Attachment 7 -760741_Life Certificate_Lot 2.pdf

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STANDARD INSURANCE COMPANY

A Stock Life Insurance Company 900 SW Fifth Avenue

Portland, Oregon 97204-1282

(503) 321-7000

CERTIFICATE

GROUP LIFE INSURANCE

Policyholder: Palm Beach County Board of County Commissioners

Policy Number: 760741-D

Effective Date: January 1, 2025

Revision Date: March 31, 2025

The Group Policy has been issued to the Policyholder.

We certify that you will be insured as provided by the terms of your Employer’s coverage under the Group Policy. If the terms of this Certificate differs from the terms of your Employer’s coverage under the Group Policy, the latter will govern. 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 Death Benefit. Death benefits will be reduced if an Accelerated Death 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” in Internal Revenue Code section 101, your Accelerated Death Benefit may be non-taxable. You should consult your personal tax and/or legal advisor before you apply for an Accelerated Death 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.

Unless defined differently within a particular provision, the terms "you" and "your" mean the Member. "We", "us", and "our" mean Standard Insurance Company. Other defined terms appear with their initial letters capitalized. Section headings, and references to them, appear in bold face type.

President and CEO

GC1219-LIFE

GC1219-LIFE 760741-D

TABLE OF CONTENTS

COVERAGE FEATURES

GENERAL POLICY INFORMATION

BECOMING INSURED

PREMIUM CONTRIBUTIONS

SCHEDULE OF INSURANCE

REDUCTIONS IN INSURANCE

OTHER AD&D BENEFITS

OTHER PROVISIONS

INSURING CLAUSE

EVIDENCE OF INSURABILITY

LIFE INSURANCE

A. Amount Of Life Insurance

B. When Life Insurance Becomes Effective

C. Changes In Life Insurance

E. When Life Insurance Ends

F. Reinstatement Of Life Insurance

DEPENDENT LIFE INSURANCE FOR YOUR SPOUSE

A. Amount Of Insurance

B. Insuring Your Spouse

C. Changes In Insurance

E. When Insurance Ends

DEPENDENT LIFE INSURANCE FOR YOUR CHILD

A. Amount Of Insurance

B. Insuring Your Child

C. Changes In Insurance

D. When Insurance Ends

REPATRIATION BENEFIT

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

A. Insuring Clause

B. Becoming Insured For AD&D Insurance

C. Changes In AD&D Insurance

D. Definition Of Loss For AD&D Insurance

E. AD&D Insurance Exclusions

F. Amount Payable

G. Other AD&D Benefits

H. When AD&D Insurance Ends

ACTIVE WORK PROVISIONS

CONTINUITY OF COVERAGE

PORTABILITY OF INSURANCE

RETIREMENT CONTINUATION

WAIVER OF PREMIUM

ACCELERATED DEATH BENEFIT

RIGHT TO CONVERT

CLAIMS

ASSIGNMENT

BENEFIT PAYMENT AND BENEFICIARY PROVISIONS

RIGHT TO RECOVERY

CLAIMANT COOPERATION

AGENCY, RELEASE AND INDEMNIFICATION

TIME LIMITS ON LEGAL ACTIONS

INCONTESTABILITY OF INSURANCE

CLERICAL ERROR, MISSTATEMENT AND AGENCY

DEFINITIONS

INDEX OF DEFINED TERMS

Active Work, Actively At Work, 24

AD&D Insurance, 38

Air Bag System, 23

Annual Earnings, 38

Annual Enrollment Period, 13

Automobile (Air Bag), 23

Automobile (Seat Belt), 24

Beneficiary, 35

Child, 38

Contributory, 38

Conversion Period, 30

Dependent, 38

Dependent Life Insurance, 38

Domestic Partner, 39

Eligibility Waiting Period, 38

Employer, 38

Evidence Of Insurability, 39

Family Status Change, 13

Group Policy, 39

Group Policy Effective Date, 5

Group Policy Number, 5

Helmet, 23

Hospital, 39

Injury, 39

Insurance (Accelerated Death Benefit), 30

Insurance (Right To Convert), 30

Insurance (Waiver Of Premium), 27

Life Insurance, 39

Loss (Accidental Death and Dismemberment

Insurance), 21

Material Duties (Active Work), 25

Material Duties (Waiver Of Premium), 27

Noncontributory, 39

Nursing Home, 39

Own Occupation, 25

Physician, 39

Policyholder, 5

Portable Event, 25

Pregnancy, 39

Prior Plan, 39

Proof Of Loss, 31

Qualifying Event, 30

Qualifying Medical Condition, 29

Recipient, 36

Seat Belt System, 24

Sickness, 39

Signed, 39

Social Security Normal Retirement Age

(SSNRA), 28

Spouse, 39

Total Disability and Totally Disabled, 39

Totally Disabled (Waiver Of Premium), 27

Waiting Period, 27

War, 22

Writing or Written, 39 You and Your, 30

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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: 760741-D

