Atch1_DentalPlanCertificate.pdf

Certificate Number 1

YOUR BENEFIT PLAN

Consumer Financial Protection Bureau

Regular Full-Time or Part-Time Employees Temporary Employees Who Have An Appointment Greater Than One Year

Dental Insurance for You and Your Dependents

Certificate Date: July 17, 2011

1801 L St., NW Washington, DC 20036

TO OUR EMPLOYEES:

All of us appreciate the protection and security insurance provides.

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

GCERT2000

fp 1

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

CERTIFICATE OF INSURANCE

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

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

Policyholder: Consumer Financial Protection Bureau

Group Policy Number:

147398-1-G

Type of Insurance: Dental Insurance

MetLife Toll Free Number(s):

For Claim Information FOR DENTAL CLAIMS: 1-800-942-0854

THIS CERTIFICATE ONLY DESCRIBES DENTAL INSURANCE.

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

LAWS OF A STATE OTHER THAN FLORIDA.

THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED

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

REQUIRED BY MARYLAND LAW.

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

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

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

CAREFULLY.

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For Texas Residents:

IMPORTANT NOTICE

To obtain information or make a complaint:

You may call MetLife’s toll free telephone number for information or to make a complaint at

1-800-942-0854

You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at

1-800-252-3439

You may write the Texas Department of Insurance P.O. Box 149104 Austin, TX 78714-9104 Fax # (512) 475-1771 Web: http://www.tdi.state.tx.us

Email: ConsumerProtection@tdi.state.tx.us

PREMIUM OR CLAIM DISPUTES: Should You have a dispute concerning Your premium or about a claim, You should contact MetLife first. If the dispute is not resolved, You may contact the Texas Department of Insurance.

ATTACH THIS NOTICE TO YOUR CERTIFICATE:

This notice is for information only and does not become a part or condition of the attached document.

Para Residentes de Texas:

AVISO IMPORTANTE

Para obtener información o para someter una queja:

Usted puede llamar al numero de teléfono gratis de MetLife para información o para someter una queja al

1-800-942-0854

Puede comunicarse con el Departamento de Seguros de Texas para obtener información acerca de compañías, coberturas, derechos o quejas al

1-800-252-3439

Puede escribir al Departamento de Seguros de Texas P.O. Box 149104 Austin, TX 78714-9104 Fax # (512) 475-1771 Web: http://www.tdi.state.tx.us

Email: ConsumerProtection@tdi.state.tx.us

DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con MetLife primero. Si no se resuelve la disputa, puede entonces comunicarse con el departamento (TDI).

UNA ESTE AVISO A SU CERTIFICADO:

Este aviso es solo para propósito de información y no se convierte en parte o condición del documento adjunto.

DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS

notice/denc/tx

NOTICE FOR RESIDENTS OF TEXAS

If You reside in Texas, note the following Procedures for Dental Claims will be followed:

Procedures for Presenting Claims for Dental Insurance Benefits

All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained from the Employer who can also answer questions about the insurance benefits and to assist You or, if applicable, Your beneficiary in filing claims. Dental claim forms can also be downloaded from www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are answered fully.

Routine Questions on Dental Insurance Claims

If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1-800- 942-0854.

Claim Submission

For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit the required proof as described in the FILING A CLAIM section of the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

Initial Determination

After You submit a claim for Dental Insurance benefits to MetLife, MetLife will notify You acknowledging receipt of Your claim, commence with any investigation, and request any additional information within 15 days of receipt of Your claim.

MetLife will notify You in writing of the acceptance or rejection of Your claim within 15 business days of receipt of all information needed to process Your claim.

If MetLife cannot accept or reject Your claim within 15 business days after receipt of all information, MetLife will notify You within 15 business days stating the reason why we require an extension. If an extension is requested, We will notify You of our decision to approve or deny Your claim within 45 days. Upon notification of approval, Your claim will be paid within 5 business days.

