal Beneficiary relationship has not been obtained by force, duress, or fraud.

Regular Care means:

1. You personally visit a Physician as often as is medically required to effectively manage and treat Your condition(s), according to generally accepted medical standards; and

2. You are receiving appropriate Treatment and care, according to generally accepted medical standards.

Retiree or Retirement means You begin receiving Retirement benefits from either:

1. a Retirement Plan sponsored by Your Employer, the Policyholder, or an Affiliate, or

2. a government Plan.

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Riot means all forms of public violence, disorder, or disturbance of the public peace, by three or more persons assembled together, acting with common intent to damage persons or property or unlawfully acting with the intent or the consequence of such disorder.

Sickness means Illness, disease, acting as an organ donor, or Complications of Pregnancy.

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

Spouse means a Person to whom You are legally married and not legally separated from and any other person required to be covered as the Employee’s Spouse under the civil union, Domestic Partnership, marriage or other Family or domestic relations law and case law of the state where the Policy is delivered or issued for delivery.

Terminal Illness means a medical condition diagnosed by a Physician that is reasonably expected to result in the Covered Person’s death within twelve (12) months of the date the medical evidence of such Terminal Illness is received.

Terminally Ill means that the Covered Person has a medical prognosis that his or her life expectancy is one (1) year or less if the illness runs its normal course.

Terrorism means any act of violence that is dangerous to human life or potentially destructive of critical infrastructure or key resources committed by a group or individual, with or without foreign direction or inspiration, with the intent to intimidate or coerce a civilian population; or to influence the Policy or to affect the conduct of a government by intimidation, coercion, violence, mass destruction, assassination, or kidnapping.

Treatment means:

1. Consulting with a Physician;

2. Receiving care or services from a Physician or from another medical professional a

Physician recommends;

3. Taking prescribed medicines as prescribed; and

4. Receiving diagnostic measures.

Total Disability or Totally Disabled means that You are under the Regular Care of a Physician, and prevented by Injury or Sickness from performing the Material and Substantial Duties of any Gainful Occupation.

Uniformed Services means the active and reserved Armed Forces, the Army National Guard and the Air National Guard, the Commissioned Corps of the Public Health Service, and any other category of persons designated by the President in time of War or national emergency.

United States of America means the fifty (50) states of the United States and the District of Columbia. It does not include territories of the United States.

Waiting Period is the period of time You must be Actively at Work in an Eligible Class before You are eligible for coverage.

Any period of time prior to the Policy Effective Date the Employee was Actively at Work for the Employer as a full time Employee will count towards completion of the Waiting Period.

War means declared or undeclared War or conflict involving the Uniformed Service of any country, group of countries, governments, or international organization.

We, Us, and Our mean USAble Life.

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

You and Your means an Employee of the Policyholder or an Affiliate who has met all the eligibility requirements for coverage, and is:

1. directly employed in the normal business of the Employer; and

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2. paid for services by the Employer; and

3. Actively at Work for the Employer, or Affiliate covered under the Policy; or

4. a Retiree, if listed as eligible in the group Policy.

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ELIGIBILITY

EMPLOYEE ELIGIBILITY DATE

You are eligible for coverage under this Policy on the later of:

1. The Policy Effective Date;

2. The date You complete the Waiting Period following the Policy Effective Date;

3. The date the Policy is changed to include Your class;

4. The date You become a member of an Eligible Class for coverage as shown in the

Schedule of Insurance.

DEPENDENT ELIGIBILITY DATE

A Dependent will be eligible for coverage on the date You become insured for Employee coverage.

ELIGIBILITY RESTRICTIONS

You cannot be covered under this Policy as both an Employee and a Dependent Spouse or Child of another Employee covered under this Policy.

You cannot elect Dependent coverage for anyone who is also covered as an Employee or Child by another Employee covered under this Policy.

CREDIT FOR PREVIOUS SERVICE

If You were Actively at Work in an Eligible Class with the Employer under the Prior Plan but did not complete Your Waiting Period for coverage, the amount of time You were Actively at Work will be applied toward the Waiting Period under this Policy to determine Your Effective Date.

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ENROLLMENT FOR COVERAGE

ACTIVE WORK REQUIREMENT

On the Effective Date of this Policy, You must be Actively at Work on a Full-Time basis to be eligible for coverage.

