Appendix_B_-_Life_and_Disability_Insurance_Documents.pdf

STANDARD INSURANCE COMPANY

A Stock Life Insurance Company 900 SW Fifth Avenue

Portland, Oregon 97204-1282

(503) 321-7000

CERTIFICATE

GROUP LIFE INSURANCE

Policyholder: Orange County Board of County Commissioners

Policy Number: 641718-J

Effective Date: January 1, 2018

A Group Policy has been issued to the Policyholder. We certify that you will be insured as provided by the terms of the Group Policy. If your coverage is changed by an amendment to the Group Policy, we will provide the Policyholder with a revised Certificate or other notice to be given to you.

This policy includes an Accelerated Benefit. Death benefits will be reduced if an Accelerated Benefit is paid. The receipt of this benefit may be taxable and may affect your eligibility for Medicaid or other government benefits or entitlements. However, if you meet the definition of "terminally ill individual" according to the Internal Revenue Code Section 101, your Accelerated Benefit may be non-taxable. You should consult your personal tax and/or legal advisor before you apply for an Accelerated Benefit.

Possession of this Certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this Certificate. If the terms of the Certificate differ from the Group Policy, the terms stated in the Group Policy will govern.

"We", "us" and "our" mean Standard Insurance Company. "You" and "your" mean the Member. All other defined terms appear with the initial letter capitalized. Section headings, and references to them, appear in boldface type.

This certificate provides life insurance for employees and dependents, if applicable, of Orange County Board of County Commissioners, 450 E. South Street, 2nd Floor, Orlando FL, 32802, under 641718-J.

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.

GC190-LIFE/S399

Table of Contents

COVERAGE FEATURES

GENERAL POLICY INFORMATION

BECOMING INSURED

PREMIUM CONTRIBUTIONS

SCHEDULE OF INSURANCE

REDUCTIONS IN INSURANCE

OTHER BENEFITS

OTHER PROVISIONS

LIFE INSURANCE

A. Insuring Clause B. Amount Of Life Insurance C. Changes In Life Insurance D. Repatriation Benefit E. Suicide Exclusion: Life Insurance F. When Life Insurance Becomes Effective G. When Life Insurance Ends H. Reinstatement Of Life Insurance

DEPENDENTS LIFE INSURANCE

A. Insuring Clause B. Amount Of Dependents Life Insurance C. Changes In Dependents Life Insurance D. Definitions For Dependents Life Insurance E. Becoming Insured For Dependents Life Insurance F. When Dependents Life Insurance Ends

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

A. Insuring Clause B. Definition Of Loss For AD&D Insurance C. Amount Payable D. Changes In AD&D Insurance E. AD&D Insurance Exclusions F. Additional AD&D Benefits G. Becoming Insured For AD&D Insurance H. When AD&D Insurance Ends

ACTIVE WORK PROVISIONS

CONTINUITY OF COVERAGE

PORTABILITY OF INSURANCE

WAIVER OF PREMIUM

ACCELERATED BENEFIT

RIGHT TO CONVERT

CLAIMS

ASSIGNMENT

BENEFIT PAYMENT AND BENEFICIARY PROVISIONS

ALLOCATION OF AUTHORITY

TIME LIMITS ON LEGAL ACTIONS

INCONTESTABILITY PROVISIONS

CLERICAL ERROR AND MISSTATEMENT

TERMINATION OR AMENDMENT OF THE GROUP POLICY

DEFINITIONS

Index of Defined Terms

Accelerated Benefit, 21 Active Work, Actively At Work, 18 AD&D Insurance, 31 Air Bag System, 16 Annual Earnings, 31 Annual Enrollment Period, 2 Automobile, 16

Beneficiary, 27

Child, 31 Contributory, 32 Conversion Period, 23

Dependent, 13 Dependents Life Insurance, 32 Disabled, 32

Eligibility Waiting Period, 32 Employer(s), 1 Evidence Of Insurability, 32

Family Status Change, 32

Group Policy, 32 Group Policy Effective Date, 1 Group Policy Number, 1 Guarantee Issue Amount (for

Dependents Life Insurance), 2 Guarantee Issue Amount (for Plan 2), 2

Injury, 32 Insurance (for Accelerated Benefit), 23 Insurance (for Right to Convert), 23 Insurance (for Waiver Of Premium), 20

Leave Of Absence Period, 7 Life Insurance, 32 Loss, 14

Maximum Conversion Amount, 7 Member, 1 Minimum Time Insured, 7

Noncontributory, 32

Physician, 32 Policyholder, 1 Pregnancy, 33 Prior Plan, 33 Proof Of Loss, 24

Qualifying Event, 23 Qualifying Medical Condition, 21

Recipient, 28 Right To Convert, 23

Seat Belt System, 16 Sickness, 33 Spouse, 33

Totally Disabled, 33

Waiting Period (for Waiver Of Premium), Waiver Of Premium, 20 War, 15

You, Your (for Right To Convert), 23

Revised 10/14/2021 - 1 - 641718-J

COVERAGE FEATURES

This section contains many of the features of your group life insurance. Other provisions, including exclusions and limitations, appear in other sections. Please refer to the text of each section for full details. The Table of Contents and the Index of Defined Terms help locate sections and definitions.