Type of Insurance Provided:

Life Insurance: Yes

Accidental Death And Dismemberment (AD&D) Insurance: Yes

Dependent Life Insurance For Your Spouse: Yes

Dependent Life Insurance For Your Child: Yes

Policyholder: Palm Beach County Board of County Commissioners

Employer(s): Palm Beach County Board of County Commissioners

Group Policy Effective Date: January 1, 2025

Revision Date: March 31, 2025

State of Issue: 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 Active Work requirement does not apply to Members who are retired and eligible on the Group Policy Effective Date.

The requirements for becoming insured for coverages other than Life Insurance are set out in the text.

Member means one of the following:

1. A regular permanent employee of the Board of County Commissioners, Supervisor of Elections or Palm Tran, Inc., who is Actively At Work at least 30 hours each week, other than Palm Beach County Fire Rescue who are members of Professional Fire Fighters of Palm Beach County IAFF Local 2928, Palm Beach County Sheriff's office, Tax Collector, Property Appraiser, or Clerk of the Court; or

2. An employee of the Employer who retires under a Florida state retirement system or state optional annuity or retirement program or is placed on disability retirement and who begins receiving benefits immediately after retirement from employment and meets all other requirements for retiree coverage of the Employer and the Florida state retirement plan.

For the purposes of the Member definition, Actively At Work will include regularly scheduled days off, holidays, or vacation days, so long as the person is capable of Active Work on those days.

You are not a Member if you are:

1. A temporary or seasonal employee.

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

3. A leased employee.

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4. An independent contractor.

Class Definition:

Class 1: Active Members

Class 2: Retired Members

Classes for retired Members do not include a Member who is covered under Waiver Of Premium.

Eligibility Waiting Period: You are eligible on one of the following dates:

Class 1: If you are a Member on the Group Policy Effective Date, you are eligible on the first day of the calendar month coinciding with or next following 60 consecutive days as a Member.

If you become a Member after the Group Policy Effective Date, you are eligible on the first day of the calendar month coinciding with or next following 60 consecutive days as a Member.

Class 2: If you are a Member on the Group Policy Effective Date, you are eligible on that date.

If you become a Member after the Group Policy Effective Date, you are eligible on the date you become a Member.

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.

PREMIUM CONTRIBUTIONS

Life Insurance:

Plan 1:

Class 1: Noncontributory

Class 2: Contributory

Plan 2: Contributory

Dependent Life Insurance:

For Your Spouse: Contributory

For Your Child: Contributory

AD&D Insurance:

Plan 1: Noncontributory

Plan 2: Contributory

AD&D Insurance for your Dependents:

For Your Spouse: Contributory

For Your Child: Not applicable

If you are a retired Member whose Life Insurance under the Waiver Of Premium provision is scheduled to end, you may apply for Life Insurance under the Group Policy as a Retired Member within 31 days following the date your coverage under the Waiver Of Premium provision ends.

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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.

If you are an active Member and insured under Plan 1, you may also become insured under Plan 2 if you meet the requirements to become insured under Plan 2 Life Insurance under the Group Policy. Plan 2 is a Contributory plan requiring premium contributions from Members.

A Member may not be insured as both an active Member and a retired Member. Retired members are not eligible for Plan 2 Life Insurance.

Plan 1 (basic):

Class 1: $25,000

Class 2: You may elect one of the following options:

Option 1: $5,000

Option 2: $10,000

Option 3: $15,000

Option 4: $20,000

Plan 2 (additional): Active Members: You may apply for Life Insurance in multiples of $10,000, from $10,000 to $500,000.