If You are not Actively at Work on the date Your coverage or any increase in coverage would otherwise be effective, Your coverage or increase in coverage will be effective on the date You return to Active Work.

If Your coverage is scheduled to take effect on a non-working day, Your Active Work status will be based on the last working day before the scheduled Effective Date of Your insurance.

INITIAL COVERAGE ENROLLMENT

If You are eligible for coverage, Your Employer will automatically enroll You in Non-Contributory coverage.

You are not automatically enrolled for Contributory coverage. In order to obtain Contributory coverage, You or Your Employer must apply for coverage. To apply for Contributory coverage, You must:

1. Complete and sign an Enrollment Form; and

2. Return it to Your Employer or Us.

INITIAL COVERAGE EFFECTIVE DATE

Your coverage will be effective on the 1st day of the month following the date You have satisfied the Waiting Period.

If Your coverage is subject to Evidence of Insurability requirements, Your coverage will be effective on the 1st day of the month following the date Your Application is approved.

LATE ENTRANT COVERAGE ENROLLMENT

If You were eligible for coverage under this Plan but did not enroll for coverage during Your initial Open Enrollment for this Plan or within 31 days after becoming eligible, You will not be eligible to enroll in coverage until:

1. Your next Annual Enrollment Period; or

2. The date agreed upon by the Policyholder and Us.

Your enrollment for coverage may be subject to Evidence of Insurability requirements.

LATE ENTRANT COVERAGE EFFECTIVE DATE

If Your coverage is subject to Evidence of Insurability requirements, Your coverage will be effective on the 1st day of the month following the date Your Application is approved.

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EVIDENCE OF INSURABILITY

Evidence of Insurability is a process where You provide Us with Your proof of good health and medical information. This information is used to determine if You are eligible for coverage or an increase in coverage under the Policy. This may include, but is not limited to:

1. a completed and Signed Evidence of Insurability form; and

2. any additional information We may require to complete the underwriting process.

We may require You to provide Us with Evidence of Insurability if You:

1. Apply for coverage more than 30 days after the date You are first eligible to apply during

Your initial Open Enrollment Period; or

2. Apply for coverage during Your Annual Enrollment if You previously declined coverage during Your initial Open Enrollment Period; or

3. Voluntarily terminated Your insurance or Your insurance ended for failure to pay

Premium when due, and You want to reapply for coverage; or

4. Apply for coverage or an amount of coverage for which We require Evidence of

Insurability.

You and Your Employer will be notified in Writing of Evidence of Insurability decisions.

If Your Evidence of Insurability is not satisfactory, or If You do not submit Evidence of Insurability, the amount of additional coverage or coverage increase requested will not become effective. The coverage in effect on the date immediately prior to the date of Your request will not change.

DEPENDENT COVERAGE

If Evidence of Insurability for any Dependent coverage is not satisfactory, or If You do not submit Evidence of Insurability for a Dependent, the amount of Dependent coverage in effect on the date immediately prior to the date of Your request will not change.

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EFFECTIVE DATE

EMPLOYEE EFFECTIVE DATE

Non-Contributory Coverage when Evidence of Insurability (EOI) is not Required:

If You are not required to contribute toward the cost of Your coverage and Evidence of Insurability is not required, Your coverage will become effective on the 1st day of the Policy month following the date You become eligible for coverage.

Non-Contributory Coverage when Evidence of Insurability (EOI) is Required:

If You are not required to contribute toward the cost of Your coverage and Evidence of Insurability is required, Your coverage will become effective on the 1st day of the Policy month following the date You become eligible for coverage and We approve Your Evidence of Insurability.

Contributory Coverage when Evidence of Insurability (EOI) is not Required:

If You are required to contribute towards the cost of Your coverage and Evidence of Insurability is not required, Your coverage will become effective on the 1st day of the Policy month following the date You enroll, if You do so within 30 days from the date You become eligible for coverage.

Contributory Coverage when Evidence of Insurability (EOI) is Required:

If You are required to contribute towards the cost of Your coverage and Evidence of Insurability is required, Your coverage will become effective on the 1st day of the Policy month following the date You become eligible for coverage and We approve Your Evidence of Insurability.

DEPENDENT EFFECTIVE DATE

If Your Dependent’s coverage does not require Evidence of Insurability, Dependent Coverage will become effective the date Your coverage becomes effective.