If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why Your claim was denied and reference the specific Plan provision(s) on which the denial is based. If the claim is denied because MetLife did not receive sufficient information, the claims decision will describe the additional information needed and explain why such information is needed. Further, if an internal rule, protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Appealing the Initial Determination

If MetLife denies Your claim, You may take two appeals of the initial determination. Upon Your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife’s decision. Appeals must be in writing and must include at least the following information:

• Name of Employee

• Name of the Plan

• Reference to the initial decision

• Whether the appeal is the first or second appeal of the initial determination

• An explanation why You are appealing the initial determination.

DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS (continued) notice/denc/tx

As part of each appeal, You may submit any written comments, documents, records, or other information relating to Your claim.

After MetLife receives Your written request appealing the initial determination or determination on the first appeal, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials, and MetLife’s review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of dentistry involved in the judgment. This health care professional will not have consulted on the initial determination, and will not be a subordinate of any person who was consulted on the initial determination.

MetLife will notify You in writing of its final decision within 30 days after MetLife’s receipt of Your written request for review, except that under special circumstances MetLife may have up to an additional 30 days to provide written notification of the final decision. If such an extension is required, MetLife will notify You prior to the expiration of the initial 30 day period, state the reason(s) why such an extension is needed, and state when it will make its determination.

If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s) why the claim You appealed is being denied and references any specific Plan provision(s) on which the denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Upon written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim.

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NOTICE FOR RESIDENTS OF LOUISIANA, MINNESOTA, MONTANA, NEW MEXICO,

TEXAS, AND UTAH

Definition of Child

For Louisiana Residents (Dental Insurance):

The term also includes Your grandchildren residing with You. The limiting age for children and grandchildren will not be less than 26 regardless of marital status, student status or full-time employment status. Marital status will not prevent or cease the continuation of insurance for a mentally or physically handicapped child or grandchild past the limiting age.

For Minnesota Residents (Dental Insurance):

The term also includes Your grandchildren who are financially dependent upon You and reside with You continuously from birth. The limiting age for children and grandchildren will not be less than 25 regardless of student status or full-time employment status.

For Montana Residents (Dental Insurance):

The term also includes newborn infants of any person insured under this certificate. The limiting age for children will not be less than 25 regardless of student status or full-time employment status.

For New Mexico Residents (Dental Insurance):

The limiting age for children will not be less than 25 regardless of student status or full-time employment status.

Your natural child, adopted child and step-child will not be denied dental insurance coverage under this certificate because:

1. that child was born out of wedlock;

2. that child is not claimed as Your dependent on Your federal income tax return; or

3. that child does not reside with You.

For Texas Residents (Dental Insurance):

The term also includes Your grandchildren. The limiting age for children and grandchildren will not be less than 25 regardless of student status or military service status. Grandchildren must be able to be claimed by You as a dependent for Federal Income Tax purposes at the time You applied for Insurance.

For Utah Residents (Dental Insurance):

The limiting age for children will not be less than 26 regardless of student status or full-time employment status.

Your natural child, adopted child and step-child will not be denied dental insurance coverage solely because that child does not reside with You or solely because that child is solely dependent on Your former spouse rather than on You.

NOTICE FOR RESIDENTS OF ALL STATES WHO ARE INSURED FOR DENTAL

INSURANCE

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Notice Regarding Your Rights and Responsibilities

Rights:

• We will treat communications, financial records and records pertaining to Your care in accordance with all applicable laws relating to privacy.

• Decisions with respect to dental treatment are the responsibility of You and the dentist. We neither require nor prohibit any specified treatment. However, only certain specified services are covered for benefits. Please see the Dental Insurance sections of this certificate for more details.

• You may request a pre-treatment estimate of benefits for the dental services to be provided. However, actual benefits will be determined after treatment has been performed.

• You may request a written response from MetLife to any written concern or complaint.

• You have the right to receive an explanation of benefits which describes the benefit determinations for Your dental insurance.