Retired Members: None

SCHEDULE OF DEPENDENT LIFE INSURANCE

If you are an active Member and insured under Plan 1 Life Insurance, you may apply for Dependent Life Insurance for your Dependents. You may elect to insure your Spouse, your Child, or both.

For your Spouse:

Spouse Life Insurance Benefit: You may apply for Dependent Life Insurance in multiples of $5,000 from $5,000 to $100,000.

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

For your Child:

Child Life Insurance Benefit: You may elect one of the following options:

Option 1: $5,000

Option 2: $10,000

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

A Member may not be insured as both an active Member and a retired Member. Retired members are not eligible for Dependent Life Insurance.

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SCHEDULE OF AD&D INSURANCE

The amount payable for certain Losses is less than 100% of the AD&D Insurance Benefit for you or your Spouse. See AD&D Table Of Losses below. Retired Members are not eligible for AD&D Insurance.

For you:

AD&D Insurance Benefit:

Active Members: If you are insured for Plan 1 Life Insurance, the amount of your Plan 1 AD&D Insurance Benefit is equal to $15,000.

If you are insured for Plan 2 Life Insurance, the amount of your Plan 2 AD&D Insurance Benefit is equal to the amount of your Plan 2 Life Insurance Benefit.

For your Spouse:

AD&D Insurance Benefit: If you are insured for Dependent Life Insurance for your Spouse, the amount of your AD&D Insurance Benefit for your Spouse is equal to the amount of your Spouse Life Insurance Benefit.

For your Child:

AD&D Insurance Benefit: None

AD&D TABLE OF LOSSES

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 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 above 100%

e. Thumb and index finger of the same hand 25%*

f. Quadriplegia 100%

g. Triplegia 75%

h. Paraplegia 75%

i. Hemiplegia 50%

j. Uniplegia 25%

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

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

** If you lose a hand or foot and an AD&D Insurance Benefit is payable for Quadriplegia, Hemiplegia, Uniplegia, Triplegia, or Paraplegia involving that same hand or foot, we will pay the higher of the AD&D Insurance Benefits for that Loss.

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REDUCTIONS IN INSURANCE

If you reach an age shown below, the amount of insurance will be the amount determined from the Schedule Of Insurance, multiplied by the appropriate percentage below.

Plan 1 and Plan 2 Life and AD&D Insurance:

Class 1:

Age of Member Percentage as of January 1

70 or over 50%

Insurance for retired Members is not subject to reductions due to age.

Insurance for your Spouse is not subject to reductions due to age.

OTHER AD&D BENEFITS

Air Bag Benefit:

For you: The lesser of (1) $5,000; or (2) 5% of the amount of AD&D Insurance Benefit otherwise payable for Loss of that life.

For your Spouse: The lesser of (1) $5,000; or (2) 5% of the amount of AD&D Insurance Benefit otherwise payable for Loss of that life.

Career Adjustment Benefit:

For you: 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:

For you: 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.

Helmet Benefit:

For you: The lesser of (1) $5,000; or (2) 10% of the amount of AD&D Insurance Benefit otherwise payable for Loss of that life.

For your Spouse: The lesser of (1) $5,000; or (2) 10% of the amount of AD&D Insurance Benefit otherwise payable for Loss of that life.

Higher Education Benefit:

For you: 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

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$5,000 per year, or the cumulative total of $20,000 or 25% of the AD&D Insurance Benefit, whichever is less.

Seat Belt Benefit:

For you: The lesser of (1) $25,000; or (2) 10% of the amount of AD&D Insurance Benefit otherwise payable for Loss of that life.

For your Spouse: The lesser of (1) $25,000; or (2) 10% of the amount of AD&D Insurance Benefit otherwise payable for Loss of that life.

OTHER PROVISIONS

Repatriation Benefit: The lesser of (1) $5,000; or (2) 10% of the expenses incurred to transport your body to a mortuary near your primary place of residence including expenses to prepare the body for shipment.