If Your Dependent’s coverage requires Evidence of Insurability, Dependent coverage will become effective the 1st day of the Policy month following the date Evidence of Insurability is approved.

If both Your and Your Dependent’s coverage requires Evidence of Insurability, Your Dependent’s coverage will not become effective until Your coverage becomes effective.

Your and Your Dependent’s Coverage Effective Date is subject to the Deferred Effective Date provision.

NEWBORN CHILD COVERAGE

A newborn Child, foster or adopted Child will be immediately covered from the date of birth, adoption or placement without submitting Evidence of Insurability for 30 days.

To continue the Child’s coverage, We must receive Written notification of Your intent to continue coverage, the Child’s name, date of birth, and if applicable, date of placement or date of adoption and any required Premium within the 30 day initial coverage period.

If We do not receive the required notice within 30 days from the date of birth, adoption or placement, Evidence of Insurability will be required for coverage and if approved, any required Premium must be paid.

If Your Child’s Evidence of Insurability is approved, Your Child’s coverage will become effective on the 1st day of the Policy month following the date Your Child’s Evidence of Insurability is approved.

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DEFERRED EFFECTIVE DATE

EMPLOYEE DEFERRED EFFECTIVE DATE

If You are not Actively at Work on the date Your coverage is scheduled to become effective due to Your Injury, Sickness, Leave of Absence or Layoff, the Effective Date of Your coverage will be deferred.

Your coverage will be effective on the date You return to Active Work.

DEPENDENT DEFERRED EFFECTIVE DATE

The Effective Date of Dependent coverage or a change in coverage will be deferred if, on the date the Dependent coverage is scheduled to become effective:

1. You are not Actively at Work; or

2. Your Dependent, other than a newborn or disabled Child, is Hospital Confined or

Confined Elsewhere.

Your Dependent coverage will instead be effective:

1. the date You return to Active Work; or

2. The date Your Dependent is no longer Hospital Confined or Confined Elsewhere.

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CONTINUITY OF COVERAGE: TAKEOVER PROVISION

EMPLOYEE CONTINUITY OF COVERAGE

If You were insured under the Prior Plan on the day before the Plan Effective Date and would be eligible for coverage on the Plan Effective Date, but You do not meet the Active Work requirements, Your coverage under this Policy will be the lesser of:

1. The amount of the Group Term Life and Accidental Death and Dismemberment benefit under the Prior Plan; or

2. The amount of Group Term Life and Accidental Death and Dismemberment shown in the Schedule of Insurance, reduced by any coverage amount:

a. in force, paid or payable under the Prior Plan; or

b. that would have been payable under the Prior Plan had that Plan not terminated.

DEPENDENT CONTINUITY OF COVERAGE

If Your Dependent was insured under the Prior Plan but You do not meet the Active Work requirements, Your Dependent’s coverage will be continued under this Plan, provided the cost of Your Dependent’s coverage under the Prior Plan was paid.

The amount of Your Dependent Life and Accidental Death and Dismemberment coverage will be the lesser of:

1. The amount of the Dependent Life and Accidental Death and Dismemberment benefit under the Prior Plan; or

2. The amount of the Dependent Life and Accidental Death and Dismemberment coverage shown in the Schedule of Insurance, reduced by any coverage amount:

a. in force, paid or payable under the Prior Plan; or

b. that would have been payable under the Prior Plan had that Plan not terminated.

CONTINUITY OF COVERAGE TERMINATION

You and Your Dependent will remain insured under this provision until the earliest of the following:

1. The date You return to Active Work;

2. The date Your coverage terminates for a reason stated in the “Termination of Insurance” section; or

3. The last day for which You would have been covered under the Prior Plan, had the Prior

Plan not terminated.

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CHANGES IN COVERAGE

EMPLOYER POLICY CHANGES

Following initial Open Enrollment, Your Employer may make changes to the Policy on the Policy Anniversary date or anytime during the Plan year as agreed upon by Us and Your Employer.

SALARY INCREASES

Evidence of Insurability may be required if, as a result of Your salary increase, the amount of Your salary based benefit exceeds the Policy’s Guaranteed Issue amount. Your Employer must provide proof of Your current earnings.