Responsibilities:

• You are responsible for the prompt payment of any charges for services performed by the dentist. If the dentist agrees to accept part of the payment directly from MetLife, You are responsible for prompt payment of the remaining part of the dentist’s charge.

• You should consult with the dentist about treatment options, proposed and potential procedures, anticipated outcomes, potential risks, anticipated benefits and alternatives. You should share with the dentist the most current, complete and accurate information about Your medical and dental history and current conditions and medications.

• You should follow the treatment plans and health care recommendations agreed upon by You and the dentist.

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NOTICE FOR RESIDENTS OF ARKANSAS

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

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

Arkansas Insurance Department Consumer Services Division

1200 West Third Street Little Rock, Arkansas 72201

(501) 371-2640 or (800) 852-5494

GCERT2000 8

notice/ca

NOTICE FOR RESIDENTS OF CALIFORNIA

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

POLICYHOLDER OR THE METLIFE CLAIM OFFICE SHOWN ON THE EXPLANATION OF BENEFITS

YOU RECEIVE AFTER FILING A CLAIM.

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

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

INSURANCE DEPARTMENT AT:

DEPARTMENT OF INSURANCE

300 SOUTH SPRING STREET

LOS ANGELES, CA 90013

1 (800) 927-4357 notice/ga 9

NOTICE FOR RESIDENTS OF GEORGIA

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

notice/id 10

NOTICE FOR RESIDENTS OF IDAHO

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

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

Idaho Department of Insurance Consumer Affairs

700 West State Street, 3rd Floor PO Box 83720

Boise, Idaho 83720-0043 1-800-721-3272 or www.DOI.Idaho.gov notice/il 11

NOTICE FOR RESIDENTS OF ILLINOIS

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

MetLife

200 Park Avenue New York, New York 10166

The address of the Illinois Department of Insurance is:

Illinois Department of Insurance

Public Services Division Springfield, Illinois 62767 notice/coi/nh 12

NOTICE FOR NEW HAMPSHIRE RESIDENTS

CONTINUATION OF YOUR DENTAL INSURANCE

If You are a resident of New Hampshire, Your Dental Insurance may be continued if it ends because Your employment ends unless:

• Your employment ends due to Your gross misconduct;

• this Dental Insurance ends for all employees;

• this Dental Insurance is changed to end Dental Insurance for the class of employees to which You belong;

• You are entitled to enroll in Medicare; or

• Your Dental Insurance ends because You failed to pay the required premium.

The Employer must give You written notice of:

• Your right to continue Your Dental Insurance;

• the amount of premium payment that is required to continue Your Dental Insurance;

• the manner in which You must request to continue Your Dental Insurance and pay premiums; and

• the date by which premium payments will be due.

The premium that You must pay for Your continued Dental Insurance may include:

• any amount that You contributed for Your Dental Insurance before it ended;

• any amount the Employer paid; and

• an administrative charge which will not to exceed two percent of the rest of the premium.

To continue Your Dental Insurance, You must:

• send a written request to continue Your Dental Insurance; and

• pay the first premium within 30 days after the date Your employment ends.

The maximum continuation period will be the longest of:

• 36 months if Your employment ends because You retire, and within 12 months of retirement You have a substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the United States Code;

• 29 months if You become entitled to disability benefits under Social Security within 60 days of the date Your Employment ends; or

• 18 months.

Your continued Dental Insurance will end on the earliest of the following to occur:

• the end of the maximum continuation period;

• the date this Dental Insurance ends;

• the date this Dental Insurance is changed to end Dental Insurance for the class of employees to which You belong;

• the date You are entitled to enroll for Medicare;

• if You do not pay the required premium to continue Your Dental Insurance; or

• the date You become eligible for coverage under any other group dental coverage.

notice/coi/nh 13

NOTICE FOR NEW HAMPSHIRE RESIDENTS (Continued)

CONTINUATION OF YOUR DEPENDENT’S DENTAL INSURANCE

If You are a resident of New Hampshire, Your Dental Insurance for Your Dependents may be continued if it ends because Your employment ends, Your marriage ends in divorce or separation, or You die, unless:

• Your employment ends due to Your gross misconduct;

• this Dental Insurance ends for all Dependents;

• this Dental Insurance is changed, for the class of employees to which You belong, to end Dental Insurance for Dependents;

• the Dependent is entitled to enroll in Medicare; or

• Your Dental Insurance for Your Dependents ends because You fail to pay a required premium.