GENERAL POLICY INFORMATION

Group Policy Number: 641718-J

Type of Insurance Provided:

Life Insurance: Yes

Dependents Life Insurance: Yes

Accidental Death And Dismemberment (AD&D) Insurance:

Member: Yes Spouse: Yes

Policyholder: Orange County Board of County Commissioners

Employers: Orange County Board of County Commissioners Central Florida Research Park International Drive Master Transit & Improvement District

(IDMTID)

Metroplan Orange County Clerk of Circuit Courts Orange County Comptroller's Office Orange County Housing & Finance Authority Orange County Property Appraiser's Office Orange County Supervisor of Elections Orlando Housing Authority S.O.B.T. Development Board

Group Policy Effective Date: January 1, 2018

Policy Issued in: Florida

BECOMING INSURED

To become insured for Life Insurance you must: (a) Be a Member; (b) Complete your Eligibility Waiting Period; and (c) Meet the requirements in Life Insurance and Active Work Provisions. The requirements for becoming insured for coverages other than Life Insurance are set out in the text.

Definition of Member: You are a Member if you are:

1. An active employee of the Employer; and

2. Regularly working at least 20 hours each week.

You are not a Member if you are:

1. A temporary or seasonal employee.

2. A leased employee.

3. An independent contractor.

Revised 10/14/2021 - 2 - 641718-J

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

Eligibility Waiting Period: You are eligible on the date you become a Member.

Evidence Of Insurability: Required in all of the following instances:

a. For late application for Plan 2 Life Insurance and Dependents Life Insurance for your Spouse.

b. For reinstatements if required.

c. For Members and Spouses eligible but not insured under the Prior Plan.

d. For any Plan 2 Life Insurance Benefit in excess of the Guarantee Issue Amount of $200,000.

e. For any Dependents Life Insurance Benefit for your Spouse in excess of the Guarantee Issue Amount of $50,000.

f. For any elective increase in Plan 2 Life Insurance or Dependents Life Insurance for your Spouse.

Note: Evidence Of Insurability is not required for a Child.

Certain Evidence Of Insurability Requirements Will Be Waived. Your insurance is subject to all other terms of the Group Policy.

During Your Employer's Annual Enrollment Period

During your Employer's Annual Enrollment Period certain Evidence Of Insurability requirements will be waived. However, we will not waive Evidence Of Insurability if you previously submitted Evidence Of Insurability on or after January 1, 2018 that was not approved by us under any group life insurance policy issued by us to the Policyholder or covering your Employer.

1. If you are insured for Plan 2 Life Insurance and you apply for an increase in Plan 2 Life Insurance during an Annual Enrollment Period, Evidence Of Insurability will not be required to increase your Plan 2 Life Insurance Benefit by $10,000, provided your total Plan 2 Life Insurance Benefit does not exceed the Guarantee Issue Amount.

2. If you are eligible but not insured for Plan 2 Life Insurance, Evidence Of Insurability will not be required for you to become insured for $10,000 of Plan 2 Life Insurance for which you apply during the Annual Enrollment Period.

3. If your Spouse is insured for an amount of Dependents Life Insurance less than the Guarantee Issue Amount and you apply for an increase in Dependents Life Insurance for your Spouse during an Annual Enrollment Period, Evidence Of Insurability will not be required to increase the amount of Dependents Life Insurance for your Spouse by up to $10,000, not to exceed the Guarantee Issue Amount.

4. If your Spouse is eligible but not insured for Dependents Life Insurance, Evidence Of Insurability will not be required for your Spouse to become insured for up to $10,000 of Dependents Life Insurance if you apply during the Annual Enrollment Period.

Annual Enrollment Period means the period designated each year by your Employer when you may change insurance elections.

Revised 10/14/2021 - 3 - 641718-J

During the Special Open Enrollment Period for your class (shown below)

Evidence Of Insurability will be waived on January 1, 2018 for the following amounts for which you apply during the Special Open Enrollment Period for your class (shown below), even if Evidence Of Insurability has been previously submitted and not approved by us.

Classification Special Open Enrollment Period

Board of County Commissioners October 2, 2017, through October 20, 2017

Comptroller’s Office October 2, 2017, through October 20, 2017

Clerk of Courts October 9, 2017, through October 20, 2017

Property Appraisers October 16, 2017, through November 3, 2017

Housing Finance Authority October 2, 2017, through October 20, 2017

Tax Collector October 2, 2017, through October 20, 2017

Supervisor of Elections October 2, 2017, through October 20, 2017

Metroplan October 5, 2017, through October 20, 2017

OBTDB October 2, 2017, through October 20, 2017

Orlando Housing Authority November 13, 2017, through November 17, 2017

1. Evidence Of Insurability will not be required to become insured on January 1, 2018 for an amount for which you or your Spouse were insured on December 31, 2017 under Group Policy 641718-G.

2. If you are eligible but not insured for Plan 2 Life Insurance, Evidence Of Insurability will not be required for you to become insured for an amount that does not exceed the Guarantee Issue Amount.

3. If you are insured for an amount of Plan 2 Life Insurance that is less than the Guarantee Issue Amount, Evidence Of Insurability will not be required for you to become insured for a total Plan 2 Life Insurance Benefit that does not exceed the Guarantee Issue Amount.

4. If your Spouse is eligible but not insured for Dependents Life Insurance, Evidence Of Insurability will not be required for your Spouse to become insured for an amount that does not exceed the Guarantee Issue Amount.

5. If your Spouse is insured for an amount of Dependents Life Insurance that is less than the Guarantee Issue Amount, Evidence Of Insurability will not be required for your Spouse to become insured for a total Dependents Life Insurance Benefit that does not exceed the Guarantee Issue Amount.