Benefit increases due to Your salary are subject to any Evidence of Insurability requirements of the Policy. We will use Your salary or earnings on record with Us to:

1. Set or adjust rates;

2. Set benefit amounts and limits; and

3. Calculate Premium due.

MAKING CHANGES TO YOUR COVERAGE

You can make changes to Your and Your Dependents coverage during the Annual Enrollment Period or within 30 days following a change in status.

If You and Your Dependents are currently enrolled for coverage and do not re-enroll for coverage during the Annual Enrollment Period, You and Your Dependents will continue to be insured for the same coverage and coverage amounts elected the during the prior year’s Annual Enrollment.

A change in status occurs when:

1. You acquire a Spouse or Reciprocal Beneficiary;

2. You cease to have a Spouse or Reciprocal Beneficiary through death divorce or otherwise;

3. Your Child is born, You adopt or become the legal guardian of a Child;

4. Your Child is no longer a Dependent or dies;

5. You move into or out of an Eligible Class;

6. Your Spouse is no longer employed, resulting in a loss of group insurance.

CHANGE IN COVERAGE EFFECTIVE DATE

Changes in coverage due to Policy changes made by Your Employer will be effective at 12:00 A.M. on the 1st day of the Policy month following the date of the change.

Changes in coverage due to a salary change will become effective at 12:00 A.M. on the later of the:

1. 1st day of the Policy month following the date of the change;

2. 1st day of the Policy month following the date We approve Your Evidence of Insurability for any amount of insurance that is subject to Evidence of Insurability;

3. the date You return to Active Work following Lay-off or Leave of Absence, Sickness or

Injury.

Changes in coverage will not affect a payable claim that occurs prior to the date of the coverage change.

Changes in coverage are subject to the Active Work provisions.

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TERMINATION OF INSURANCE

TERMINATION OF EMPLOYEE INSURANCE:

Your coverage under this Policy will end at 12:00 A.M. on the earliest of the following:

1. The last day of the month following the date the Policy terminates;

2. The last day of the month following the date Your Employer is no longer participating in this Plan;

3. The last day of the month following the date You are no longer in an Eligible Class for coverage;

4. The last day of the month following the date You are no longer eligible for coverage;

5. The last day of the month following the date for which Premium for Your coverage is required but has not been paid;

6. The last day of the month following the date You cease to be Actively at Work due to a labor dispute, including but not limited to strike, work slowdown, or lockout;

7. The last day of the month following the date You cease to be Actively at Work with the

Employer unless You are disabled, on a Layoff or on Leave of Absence as defined in the Continuation of Coverage section; or

8. The last day of the month following the date You Retire.

If You are receiving benefits and the Policy terminates, We will continue to pay any benefit due to You.

TERMINATION OF DEPENDENT INSURANCE:

Unless Dependent coverage is being continued under one of the Continuation of Coverage Provisions, Dependent coverage will end at 12:00 A.M. on the earliest of the following:

1. The last day of the month following the date the Policy terminates;

2. The last day of the month following the date for which Premium for Your coverage is required but has not been paid;

3. The last day of the month following the date the Dependent ceases to be a Dependent as defined in the Definitions section;

4. The last day of the month following the date You are no longer eligible for coverage, unless Your coverage is being continued under the Continuation of Coverage or Waiver of Premium Provision; or

5. The last day of the month following the date the Dependent enters into Military Service.

CONTINUATION OF COVERAGE FOR A DISABLED CHILD:

If Your Dependent Child is not capable of self-sustaining employment due to mental or physical disability, the Dependent Child’s coverage will not terminate once the Child no longer meets the Dependent Definition.

Coverage will continue as long as Your Child remains disabled, unless coverage terminates for any other reason outlined in the “Termination of Employee Insurance” section. To keep this coverage in force, We may require proof at Our expense of Your Child’s continued disability including proof that Your disabled Child is:

1. incapable of self-sustaining employment; and

2. primarily dependent on You for support and maintenance.

We may request continuous proof of Your Child’s disability, but will not request this information more than 1 time(s) a year.

If at the end of the continuation period Your Child is no longer eligible for insurance under this Certificate, the “Conversion Privilege” provision of this Certificate shall describe Your Child’s right to convert.