Waiver Of Premium:

Active Members: Yes

Retired Members: No

Accelerated Death Benefit:

Active Members: Yes

Retired Members: No

Insurance Eligible For Portability:

For you:

Life Insurance: Yes

Minimum amount $10,000

Maximum amount $500,000

AD&D Insurance: Yes

Minimum amount $10,000

Maximum amount $500,000

For your Spouse:

Dependent Life Insurance: Yes

Minimum amount $5,000

Maximum amount $100,000

AD&D Insurance: Yes

Minimum amount $5,000

Maximum amount $100,000

For your Child:

Dependent Life Insurance: Yes

Minimum amount $1,000

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Maximum amount $10,000

Suicide Exclusion: Applies to AD&D Insurance.

See Accidental Death And Dismemberment Insurance for other exclusions.

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INSURING CLAUSE

If you, your Spouse or your Child die or have a loss while insured under the Group Policy, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us, subject to the Claims provision.

LI.IC.OT.1

EVIDENCE OF INSURABILITY

A. Evidence of Insurability will be required as follows:

1. If you apply for Contributory Life Insurance for yourself or Dependent Life Insurance for your Spouse more than 31 days after you become eligible.

2. For any Plan 2 Life Insurance Benefit in excess of the Guarantee Issue Amount of $300,000.

3. For any Spouse Life Insurance Benefit in excess of the Guarantee Issue Amount of $50,000.

4. For reinstatements, if required.

5. For Members or a Spouse eligible, but not insured under the Prior Plan.

6. For any increase in Plan 2 Life Insurance or Spouse Life Insurance Benefit resulting from a plan or option change you elect.

B. Evidence Of Insurability will not be required as follows:

1. Evidence Of Insurability is not required for a Child.

2. If you or your Spouse were insured under the Prior Plan for an amount in excess of the Guarantee Issue Amount on the day before the Group Policy Effective Date, the Evidence Of Insurability requirement will be waived for you for that amount on the Group Policy Effective Date.

3. One Time Open Enrollment

Your Employer will hold a One Time Open Enrollment before the Group Policy Effective Date.

During this One Time Open Enrollment, the following will not require Evidence Of Insurability as long as your total Life Insurance Benefit or your total Spouse Life Insurance Benefit after an election, does not exceed the Guarantee Issue Amount.

a. For those insured or eligible for Additional life under the Prior Plan, you may apply or increase Plan 2 Life Insurance up to $300,000.

b. For a Spouse who is insured or eligible for dependent life under the Prior Plan, you may apply or increase your Spouse Life Insurance Benefit up to $50,000.

c. For a Retired Member who is insured under the Prior Plan, you may increase your Plan 1 Life Insurance up to $20,000.

4. Annual Open Enrollment

Your Employer will offer an Annual Open Enrollment. During your Employer’s Annual Enrollment Period, Evidence Of Insurability will not be required as follows as long as your total Life Insurance Benefit or your total Spouse Life Insurance Benefit after an election, does not exceed the Guarantee Issue Amount described above.

a. For those insured or eligible for Plan 2 Life Insurance, you may apply for or increase your Plan 2 Life Insurance in one increment of $10,000.

b. For a Spouse who is insured or eligible for Dependent Life Insurance, you may apply for or increase your Spouse Life Insurance Benefit in one increment of $5,000.

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However, we will not waive the Evidence Of Insurability requirements if you previously submitted evidence of good health on or after January 1, 2025 that was not approved by us under any group life insurance policy issued by us to the Policyholder covering your employer.

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

5. Family Status Change

a. If you experience a Family Status Change, you may make the following election changes without providing Evidence Of Insurability, provided an election or increase is made within 31 days of the status change.

i. For those insured for Plan 2 Life Insurance, you may increase your Plan 2 Life Insurance in one increment of $10,000 not to exceed the Guarantee Issue Amount.

However, we will not waive the Evidence Of Insurability requirements if you or your Spouse previously submitted evidence of good health that was not approved by us under any group life insurance policy issued by us to the Policyholder covering your employer.

b. Family Status Change means any of the following events:

i. The birth of your Child or the adoption of a Child by you.

ii. Death of a Spouse or Child.

iii. Divorce or legal separation from your Spouse or your Domestic Partnership is legally dissolved.

iv. Marriage or creation of a Domestic Partnership.

v. The commencement or termination of your Spouse's employment.

vi. A change in employment from full-time to part-time by you or your Spouse.