If Dental Insurance for Your Dependents ends because Your marriage ends in divorce or separation, the party responsible under the divorce decree or separation agreement for payment of premium for continued Dental Insurance must notify the employer, in writing, within 30 days of the date of the divorce decree or separation agreement that the divorce or separation has occurred. If You and Your divorced or separated Spouse share responsibility for payment of the premium for continued Dental Insurance, both You and Your divorced or separated Spouse must provide the notification.

The Employer must give You, or Your former Spouse if You have died or Your marriage has ended, written notice of:

• Your right to continue Your Dental Insurance for Your Dependents;

• the amount of premium payment that is required to continue Your Dental Insurance for Your Dependents;

• the manner in which You or Your former Spouse must request to continue Your Dental Insurance for Your Dependents and pay premiums; and

• the date by which premium payments will be due.

The premium that You or Your former Spouse must pay for continued Dental Insurance for Your Dependents may include:

• any amount that You contributed for Your Dental Insurance before it ended; and

• any amount the Employer paid.

To continue Dental Insurance for Your Dependents, You or Your former Spouse must:

• send a written request to continue Dental Insurance for Your Dependents; and

• must pay the first premium within 30 days of the date Dental Insurance for Your Dependents ends.

If You, and Your former Spouse, if applicable, fail to provide any required notification, or fail to request to continue Dental Insurance for Your Dependents and pay the first premium within the time limits stated in this section, Your right to continue Dental Insurance for Your Dependents will end.

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NOTICE FOR NEW HAMPSHIRE RESIDENTS (Continued)

CONTINUATION OF YOUR DEPENDENT’S DENTAL INSURANCE (Continued)

The maximum continuation period will be the longest of the following that applies:

• 36 months if Dental Insurance for Your Dependents ends because Your marriage ends in divorce or separation, except that with respect to a Spouse who is age 55 or older when your marriage ends in divorce or separation the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group plan;

• 36 months if Dental Insurance for Your Dependents ends because You die, except that with respect to a Spouse who is age 55 or older when You die, the maximum continuation period will end when Your surviving Spouse becomes eligible for Medicare or eligible for participation in another employer’s group dental coverage;

• 36 months if Dental Insurance for Your Dependents ends because You become entitled to benefits under Title XVIII of Social Security, except that with respect to a Spouse who is age 55 or older when You become entitled to benefits under Title XVIII of Social Security, the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group dental coverage;

• 36 months if You become entitled to benefits under Title XVIII of Social Security while You are already receiving continued benefits under this section, except that with respect to a Spouse who is age 55 or older when You first become entitled to continue Your Dental Insurance the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group dental coverage;

• 36 months with respect to a Dependent Child if Dental Insurance ends because the Child ceases to be a Dependent Child;

• 36 months if Your employment ends because You retire, and within 12 months of retirement You have a substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the United States Code;

• 29 months if Dental Insurance for Your Dependents ends because Your employment ends, and within 60 days of the date Your employment ends you become entitled to disability benefits under Social Security;

or

• 18 months if Dental Insurance for Your Dependents ends because Your employment ends.