PREMIUM CONTRIBUTIONS

Life Insurance: Plan 1 (basic): Noncontributory

Plan 2 (employee additional): Contributory

AD&D Insurance:

Member: Plan 1 (basic): Noncontributory

Plan 2 (employee additional): Contributory

Spouse: Contributory

Revised 10/14/2021 - 4 - 641718-J

Dependents Life Insurance:

Spouse: Contributory

Child: Contributory

SCHEDULE OF INSURANCE

SCHEDULE OF LIFE INSURANCE

For you:

Life Insurance Benefit:

You will become insured under Plan 1 if you meet the requirements to become insured under the Group Policy. The Employer pays the cost of Plan 1 Life Insurance.

If you are insured under Plan 1, you may also become insured under Plan 2, provided you meet the requirements to become insured for Plan 2 Life Insurance. Plan 2 is a Contributory plan requiring premium contributions from Members.

Plan 1 (basic): 1 times your Annual Earnings, rounded to the next higher multiple of $1,000, if not already a multiple of $1,000. The maximum amount is $200,000.

Plan 2 (additional): You may apply for Plan 2 Life Insurance in multiples of $10,000, from $10,000 to $300,000, but not to exceed an amount equal to 5 times your Annual Earnings.

The Repatriation Benefit: The expenses incurred to transport your body to a mortuary near your primary place of residence, but not to exceed $5,000 or 10% of the Life Insurance Benefit, whichever is less.

For your Spouse:

Dependents Life Insurance Benefit:

For Members with Annual Earnings of less than $20,000 who are not insured for Plan 2 Life Insurance: You may apply for Dependents Life Insurance for your

Spouse in multiples of $5,000, from $5,000 to $20,000

For all other Members: You may apply for Dependents Life Insurance for your Spouse in multiples of $10,000, from $10,000 to $250,000

The amount of Dependents Life Insurance for your Spouse may not exceed 100% of the amount of your combined Plan 1 and Plan 2 Life Insurance.

For your Child:

Dependents Life Insurance Benefit: You may apply for one of the following amounts of Dependents Life Insurance for your Children: $5,000 or $10,000

The amount of Dependents Life Insurance for your Child may not exceed 100% of the amount of your combined Plan 1 and Plan 2 Life Insurance.

Revised 10/14/2021 - 5 - 641718-J

SCHEDULE OF AD&D INSURANCE

For you:

AD&D Insurance Benefit: The amount of your Plan 1 AD&D Insurance Benefit is equal to 2 times the amount of your Plan 1 Life Insurance Benefit.

The amount payable for certain Losses is less than 100% of the AD&D Insurance Benefit. See AD&D Table Of Losses.

The amount of your Plan 2 AD&D Insurance Benefit is equal to 2 times the amount of your Plan 2 Life Insurance Benefit.

The amount payable for certain Losses is less than 100% of the AD&D Insurance Benefit. See AD&D Table Of Losses.

Seat Belt Benefit: The amount of the Seat Belt Benefit is the lesser of

(1) $10,000, or (2) the AD&D Insurance Benefit payable for Loss of your life.

Air Bag Benefit: The amount of the Air Bag Benefit is the lesser of

(1) $10,000, or (2) the AD&D Insurance Benefit payable for Loss of your life.

Career Adjustment Benefit: The tuition expenses for training incurred by your Spouse within 36 months after the date of your death, exclusive of board and room, books, fees, supplies and other expenses, but not to exceed $5,000 per year, or the cumulative total of $10,000 or 25% of the AD&D Insurance Benefit, whichever is less.

Child Care Benefit: The total child care expense incurred by your Spouse within 36 months after the date of your death for all Children under age 13, but not to exceed $5,000 per year, or the cumulative total of $10,000 or 25% of the AD&D Insurance Benefit, whichever is less.

Higher Education Benefit: The tuition expenses incurred per Child within 4 years after the date of your death at an accredited institution of higher education, exclusive of board and room, books, fees, supplies and other expenses, but not to exceed $5,000 per year, or the cumulative total of $20,000 or 25% of the AD&D Insurance Benefit, whichever is less.

Occupational Assault Benefit: The lesser of (1) $25,000, or (2) 50% of the AD&D Insurance Benefit otherwise payable for the Loss.

Public Transportation Benefit: The lesser of (1) $200,000, or (2) 100% of the AD&D Insurance Benefit otherwise payable for the Loss of your life.

For your Spouse:

AD&D Insurance Benefit: The amount of AD&D Insurance Benefit for your Spouse is equal to 2 times the amount of Dependents Life Insurance Benefit for your Spouse. The amount payable for certain Losses is less than 100% of the AD&D Insurance Benefit.

See AD&D Table Of Losses.

Seat Belt Benefit: The amount of the Seat Belt Benefit is the lesser of

(1) $10,000, or (2) the AD&D Insurance Benefit payable for Loss of your Spouse’s life.

Revised 10/14/2021 - 6 - 641718-J

Air Bag Benefit: The amount of the Air Bag Benefit is the lesser of

(1) $10,000, or (2) the AD&D Insurance Benefit payable for Loss of your Spouse’s life.

Public Transportation Benefit: The lesser of (1) $200,000, or (2) 100% of the AD&D Insurance Benefit otherwise payable for the Loss of your Spouse’s life.

AD&D TABLE OF LOSSES

The amount payable is a percentage of the AD&D Insurance Benefit or the Dependents AD&D Insurance Benefit in effect on the date of the accident and is determined by the Loss suffered as shown in the following table:

Loss: Percentage Payable:

a.