LI.EOI.OT.1

LIFE INSURANCE

A. Amount Of Life Insurance

See Coverage Features for the Life Insurance schedule.

B. 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

Life Insurance subject to Evidence Of Insurability becomes effective on the date we approve your Evidence Of Insurability.

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 for Contributory Life Insurance and agree to pay premiums.

Contributory Life Insurance not subject to Evidence Of Insurability becomes effective on:

i. The date you become eligible if you apply on or before that date.

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ii. The date you apply if you apply within 31 days after you become eligible.

iii. The later of the date you apply or the date of the Family Status Change, if you apply within 31 days of a Family Status Change.

iv. The beginning of the next plan year following the date you apply, if you apply during the Annual Enrollment Period.

C. Changes In Life Insurance

1. Increases

You must apply in Writing 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 as follows:

i. 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.

ii. The later of a) the date of the Family Status Change, or b) the date we approve your Evidence Of Insurability, if you apply during the first 31 days after a Family Status Change.

iii. The date we approve your Evidence Of Insurability, if you apply at any other time.

b. Increases Not Subject To Evidence Of Insurability

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

i. The date of change in your classification.

ii. The date you apply for an elective increase.

iii. The later of the date you apply or the date of the Family Status Change, if you apply within 31 days of a Family Status Change.

iv. The beginning of the next plan year following the date you apply, if you apply during the Annual Enrollment Period.

v. The beginning of the next plan year following the date you apply, if you apply during the One Time Open Enrollment Period.

2. Decreases

a. A decrease in your Life Insurance because of a change in your classification becomes effective on the date of the change.

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

c. Any other decrease in your Life Insurance becomes effective on the date the Policyholder or your Employer receives your Written request for the decrease.

D. When Life Insurance Ends

Your 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, except as described in Continuation During Total Disability below.

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3. The date your Employer’s coverage under the Group Policy terminates.

4. The last day of the calendar month in which your employment terminates, except as described in Continuation During Total Disability below, unless you are covered as a retired Member.

5. The last day of the calendar month in which 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 4 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. During the first 12 months while your ability to work is limited because of Sickness, accidental Injury, or Pregnancy.

Continuation During Total Disability: If you are Totally Disabled and you are not eligible for Waiver Of Premium (see Waiver Of Premium), your Life Insurance will continue with premium payment, while you remain Totally Disabled, for a maximum of 12 months. This applies even if the Group Policy or your employment terminates. The Life Insurance Benefit payable during this continuation period will be reduced by any amount payable under a replacement group life insurance plan.

c. During the first 60 days of a temporary layoff.

d. During the first 60 days of a strike, lockout, or other general work stoppage caused by a labor dispute between your collective bargaining unit and your Employer.

e. During a leave of absence under any applicable state or federally mandated family or medical leave act or law.

f. During any other scheduled leave of absence approved by your Employer in advance and in Writing and scheduled to last 60 days or less.

E. Reinstatement Of Life Insurance

If your Life Insurance ends, you may become insured again as a new Member. However, the following 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 cease to be a Member, and you become a Member again within 90 days, your Life Insurance amounts in effect prior to your last day of Active Work will be reinstated without Evidence Of Insurability.

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

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

5. 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.

LI.LF.FL.1X

DEPENDENT LIFE INSURANCE FOR YOUR SPOUSE

A. Amount Of Insurance

See Coverage Features for the Insurance amount.

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B. Insuring Your Spouse

1. Eligibility

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

a. The date you become eligible for Life Insurance.

b. The date you first acquire a Spouse.

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

2. Effective Date

The Coverage Features states whether your Dependent Life Insurance for your Spouse is Contributory or Noncontributory. Subject to the Active Work Provisions and the Dependent Deferred Effective Date If Confined section, your Dependent Life Insurance for your Spouse becomes effective as follows:

a. Insurance Subject To Evidence Of Insurability

Insurance subject to Evidence Of Insurability becomes effective on the later of:

i. The date your Life Insurance becomes effective.

ii. The date we approve the Spouse's Evidence Of Insurability.

b. Insurance Not Subject To Evidence Of Insurability

Contributory Insurance

You must apply in Writing for Contributory Dependent Life Insurance for your Spouse and agree to pay premiums. Contributory Dependent Life Insurance for your Spouse not subject to Evidence Of Insurability becomes effective on the latest of:

* The date your Life Insurance becomes effective if you apply on or before that date.