A Dependent's continued Dental Insurance will end on the earliest of the following to occur:

• the end of the maximum continuation period;

• the date this Dental Insurance ends;

• the date this Dental Insurance is changed to end Dental Insurance for Dependents for the class of employees to which You belong;

• the date the Dependent becomes entitled to enroll for Medicare;

• if You do not pay a required premium to continue Dental Insurance for Your Dependents; or

• the date the Dependent becomes eligible for coverage under any other group dental coverage.

notice/nc 15

NOTICE FOR RESIDENTS OF NORTH CAROLINA

UNDER NORTH CAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON, EMPLOYER,

PRINCIPAL, AGENT, TRUSTEE, OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE FOR THE

PAYMENT OF GROUP HEALTH OR LIFE INSURANCE OR GROUP HEALTH PLAN PREMIUMS, SHALL:

(1) CAUSE THE CANCELLATION OR NONRENEWAL OF GROUP HEALTH OR LIFE INSURANCE,

HOSPITAL, MEDICAL, OR DENTAL SERVICE CORPORATION PLAN, MULTIPLE EMPLOYER

WELFARE ARRANGEMENT, OR GROUP HEALTH PLAN COVERAGES AND THE CONSEQUENTIAL

LOSS OF THE COVERAGES OF THE PERSONS INSURED, BY WILLFULLY FAILING TO PAY THOSE

PREMIUMS IN ACCORDANCE WITH THE TERMS OF THE INSURANCE OR PLAN CONTRACT, AND

(2) WILLFULLY FAIL TO DELIVER, AT LEAST 45 DAYS BEFORE THE TERMINATION OF THOSE

COVERAGES, TO ALL PERSONS COVERED BY THE GROUP POLICY A WRITTEN NOTICE OF THE

PERSON’S INTENTION TO STOP PAYMENT OF PREMIUMS. THIS WRITTEN NOTICE MUST ALSO

CONTAIN A NOTICE TO ALL PERSONS COVERED BY THE GROUP POLICY OF THEIR RIGHTS TO

HEALTH INSURANCE CONVERSION POLICIES UNDER ARTICLE 53 OF CHAPTER 58 OF THE

GENERAL STATUTES AND THEIR RIGHTS TO PURCHASE INDIVIDUAL POLICIES UNDER THE

FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT AND UNDER ARTICLE

68 OF CHAPTER 58 OF THE GENERAL STATUTES.

VIOLATION OF THIS LAW IS A FELONY. ANY PERSON VIOLATING THIS LAW IS ALSO SUBJECT TO A

COURT ORDER REQUIRING THE PERSON TO COMPENSATE PERSONS INSURED FOR EXPENSES

OR LOSSES INCURRED AS A RESULT OF THE TERMINATION OF THE INSURANCE.

GCERT2000 16

notice/pa

NOTICE FOR RESIDENTS OF PENNSYLVANIA

Dental Insurance for a Dependent Child may be continued past the age limit if that Child is a full-time student and insurance ends due to the Child being ordered to active duty (other than active duty for training) for 30 or more consecutive days as a member of the Pennsylvania National Guard or a Reserve Component of the Armed Forces of the United States.

Insurance will continue if such Child:

• re-enrolls as a full-time student at an accredited school, college or university that is licensed in the jurisdiction where it is located;

• re-enrolls for the first term or semester, beginning 60 or more days from the child’s release from active duty;

• continues to qualify as a Child, except for the age limit; and

• submits the required Proof of the child’s active duty in the National Guard or a Reserve Component of the

United States Armed Forces.

Subject to the Date Insurance For Your Dependents Ends subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, this continuation will continue until the earliest of the date:

• the insurance has been continued for a period of time equal to the duration of the child’s service on active duty; or

• the child is no longer a full-time student.

NOTICE FOR RESIDENTS OF TEXAS

notice/cong/tx 17

The exclusion of services which are primarily cosmetic will not apply to the treatment or correction of a congenital defect of a newborn child.