Life 100% b.

One hand or one foot 50% c.

Sight in one eye, speech, or hearing in both ears

50% d.

Two or more of the Losses listed in b. and c. above

100% e.

Thumb and index finger of the same hand

25%* f.

Quadriplegia 100%** g.

Hemiplegia 50%** h.

Paraplegia 50%**

No more than 100% of the AD&D Insurance will be paid for all Losses resulting from one accident.

* No AD&D Insurance Benefit will be paid for Loss of thumb and index finger of the same hand if an AD&D Insurance Benefit is payable for the Loss of that entire hand.

** No AD&D Insurance Benefit will be paid for loss of a hand or foot if an AD&D Insurance Benefit is payable for Quadriplegia, Hemiplegia, or Paraplegia involving that same hand or foot.

REDUCTIONS IN INSURANCE

If you or your Spouse reaches an age shown below, the amount of insurance will be the amount determined from the Schedule Of Insurance, multiplied by the appropriate percentage below:

Life and AD&D Insurance for you:

Age Of Member: Percentage:

65 through 69 65% 70 through 74 50% 75 or over 35%

Revised 10/14/2021 - 7 - 641718-J

Dependents Life and AD&D Insurance for your Spouse:

Age Of Spouse: Percentage:

65 through 69 65% 70 through 74 50% 75 or over 35%

OTHER BENEFITS

Waiver Of Premium: Yes

Accelerated Benefit: Yes

OTHER PROVISIONS

Limits on Right To Convert if Group Policy terminates or is amended:

Minimum Time Insured: 5 years Maximum Conversion Amount: $10,000

Suicide Exclusion: Applies to:

a. Plan 2 Life Insurance

b. AD&D Insurance

Leave Of Absence Period: 90 days

Continuity Of Coverage: Yes

Insurance Eligible For Portability:

For you:

Life Insurance Yes

Minimum amount: $10,000 Maximum amount: $300,000

AD&D Insurance Yes

Minimum amount: $10,000 Maximum amount: $300,000

For your Spouse:

Dependents Life Insurance Yes

Minimum amount: $5,000 Maximum amount: $100,000

Dependents AD&D Insurance Yes

Minimum amount: $5,000 Maximum amount: $100,000

For your Child:

Dependents Life Insurance Yes

Revised 10/14/2021 - 8 - 641718-J

Minimum amount: $1,000 Maximum amount: $5,000

Annual Earnings based on: Earnings in effect on your last full day of Active Work.

Revised 10/14/2021 - 9 - 641718-J

LIFE INSURANCE

A. Insuring Clause

If you die while insured for Life Insurance, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us.

B. Amount Of Life Insurance

See the Coverage Features for the Life Insurance schedule.

C. Changes In Life Insurance

1. Increases

You must apply in writing or electronically for any elective increase in your Life Insurance.

Subject to the Active Work Provisions, an increase in your Life Insurance becomes effective as follows:

a. Increases Subject To Evidence Of Insurability

An increase in your Life Insurance subject to Evidence Of Insurability becomes effective on:

(i) The later of (a) the first day of the calendar month coinciding with or next following the date of change in your Annual Earnings, or (b) the date we approve your Evidence Of Insurability.

(ii) The first day of the first pay period following the date we approve your Evidence Of Insurability, if you apply within 60 days of a Family Status Change.

(iii) The later of (a) the beginning of the next plan year following the date you apply, or (b) the date we approve your Evidence Of Insurability, if you apply during an Annual Enrollment Period.

b. Increases Not Subject To Evidence Of Insurability

An increase in your Life Insurance not subject to Evidence Of Insurability becomes effective on:

(i) The first day of the calendar month coinciding with or next following the date of change in your Annual Earnings.

(ii) The first day of the first pay period following the date of the Family Status Change, if you apply within 60 days of a Family Status Change.

(iii) The beginning of the next plan year following the date you apply, if you apply during an Annual Enrollment Period.

2. Decreases

A decrease in your Life Insurance because of a change in your age becomes effective on the January 1 next following the date of the change.

A decrease in your Life Insurance because of a change in your classification or Annual Earnings becomes effective on the first day of the calendar month coinciding with or next following the date of the change.

Any other decrease in your Life Insurance becomes effective on the first day of the calendar month coinciding with or next following the date the Policyholder or your Employer receives your written request for the decrease.

D. Repatriation Benefit

The amount of the Repatriation Benefit is shown in the Coverage Features.

Revised 10/14/2021 - 10 - 641718-J

We will pay a Repatriation Benefit if all of the following requirements are met.

1. A Life Insurance Benefit is payable because of your death.

2. You die more than 200 miles from your primary place of residence.

3. Expenses are incurred to transport your body to a mortuary near your primary place of residence.

E. Suicide Exclusion: Life Insurance

If your death results from suicide or other intentionally self-inflicted Injury, while sane or insane, 1 and 2 below apply.

1. The amount payable will exclude the amount of your Life Insurance which is subject to this suicide exclusion and which has not been continuously in effect for at least 2 years on the date of your death. In computing the 2-year period, we will include time you were insured under the Prior Plan.

2. We will refund all premiums paid for that portion of your Life Insurance which is excluded from payment under this suicide exclusion.

F. When Life Insurance Becomes Effective

The Coverage Features states whether your Life Insurance is Contributory or Noncontributory.