* The date you become eligible to insure your Spouse if you apply on or before that date.

* The date you apply if you apply within 31 days after you become eligible.

* The beginning of the next plan year following the date you apply, if you apply during the Annual Enrollment Period.

c. Dependent Deferred Effective Date If Confined

Dependent Life Insurance for your Spouse and increases in Dependent Life Insurance for your Spouse will not become effective for your Spouse who is confined to a Hospital or Nursing Home on the day before the scheduled effective date of your Spouse's Insurance or the effective date of the increase in Dependent Life Insurance for your Spouse.

You may apply in Writing and agree to pay premiums for Contributory Insurance for your Spouse within 31 days of the date you are eligible to apply for Insurance for your Spouse without submitting Evidence Of Insurability. Coverage will become effective on the date the Spouse is released from a Hospital or Nursing Home. If you do not apply within this period, you must submit Evidence Of Insurability with your application.

This section will not apply to Dependent Life Insurance for your Spouse equal to the amount of dependent life insurance in effect under the Prior Plan on the date before the Group Policy Effective Date.

C. Changes In Insurance

1. Increases

You must apply in Writing for any elective increase in your Dependent Life Insurance for your Spouse.

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Subject to the Active Work Provisions and the Dependent Deferred Effective Date If Confined section, an increase in your Insurance for your Spouse becomes effective as follows:

a. Increases Subject To Evidence Of Insurability

An increase in the Spouse Life Insurance Benefit subject to Evidence Of Insurability becomes effective as follows:

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

ii. The later of a) the date of the Family Status Change, or b) the date we approve your Spouse’s Evidence Of Insurability, if you apply during the first 31 days after a Family Status Change.

iii. The date we approve your Spouse’s Evidence Of Insurability, if you apply at any other time.

b. Increases Not Subject To Evidence Of Insurability

An increase in your Dependent Life Insurance for your Spouse not subject to Evidence Of Insurability becomes effective as follows:

i. The date of the change in your classification.

ii. The date you apply for an elective increase.

iii. The later of the date you apply or the date of the Family Status Change, if you apply within 31 days of a Family Status Change.

iv. The beginning of the next plan year following the date you apply, if you apply during the Annual Enrollment Period

v. The beginning of the next plan year following the date you apply, if you apply during the One Time Open Enrollment Period.

2. Decreases

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

b. A decrease in the Spouse Life Insurance Benefit because of a change in age becomes effective on the date of the change in age.

c. A decrease in the Spouse Life Insurance Benefit because of a change in your classification becomes effective on the date of the change in your classification.

d. Any other decrease in the Spouse Life Insurance Benefit becomes effective on the date the Policyholder or Employer receives your Written request for the decrease.

D. When Insurance Ends

Insurance ends automatically on the earliest of:

1. Five months after you die. (No premium will be charged for your Dependent Life Insurance for your Spouse during this time.)

2. The date your Life Insurance ends.

3. The date Dependent Life Insurance for your Spouse terminates under the Group Policy, unless your Insurance continues under item 1 above.

4. The date the Group Policy terminates, or the date Employer’s coverage under the Group Policy for your Spouse terminates, unless Insurance continues under item 1 above.

5. The date the last period ends for which a premium was paid for your Dependent Life Insurance for your Spouse, unless it continues under item 1 above.

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6. The last day for which premium contributions have been paid following your Written request to terminate your Dependent Life Insurance for your Spouse.

7. For your Spouse, the last day of the calendar month of the date of your divorce or legal separation or termination of your Domestic Partner relationship.

LI.SP.OT.1X

DEPENDENT LIFE INSURANCE FOR YOUR CHILD

A. Amount Of Insurance

See Coverage Features for the Insurance amount.

B. Insuring Your Child

1. Eligibility

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

a. The date you become eligible for Life Insurance.

b. The date you first acquire a Child.

A Member may not be insured as both a Member and a Child. A Child may be insured by more than one Member. For purposes of insurance under the Group Policy, Child does not include a person who is a full-time member of the armed forces of any country.