NOTICE FOR RESIDENTS OF UTAH

GTY-NOTICE-UT-0710

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

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

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

The basic protections provided by the Association are:

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

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

• Annuities o $250,000 in withdrawal and cash values

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

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

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

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

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

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

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

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

notice/va 19

NOTICE FOR RESIDENTS OF VIRGINIA

IMPORTANT INFORMATION REGARDING YOUR INSURANCE

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

200 Park Avenue

New York, New York 10166 Attn: Corporate Consumer Relations Department

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

1-800-275-4638

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

The Office of the Managed Care Ombudsman Bureau of Insurance

P.O. Box 1157 Richmond, VA 23218

1-877-310-6560 - toll-free 1-804-371-9691 - locally www.scc.virginia.gov - web address ombudsman@scc.virginia.gov - email

Or:

The Virginia Department of Health (The Center for Quality Health Care Services and Consumer Protection)

3600 West Broad St Suite 216

Richmond, VA 23230 1-800-955-1819

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

notice/va1 20

NOTICE TO RESIDENTS OF VIRGINIA

IMPORTANT INFORMATION REGARDING YOUR INSURANCE

If You have any questions regarding an appeal or grievance concerning the dental services that You have been provided that have not been satisfactorily addressed by this Dental Insurance, You may contact the Virginia Office of the Managed Care Ombudsman for assistance.

You may contact the Virginia Office of the Managed Care Ombudsman either by dialing toll free at (877) 310- 6560, or locally at (804) 371-9691, via the internet at Web address www.scc.virginia.gov, email at ombudsman@scc.virginia.gov, or mail to:

The Office of the Managed Care Ombudsman Bureau of Insurance, P.O. Box 1157

Richmond, VA 23218

DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS

Claim Submission

For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit the required proof as described in the FILING A CLAIM section of the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

Appealing the Initial Determination

If MetLife denies Your claim, You may take two appeals of the initial determination. Upon your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to your claim. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife’s decision. Appeals must be in writing and must include at least the following information:

• Name of Employee

• Name of the Plan

• Reference to the initial decision

• Whether the appeal is the first or second appeal of the initial determination

• An explanation why You are appealing the initial determination.

As part of each appeal You may submit any written comments, documents, records or other information relating to Your claim.

After MetLife receives Your written request appealing the initial determination or determination on the first appeal, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials, and MetLife’s review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of dentistry involved in the judgment. This health care professional will not have consulted on the initial determination, and will not be a subordinate of any person who was consulted on the initial determination.

MetLife will notify You in writing of its final determination within 30 days after MetLife’s receipt of Your written request for review, except that under special circumstances MetLife may have up to an additional 30 days to provide written notification of the final decision. If such an extension is required, MetLife will notify notice/va1 21

NOTICE TO RESIDENTS OF VIRGINIA (continued)

You prior to the expiration of the 30 day period, state the reason(s) why an extension is needed, and state when it will make its determination.

If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s) why the claim You appealed is being denied and references any specific Plan provision(s) on which the denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge. Upon written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim.

Policies and Procedures for Emergency and Urgent Care Urgent care and Emergency services: All member dentists of the MetLife Preferred Dentist Program (PDP) are required to have 24-hour emergency coverage or have alternate arrangements for emergency care for their patients. Since the MetLife PDP is a freedom-of-choice PPO program, there is no primary care physician. No authorization of a service is necessary by a Primary Care Physician, nor is it necessary to obtain a pre-authorization of services. The patient is free to use the dentist of their choice.

An important distinction to be made for this section is the difference between Urgent Care in a dental situation versus that found in medical. Urgent care is defined more narrowly in dental to mean the alleviation of severe pain (as there are no life-threatening situations in dental). Additionally, the alleviation of pain in dental is a simple palliative treatment, which is not subject to claim review.

The benefit amount will be consistent with the terms contained in the insured’s contract.