Subject to the Active Work Provisions, your Life Insurance becomes effective as follows:

1. Life Insurance subject to Evidence Of Insurability

a. Contributory Life Insurance

You must apply in writing or electronically for Contributory Life Insurance and agree to pay premiums. Contributory Life Insurance subject to Evidence Of Insurability becomes effective on:

(i) The later of (a) the date you become eligible, and (b) the date we approve your Evidence Of Insurability, if you apply prior to or within 31 days after you become eligible.

(ii) The first day of the first pay period following the date we approve your Evidence Of Insurability, if you apply within 60 days of a Family Status Change.

(iii) The later of (a) the beginning of the next plan year following the date you apply, or (b) the date we approve your Evidence Of Insurability, if you apply during the Annual Enrollment Period.

2. Life Insurance not subject to Evidence Of Insurability

a. Noncontributory Life Insurance

Noncontributory Life Insurance not subject to Evidence Of Insurability becomes effective on the date you become eligible.

b. Contributory Life Insurance

You must apply in writing or electronically for Contributory Life Insurance and agree to pay premiums. Contributory Life Insurance not subject to Evidence Of Insurability becomes effective on:

(i) The later of (a) the date you become eligible, and (b) the date you apply, if you apply prior to or within 31 days after you become eligible.

(ii) The first day of the first pay period following the date of the Family Status Change, if you apply within 60 days of a Family Status Change.

(iii) The beginning of the next plan year following the date you apply, if you apply during the

Revised 10/14/2021 - 11 - 641718-J

Annual Enrollment Period.

Late application: Evidence Of Insurability is required if you apply more than 31 days after you become eligible, except as provided in the Coverage Features.

3. Takeover Provision

a. If you were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy, your Eligibility Waiting Period is waived on the effective date of your Employer's coverage under the Group Policy.

b. You must submit satisfactory Evidence Of Insurability to become insured for Life Insurance if you were eligible under the Prior Plan for more than 31 days but were not insured, except as provided in the Coverage Features.

G. When Life Insurance Ends

Life Insurance ends automatically on the earliest of:

1. The date the last period ends for which a premium was paid for your Life Insurance;

2. The date the Group Policy terminates. However, if you are Totally Disabled on that date, we will continue your Life Insurance for 12 months, unless you are eligible for Waiver Of Premium. The Life Insurance Benefit payable during this 12 month extension period will be reduced by any amount payable under a replacement group life insurance plan;

3. The last day of the pay period in which your employment terminates; and

4. The date you cease to be a Member. However, if you cease to be a Member because you are working less than the required minimum number of hours, your Life Insurance will be continued with premium payment during the following periods, unless it ends under 1 through 3 above.

a. While your Employer is paying you at least the same Annual Earnings paid to you immediately before you ceased to be a Member.

b. While your ability to work is limited because of Sickness, Injury, or Pregnancy.

If you are Totally Disabled and you are not eligible for Waiver Of Premium (see Waiver Of Premium), your Life Insurance will continue, while you remain Totally Disabled, for a period of 12 months, but not beyond the date the Group Policy terminates. This applies even if your employment terminates.

c. During the first 60 days of:

(1) A temporary layoff; or

(2) A strike, lockout, or other general work stoppage caused by a labor dispute between your collective bargaining unit and your Employer.

d. During a leave of absence if continuation of your insurance under the Group Policy is required by a state-mandated family or medical leave act or law.

e. During any other scheduled leave of absence approved by your Employer in advance and in writing and lasting not more than the period shown in the Coverage Features.

H. Reinstatement Of Life Insurance

If your Life Insurance ends, you may become insured again as a new Member. However, 1 through 4 below will apply.

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

2. If your Life Insurance ends because you fail to make a required premium contribution, you must provide Evidence Of Insurability to become insured again.

Revised 10/14/2021 - 12 - 641718-J

3. If you exercised your Right To Convert, you must provide Evidence Of Insurability to become insured again.

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

(REPAT_SUIC ALL_FAM STAT_ANNUAL ENROL) LI.LF.FL.3X

DEPENDENTS LIFE INSURANCE

A. Insuring Clause

If your Dependent dies while insured for Dependents Life Insurance, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us.

B. Amount Of Dependents Life Insurance

See the Coverage Features for the amount of your Dependents Life Insurance.

C. Changes In Dependents Life Insurance

1. Increases

You must apply in writing or electronically for any elective increase in your Dependents Life Insurance.

Subject to the Active Work Provisions, an increase in your Dependents Life Insurance becomes effective as follows:

a. Increases Subject To Evidence Of Insurability

An increase in your Dependents Life Insurance subject to Evidence Of Insurability becomes effective on:

(i) The first day of the first pay period following the date we approve the Dependent's Evidence Of Insurability, if you apply within 60 days of a Family Status Change.

(ii) The later of (a) the beginning of the next plan year following the date you apply, or (b) the first day of the calendar month coinciding with or next following the date we approve the Dependent's Evidence Of Insurability, if you apply during an Annual Enrollment Period.

b. Increases Not Subject To Evidence Of Insurability

An increase in your Dependents Life Insurance not subject to Evidence Of Insurability becomes effective on:

(i) The first day of the first pay period following the date of the Family Status Change, if you apply within 60 days of a Family Status Change.

(ii) The beginning of the next plan year following the date you apply, if you apply during an Annual Enrollment Period.

2. Decreases

A decrease in your Dependents Life Insurance because of a decrease in your Life Insurance becomes effective on the date your Life Insurance decreases.