2. Effective Date

The Coverage Features states whether your Dependent Life Insurance for your Child is Contributory or Noncontributory. Subject to the Active Work Provisions and the Dependent Deferred Effective Date If Confined section, your Dependent Life Insurance for your Child becomes effective as follows:

a. Insurance Not Subject To Evidence Of Insurability

Contributory Insurance

You must apply in Writing for Dependent Life Insurance for your Child and agree to pay premiums. Contributory Insurance for your Child not subject to Evidence Of Insurability becomes effective on the latest of:

* The date your Life Insurance becomes effective if you apply on or before that date.

* The date you become eligible to insure your Child if you apply on or before that date.

* The date you apply if you apply after you become eligible.

Except as provided above, your first eligible newborn Child is automatically covered for the minimum Child Life Insurance Benefit amount shown in the Coverage Features up to the date you apply, if you apply within 31 days from the Child’s live birth.

b. Dependent Deferred Effective Date If Confined

Dependent Life Insurance and increases in Dependent Life Insurance for your Child will not become effective for your Child who is confined to a Hospital or Nursing Home on the day before the scheduled effective date of your Child’s Insurance or increases to your Child’s Insurance.

You may apply in Writing and agree to pay premiums for Contributory Insurance for your Child.

Coverage will become effective on the date the Child is released from a Hospital or Nursing Home.

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This section will not apply to a newborn Child. This section will not apply to Dependent Life Insurance for your Child equal to the amount of dependent life insurance in effect under the Prior Plan on the day before the Group Policy Effective Date.

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

C. Changes In Insurance

1. Increases

You must apply in Writing for any elective increase in your insurance for your Child.

Subject to the Active Work Provisions and the Dependent Deferred Effective Date If Confined section, an increase in your Child’s Insurance becomes effective as follows:

a. Increases Not Subject To Evidence Of Insurability

An increase in your Dependent Life Insurance for your Child not subject to Evidence Of Insurability becomes effective as follows:

i. The date of the change in your classification.

ii. The date you apply for an elective increase.

2. Decreases

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

b. Any other decrease in the Child Life Insurance Benefit becomes effective on the date the Policyholder or Employer receives your Written request for the decrease.

D. When Insurance Ends

Insurance ends automatically on the earliest of:

1. Five months after you die. (No premium will be charged for your Dependent Life Insurance for your Child during this time.)

2. The date your Life Insurance ends.

3. The date Dependent Life Insurance for your Child terminates under the Group Policy, unless your Insurance continues under item 1 above.

4. The date the Group Policy terminates, or the date Employer’s coverage under the Group Policy for your Child terminates, unless Insurance continues under item 1 above.

5. The date the last period ends for which a premium was paid for your Dependent Life Insurance for your Child, unless it continues under item 1 above.

6. The last day for which premium contributions have been paid following your Written request to terminate your Dependent Life Insurance for your Child.

7. For any Child, the last day of the calendar month in which the Child ceases to be a Child.

LI.CH.OT.1X

REPATRIATION BENEFIT

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

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.

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3. Expenses are incurred to transport your body to a mortuary near your primary place of residence, including expenses to prepare the body for shipment.

LI.RB.OT.1

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

A. Insuring Clause

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

B. Becoming Insured For AD&D Insurance

1. Eligibility

a. Noncontributory AD&D Insurance

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

b. Contributory AD&D Insurance

i. You are eligible for Contributory AD&D Insurance on the date your Contributory Life Insurance is effective.

ii. AD&D Insurance For Your Spouse

To insure your Dependents for AD&D Insurance you must be insured for Life Insurance and they must be insured for Dependent Life Insurance.

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

* The date your Life Insurance is effective.

* The date your Dependent Life Insurance For Your Spouse is effective.

A Member may be insured as both a Member and a Dependent. A Child may be insured by more than one Member.

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

i. You must apply in Writing for Contributory AD&D Insurance and agree to pay premiums.

Contributory AD&D Insurance becomes effective on the later of:

* The date you become eligible if you apply on or before that date.