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WAIVER OF PREMIUM

If Total Disability has continued for 6 consecutive months, Premium payments under this Policy will be waived for any coverage period after the first day of the month following the date You are Totally Disabled under this Policy provided:

1. You are insured under this Plan and are Actively at Work on or after the Effective Date of the Plan; and

2. Your Total Disability begins before age 60; and

3. Premium payments have continued; and

4. You provide Us with proof of Total Disability as required; and

5. You are still Totally Disabled when You submit the proof of disability.

Dependent Premiums will only be waived if Employee Premiums are waived.

AMOUNT OF LIFE INSURANCE

The amount of life insurance continued will be the amount in force on the date You became Totally Disabled. This amount will be reduced or terminated based on the Schedule of Insurance in effect on the date of Total Disability. This amount will not be increased while You remain Totally Disabled.

If You are still eligible for life insurance when You return to Active Work, Your life insurance may be continued in force if Premium payments are resumed. If this is done, any increased amount of life insurance You may then be eligible for will take effect as described in the Effective Date of Insurance provision.

Premiums that have been waived will not be deducted from the Covered Person’s death benefit.

DEFINITION OF TOTAL DISABILITY

For the purposes of Waiver of Premium, Total Disability or Totally Disabled means that You are under the Regular Care of a Physician, and prevented by Injury or Sickness from performing the Material and Substantial Duties of any Gainful Occupation.

Gainful Occupation means any employment that exists in the national economy that You may be expected to follow based on Your education, training, experience, age, and physical and mental capacity, and from which You are expected to earn at least 60% of your pre-disability earnings within 12 months of Your return to Active Work.

PROOF OF TOTAL DISABILITY

Once You notify Us of Your loss, We will provide You with forms to use when giving Us Proof of Claim. (See “Proof of Claim” under the Claim Provisions.) You must give Us proof no later than 12 months after the date You became Totally Disabled. Failure to provide required proof of disability within this time frame will not invalidate or reduce any payable claim if it was not reasonably possible to provide the required proof.

We will notify You in Writing if Your Claim is approved and the amount of Premium that is being waived.

We may at any time require proof that Total Disability continues. If required, You must give Us proof of continuing disability within 60 days after Our request. After You have been Totally Disabled for more than 2 years from the date of Total Disability, We will not request proof more than once every six months, based on changes in Your diagnosed condition. We may require that You be examined at Our expense by a Physician of Our choice.

DEATH WHILE TOTALLY DISABLED

If You die while Your life insurance is being continued under this provision, We will pay the amount of insurance if We receive proof:

1. of Your death; and

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2. that Total Disability was continuous from the date it began to the date of death.

TERMINATION OF EMPLOYEE WAIVER OF PREMIUM

Your waiver of Premium benefit will end on the earliest of:

1. the date You attain age 65;

2. the last day of the 90 day period following Our request for proof of Total Disability, if You do not give Us proof or You refuse to take a medical exam;

3. the date You return to Active Work;

4. the date You are no longer Totally Disabled.

If Your life insurance terminates while You are covered under this provision, You will be eligible to convert that coverage as of the termination date. You may convert no more than the amount of term life insurance that was in force on You on that date. (See “Conversion Privilege” section.)

TERMINATION OF DEPENDENT WAIVER OF PREMIUM

Your covered Dependent will no longer be eligible for Waiver of Premium on the earliest of the following dates:

1. the date the Dependent ceases to be a Dependent as defined in the Definition section;

2. the date You cease to be eligible for coverage under the Waiver of Premium provision;

or

3. 12 months from the date Your Total Disability began.

If You return to Active Work, You may continue Your Dependent coverage if Premium payments are resumed. Any increased amount of Dependent life insurance the Dependent may then be eligible for will take effect as described in the Effective Date of Dependent Insurance provision.

If a Dependent’s insurance terminates while You are Totally Disabled, the Dependent will be eligible to convert that coverage as of the termination date. The Dependent may convert no more than the amount of Dependent life insurance that was in force on that date. (See “Conversion Privilege” section.)

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CONTINUATION OF COVERAGE

CONTINUATION OF COVERAGE GENERAL PROVISIONS

Any Leave of Absence, Layoff, Military Leave, or Family or Medical Leave from Active Work must be approved in advance and in Writing by Your Employer.

CONTINUATION DURING LAYOFF OR LEAVE OF ABSENCE

Your and Your Dependent coverage may be continued by Your Employer through the end of the 6th month following the month in which Your Layoff or Leave of Absence begins.

The Premium for Your…