A decrease in your Dependents Life Insurance because of a change in your Spouse’s age becomes effective on the January 1 next following the date of the change.

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D. Definitions For Dependents Life Insurance

Dependent means your Spouse or Child. Dependent does not include a person who is a full-time member of the armed forces of any country.

E. Becoming Insured For Dependents Life Insurance

1. Eligibility

You become eligible to insure your Dependents on the later of:

a. The date you become eligible for Life Insurance; and

b. The date you first acquire a Dependent.

A Member may be insured as both a Member and a Dependent. A Child may not be insured by more than one Member.

2. Effective Date

The Coverage Features states whether your Dependents Life Insurance is Contributory or Noncontributory. Subject to the Active Work Provisions, your Dependents Life Insurance becomes effective as follows:

a. Dependents Life Insurance Subject To Evidence Of Insurability

1. Contributory Dependents Life Insurance

You must apply in writing or electronically for Contributory Dependents Life Insurance and agree to pay premiums. Contributory Dependents Life Insurance subject to Evidence Of Insurability becomes effective on the later of the date your Life Insurance becomes effective and the following applicable date:

(i) The later of (a) the date you become eligible, and (b) the first day of the calendar month coinciding with or next following the date we approve the Dependent's Evidence Of Insurability, if you apply prior to or within 31 days after you become eligible.

(ii) The first day of the first pay period following the date we approve the Dependent's Evidence Of Insurability, if you apply within 60 days of a Family Status Change.

(iii) The later of (a) the beginning of the next plan year following the date you apply, or (b) the first day of the calendar month coinciding with or next following the date we approve the Dependent's Evidence Of Insurability, if you apply during the Annual Enrollment Period.

b. Dependents Life Insurance Not Subject To Evidence Of Insurability

1. Contributory Dependents Life Insurance

You must apply in writing or electronically for Contributory Dependents Life Insurance and agree to pay premiums. Contributory Dependents Life Insurance not subject to Evidence Of Insurability becomes effective on the later of the date your Life Insurance becomes effective and the following applicable date:

i. The later of (a) the date you become eligible, and (b) the date you apply, if you apply prior to or within 31 days after you become eligible.

ii. The first day of the first pay period following the date of the Family Status Change, if you apply within 60 days of a Family Status Change.

iii. The later of (a) the beginning of the next plan year following the date you apply, or (b) the date you apply, if you apply during the Annual Enrollment Period.

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Late Application: Evidence Of Insurability is required for each Dependent if you apply more than 31 days after you become eligible, except as provided in the Coverage Features.

c. While Dependents Life Insurance for your Children is in effect, each new Child becomes insured immediately.

d. Takeover Provision

Each Dependent who was eligible under the Prior Plan for more than 31 days but was not insured must submit satisfactory Evidence Of Insurability to become insured for Dependents Life Insurance, except as provided in the Coverage Features.

F. When Dependents Life Insurance Ends

Dependents Life Insurance ends automatically on the earliest of:

1. Five months after you die (no premiums will be charged for your Dependents Life Insurance during this time);

2. The date your Life Insurance ends;

3. The date the Group Policy terminates, or the date Dependents Life Insurance terminates under the Group Policy;

4. The date the last period ends for which you made a premium contribution, if your Dependents Life Insurance is Contributory;

5. For your Spouse, the date of your divorce or legal separation;

6. For any Dependent, the date the Dependent ceases to be a Dependent; and

7. For a Child who is Disabled, 90 days after we mail you a request for proof of Disability, if proof is not given.

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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

A. Insuring Clause

If you or your Spouse has an accident, including accidental exposure to adverse conditions, while insured for AD&D Insurance, and the accident results in a Loss, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us.

B. Definition Of Loss For AD&D Insurance

Loss means loss of life, hand, foot, sight, speech, hearing in both ears, thumb and index finger of the same hand and Quadriplegia, Hemiplegia or Paraplegia which meets all of the following requirements:

1. Is caused solely and directly by an accident.

2. Occurs independently of all other causes.

3. Occurs within 365 days after the accident.

4. With respect to Loss of life, is evidenced by a certified copy of the death certificate.

5. With respect to all other Losses, is certified by a Physician in the appropriate specialty as determined by us.

With respect to Loss of life, death will be presumed if you or your Spouse disappears and the

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

2. Occurs independently of all other causes; and

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

With respect to a hand or foot, Loss means actual and permanent severance from the body at or above the wrist or ankle joint, whether or not surgically reattached.

With respect to sight, Loss means entire, uncorrectable, and irrecoverable loss of sight.

With respect to speech, Loss means entire, uncorrectable, and irrecoverable loss of audible speech.

With respect to hearing, Loss means entire, uncorrectable, and irrecoverable loss of hearing in both ears.

With respect to thumb and index finger of the same hand, Loss means actual and permanent severance from the body at or above the metacarpophalangeal joints.

With respect to Quadriplegia, Hemiplegia, and Paraplegia, Loss must be permanent, complete, and irreversible.

Quadriplegia means total paralysis of both upper and lower limbs. Hemiplegia means total paralysis of the upper and lower limbs on the same side of the body. Paraplegia means total paralysis of both lower limbs.

C. Amount Payable

See Coverage Features for the AD&D Insurance schedule. The amount payable is a percentage of the AD&D Insurance Benefit in effect on the date of the accident and is determined by the Loss suffered. See AD&D Table Of Losses in the Coverage Features.

D. Changes In AD&D Insurance

Changes in your AD&D Insurance will become effective on the date your Life Insurance changes.