* The date you apply, if you apply after you become eligible.

ii. You must apply in Writing for Contributory AD&D Insurance for your Spouse and agree to pay premiums. Contributory AD&D Insurance for your Spouse becomes effective on the later of:

* The date you become eligible to insure your Spouse if you apply on or before that date.

* The date you apply, if you apply after you become eligible to insure your Spouse.

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C. Changes In AD&D Insurance

1. Increases

You must apply in Writing for any elective increase in your AD&D Insurance or AD&D Insurance for your Spouse. Subject to the Active Work Provisions:

a. An increase in AD&D Insurance because of a change in your classification becomes effective on the date of the change.

b. An elective increase in Contributory AD&D Insurance becomes effective on the date you apply for an elective increase.

c. An increase in AD&D Insurance for your Spouse because of a change in your classification becomes effective on the date of the change.

d. An elective increase in AD&D Insurance for your Spouse becomes effective on the date you apply for an elective increase.

2. Decreases

a. A decrease in AD&D Insurance because of a change in your classification becomes effective on the date of the change.

b. A decrease in AD&D Insurance because of a change in your age becomes effective on the date of the change.

c. Any other decrease in AD&D Insurance becomes effective on the date the Policyholder or your Employer receives your Written request for the decrease.

d. A decrease in AD&D Insurance for your Spouse because of a decrease in your Life Insurance becomes effective on the date your Life Insurance decreases.

e. A decrease in AD&D Insurance for your Spouse because of a change in age becomes effective on the date of the change in age.

f. A decrease in AD&D Insurance for your Spouse because of a change in your classification becomes effective on the date of the change in your classification.

g. Any other decrease in AD&D Insurance for your Spouse becomes effective on the date the Policyholder or Employer receives your Written request for the decrease.

D. 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, Quadriplegia, Hemiplegia, Uniplegia, Triplegia, and 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 Proof Of Loss satisfactory to us.

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 Dependent disappear and the disappearance meets all of the following requirements:

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

2. Occurs independently of all other causes.

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

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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, Uniplegia, Triplegia, 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. Uniplegia means the complete and irreversible paralysis of one limb. Triplegia means the complete and irreversible paralysis of three limbs.

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 intake by any means of any poison, gas, fumes, prescription drugs, non-prescription drugs or illegal drugs, unless prescribed or taken under the direction of a Physician and taken in accordance with the Physician’s instructions.

5. Alcohol – if your blood alcohol content is in excess of the legal limit for operating a motor vehicle as defined by the jurisdiction where the accident or Loss occurred. This exclusion applies regardless of whether the accident or Loss involved the operation of a motor vehicle.

6. Sickness or Pregnancy existing at the time of the accident or a heart attack or stroke.

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

F. 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.

G. Other AD&D Benefits

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 die 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 System manufacturer.

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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 Proof Of Loss satisfactory to us.

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

2. 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.

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

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

3. 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.

Helmet Benefit

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

We will pay a Helmet Benefit if you or your Spouse meet all of the following requirements:

1. An AD&D Loss of life occurs while operating or riding a motorcycle or bicycle for which an AD&D Insurance Benefit is payable.

2. Wearing a Helmet at the time of the Loss as evidenced by a police accident report, medical examiner report, or coroner’s report.

3. The operator of the motorcycle has a current and valid driver’s license at the time of the Loss.

Helmet means protective headgear that meets or exceeds the standards established by the Code of Federal Regulations (CFR) in Title 16 Part 1203, Snell Memorial Foundation Standards M-95 or M2000, the American National Standards Institute specification Z 90. 1, or the United States Department of Transportation’s Federal Motor Vehicle Safety Standard No. 218, as amended and updated.

Higher Education Benefit

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

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

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

2. 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 annually to each Child who meets the requirements of item 2 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.

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 die as a result of an Automobile accident for which an AD&D Insurance Benefit is payable for that Loss of life.

2. The deceased is wearing and properly utilizing a Seat Belt System at the time of the accident, as evidenced by Proof Of Loss satisfactory to us.

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.

H. When AD&D Insurance Ends

AD&D Insurance for you and your Spouse 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. The last day for which premium contributions have been paid following your Written request to terminate your AD&D Insurance for you or your Spouse.

6. For your Spouse, the date your Dependent Life Insurance For Your Spouse ends.

LI.AD.FL.1

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…