Changes in AD&D Insurance for your Spouse will become effective on the date your Spouse’s Dependents Life Insurance changes.

E. AD&D Insurance Exclusions

No AD&D Insurance benefit is payable if the accident or Loss is caused or contributed to by any of the following:

1. War or act of War. War means declared or undeclared war, whether civil or international, and any substantial armed conflict between organized forces of a military nature.

2. Suicide or other intentionally self-inflicted Injury, while sane or insane.

3. Committing or attempting to commit an assault or felony, or actively participating in a violent disorder or riot. Actively participating does not include being at the scene of a violent disorder or riot while performing your official duties.

4. The voluntary use or consumption of any poison, chemical compound or drug, unless used or consumed according to the directions of a Physician.

5. Sickness or Pregnancy existing at the time of the accident.

6. Heart attack or stroke.

7. Medical or surgical treatment for any of the above.

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F. Additional AD&D Benefits

Seat Belt Benefit

The amount of the Seat Belt Benefit is shown in the Coverage Features.

We will pay a Seat Belt Benefit if all of the following requirements are met:

1. You or your Spouse dies as a result of an Automobile accident for which an AD&D Insurance Benefit is payable for that Loss of life; and

2. The deceased was wearing and properly utilizing a Seat Belt System at the time of the accident, as evidenced by a police accident report.

Seat Belt System means a properly installed combination lap and shoulder restraint system that meets the Federal Vehicle Safety Standards of the National Highway Traffic Safety Administration. Seat Belt System will include a lap belt alone, but only if the Automobile did not have a combination lap and shoulder restraint system when manufactured. Seat Belt System does not include a shoulder restraint alone.

Automobile means a motor vehicle licensed for use on public highways.

Air Bag Benefit

The amount of the Air Bag Benefit is shown in the Coverage Features.

We will pay an Air Bag Benefit if all of the following requirements are met:

1. You or your Spouse dies as a result of an Automobile accident for which a Seat Belt Benefit is payable for that Loss of life.

2. The Automobile is equipped with an Air Bag System that was installed as original equipment by the Automobile manufacturer and has received regular maintenance or scheduled replacement as recommended by the Automobile or Air Bag manufacturer.

3. The deceased is seated in the driver's or a passenger's seating position intended to be protected by the Air Bag System and the Air Bag System deploys, as evidenced by a police accident report.

Air Bag System means an automatically inflatable passive restraint system that is designed to provide automatic crash protection in front or side impact Automobile accidents and meets the Federal Vehicle Safety Standards of the National Highway Traffic Safety Administration.

Automobile means a motor vehicle licensed for use on public highways.

Career Adjustment Benefit

The amount of the Career Adjustment Benefit is shown in the Coverage Features.

We will pay a Career Adjustment Benefit to your Spouse if all of the following requirements are met:

1. You are insured for AD&D Insurance under the Group Policy.

2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss of your life.

3. Your Spouse is, within 36 months after the date of your death, registered and in attendance at an accredited institution of higher education or trades training program for the purpose of obtaining employment or increasing earnings.

No Career Adjustment Benefit will be paid if you have no surviving Spouse.

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Child Care Benefit

The amount of the Child Care Benefit is shown in the Coverage Features.

We will pay a Child Care Benefit to your Spouse if all of the following requirements are met:

1. You are insured for AD&D Insurance under the Group Policy.

2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss of your life.

3. Your Spouse pays a licensed child care provider who is not a member of your family for child care provided to your Child(ren) under age 13 within 36 months of your death.

4. The child care is necessary in order for your Spouse to work or to obtain training for work or to increase earnings.

No Child Care Benefit will be paid if you have no surviving Spouse.

Higher Education Benefit

The amount of the Higher Education Benefit is shown in the Coverage Features.

We will pay a Higher Education Benefit to your Child if all of the following requirements are met:

1. You are insured for AD&D Insurance under the Group Policy.

2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss of your life.

3. Your Child is, within 12 months after the date of your death, registered and in full-time attendance at an accredited institution of higher education beyond high school.

The Higher Education Benefit will be paid to each Child who meets the requirements of item 3 above, for a maximum of 4 consecutive years beginning on the date of your death. No Higher Education Benefit will be paid if there is no Child eligible to receive it.

Occupational Assault Benefit

The amount of the Occupational Assault Benefit is shown in the Coverage Features.

We will pay an Occupational Assault Benefit if all of the following requirements are met:

1. While Actively At Work you suffer a Loss for which an AD&D Insurance Benefit is payable.

2. The Loss is the result of an act of physical violence against you that is punishable by law and is evidenced by a police report.

Public Transportation Benefit

The amount of the Public Transportation Benefit is shown in the Coverage Features.

We will pay a Public Transportation Benefit if all of the following requirements are met:

1. You or your Spouse dies as a result of an accident for which an AD&D Insurance Benefit is payable for Loss of life.

2. The accident occurs while the deceased is riding as a fare-paying passenger on Public Transportation.

Public Transportation means a public passenger conveyance operated by a licensed common carrier for the transportation of the general public for a fare and operating on regular passenger routes with a definite schedule of departures and arrivals.

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G. Becoming Insured For AD&D Insurance

1. Eligibility

You become eligible for AD&D Insurance on the date your Life Insurance is effective.

You become eligible to insure your Spouse on the later of:

a. The date your Life Insurance is effective; and

b. The date your Spouse’s Dependents Life Insurance is effective.

A Member may not be insured as both a Member and a Dependent.

2. Effective Date

The Coverage Features states whether AD&D Insurance is Contributory or Noncontributory.

Subject to the Active Work Provisions, AD&D Insurance becomes effective as follows:

a. Noncontributory AD&D Insurance

Noncontributory AD&D Insurance becomes effective on the date you become eligible.

b. Contributory AD&D Insurance

You must apply in writing or electronically for Contributory AD&D Insurance and agree to pay premiums. Contributory AD&D Insurance becomes effective on the following applicable date:

(i) The later of (a) the date you become eligible, and (b) the date you apply, if you apply prior to or within 31 days after you become eligible;

(ii) The first day of the first pay period following the date of the Family Status Change, if you apply within 60 days of a Family Status Change.

(iii) The later of (a) the beginning of the next plan year following the date you apply, or (b) the date you apply, if you apply during the Annual Enrollment Period.

H. When AD&D Insurance Ends

AD&D Insurance ends automatically on the earliest of:

1. The date your Life Insurance ends.

2. The date your Waiver Of Premium begins.

3. The date AD&D Insurance terminates under the Group Policy.

4. The date the last period ends for which a premium was paid for your AD&D Insurance.

5. For your Spouse, the date your Spouse’s Dependents Life Insurance ends.

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ACTIVE WORK PROVISIONS

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

Active Work and Actively At Work mean performing the material duties of your own occupation at your Employer's usual place of business. You will also meet the Active Work requirement if:

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

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

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

LI.AW.OT.1

CONTINUITY OF COVERAGE

A. Waiver Of Active Work Requirement

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

B. Payment Of Benefit

The benefits payable before you meet the Active Work requirement will be:

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

2. Any benefits payable under the Prior Plan.

LI.CC.FL.1

PORTABILITY OF INSURANCE

A. Portability Of Insurance

If your insurance under the Group Policy ends because your employment with your Employer terminates, you may be eligible to buy portable group insurance coverage as shown in the Coverage Features for yourself and your Dependents without submitting Evidence Of Insurability. To be eligible you must satisfy the following requirements:

1. On the date your employment terminates, you must be able to perform with reasonable continuity the material duties of at least one gainful occupation for which you are reasonably fitted by education, training and experience.

(If you are unable to meet this requirement, see the Right To Convert and Waiver Of Premium provisions for other options that may be available to you under the Group Policy.)

2. On the date your employment terminates, you are under age 65.

3. On the date your employment terminates, you must have been continuously insured under the Group Policy for at least 12 consecutive months. In computing the 12 consecutive month period, we will include time insured under the Prior Plan.

4. You must apply in writing and pay the first premium directly to us at our Home Office within 60 days after the date your employment terminates. You must purchase portable group life insurance coverage for yourself in order to purchase any other insurance eligible for portability.

This portable group insurance will be provided under a master Group Life Portability Insurance Policy we have issued to the Standard Insurance Company Group Insurance Trust. If approved, the certificate you will receive will be governed under the terms of the Group Life Portability Insurance Policy and will contain provisions that differ from your Employer's coverage under the Group Policy.

B. Amount Of Portable Insurance

The minimum and maximum amounts that you are eligible to buy under the Group Life Portability Insurance Policy are shown in the Coverage Features. You may buy less than the maximum amounts in increments of $1,000.

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The combined amounts of insurance purchased under this Portability Of Insurance provision and the Right To Convert provision cannot exceed the amount in effect under the Group Policy on the day before your employment terminates.

C. When Portable Insurance Becomes Effective

Portable group insurance will become effective the day after your employment with your Employer terminates, if you apply within 60 days after the date your employment terminates.

If death occurs within 60 days after the date insurance ends under the Group Policy, life insurance benefits, if any, will be paid according to the terms of the Group Policy in effect on the date your employment terminates and not the terms of the Group Life Portability Insurance Policy. AD&D benefits, if any, will be paid according to the terms of the Group Policy or the Group Life Portability Insurance Policy, but not both. In no event will the benefits paid exceed the amount in effect under the Group Policy on the day before your employment terminates

(WITH DL REF) LI.TP.OT.1

WAIVER OF PREMIUM

A. Waiver Of Premium Benefit

Insurance will be continued without payment of premiums while you are Totally Disabled if:

1. You become Totally Disabled while insured under the Group Policy and under age 60;

2. You complete your Waiting Period; and

3. You give us satisfactory Proof Of Loss.

However, continuation of insurance without payment of premium is limited to 12 months if you become Totally Disabled on or after age 60.

We may have you examined at our expense at reasonable intervals. Any such examination will be conducted by specialists of our choice.

B. Definitions For Waiver Of Premium

1. Insurance means all your insurance under the Group Policy, except AD&D Insurance and Dependents AD&D Insurance.

2. Waiting Period means the 180 consecutive day period beginning on the date you become Totally Disabled. Waiver Of Premium begins when you complete the Waiting Period.

C. Premium Payment

Premium payment must continue until the later of:

1. The date you complete your Waiting Period; and

2. The date we approve your claim for Waiver Of Premium.

D. Refund Of Premiums

We will refund up to 12 months of the premiums that were paid for Insurance after the date you become Totally Disabled.

E. Amount Of Insurance

The amount of Insurance eligible for Waiver Of Premium is the amount in effect on the day before you become Totally Disabled. However, the following will apply:

1. Insurance will be reduced or terminated according to the Group Policy provisions in effect on the day before you…