Urgent Care Submission:

A small number of claims for dental expense benefits may be urgent care claims. Urgent care claims for dental expense benefits are claims for reimbursement of dental expenses for services which a dentist familiar with the dental condition determines would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Of course any such claim may always be submitted in accordance with the normal claim procedures. However your dentist may also submit such a claim to MetLife by telephoning MetLife and informing MetLife that the claim is an Urgent Care Claim. Urgent Care Claims are processed according to the procedures set out above, however once a claim for urgent care is submitted MetLife will notify you of the determination on the claim as soon as possible, but no later than 72 hours after the claim is filed. If you or your covered dependent does not provide the claims administrator with enough information to decide the claim, MetLife will notify you within 24 hours after it receives the claim of the further information that is needed. You will have 48 hours to provide the information. If the needed information is provided, MetLife will then notify you of the claim decision within 48 hours after MetLife received the information. If the needed information is not provided, MetLife will notify you or your covered dependent of its decision within 120 hours after the claim was received.

If your urgent care claim is denied but you receive the care, you may appeal the denial using the normal claim procedures. If your urgent care claim is denied and you do not receive the care, you can request an expedited appeal of your claim denial by phone or in writing. MetLife will provide you any necessary information to assist you in your appeal. MetLife will then notify you of its decision within 72 hours of your request in writing.

However, MetLife may notify you by phone within the same time frames above and then mail you a written notice.

GCERT2000 22

notice/wa

NOTICE FOR RESIDENTS OF THE STATE OF WASHINGTON

Washington law provides that the following apply to Your certificate:

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

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

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

notice/wi 23

NOTICE FOR RESIDENTS OF WISCONSIN

KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS

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

Attn: Corporate Consumer Relations Department

200 Park Avenue New York, NY 10166-0188

1-800-638-5433

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

Office of the Commissioner of Insurance Complaints Department

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

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

TABLE OF CONTENTS

Section Page toc 24

CERTIFICATE FACE PAGE

NOTICES

SCHEDULE OF BENEFITS

DEFINITIONS

ELIGIBILITY PROVISIONS: INSURANCE FOR YOU

Eligible Classes

Date You Are Eligible for Insurance

Enrollment Process For Dental Insurance

Date Your Insurance Takes Effect

Date Your Insurance Ends

ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS

Eligible Classes For Dependent Insurance

Date You Are Eligible For Dependent Insurance

Enrollment Process For Dependent Dental Insurance

Date Dental Insurance Takes Effect For Your Dependents

Date Your Insurance For Your Dependents Ends

CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT

For Mentally or Physically Handicapped Children

For Family And Medical Leave

At The Policyholder's Option

DENTAL INSURANCE

DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES

Type A Covered Services

Type B Covered Services

Type C Covered Services

Orthodontic Covered Services

DENTAL INSURANCE: EXCLUSIONS

TABLE OF CONTENTS (continued)

Section Page toc 25

DENTAL INSURANCE: COORDINATION OF BENEFITS

FILING A CLAIM

DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS

GENERAL PROVISIONS

Assignment

Dental Insurance: Who We Will Pay

Entire Contract

Incontestability: Statements Made by You

Conformity with Law

Overpayments

SCHEDULE OF BENEFITS

sch

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

• for which You and Your Dependents become and remain eligible;

• which You elect, if subject to election; and

• which are in effect.

BENEFIT BENEFIT AMOUNT AND HIGHLIGHTS

Dental Insurance For You and Your Dependents

Covered Percentage for:

In-Network based on the

Out-of-Network based on the

Maximum Allowed Charge Reasonable and Customary Charge

Type B Services 80%

80%

Type C Services

60% 60%

Orthodontic Covered Services

60%

60%

Deductibles for:

Yearly Individual Deductible

$50 for the following Covered Services Combined: Type B; Type C

$50 for the following Covered

Yearly Family Deductible $150 for the following Covered

$150 for the following Covered

Maximum Benefit:

Yearly Individual Maximum Benefit Amount

$2,500 for the following Covered Services: Type A; Type B; Type C

$2,500 for the following Covered Services: Type A; Type B; Type C

Lifetime Individual Maximum Benefit Amount for Orthodontic Covered Services

$1,500

$1,500

Type A Services

100%

100%

DEFINITIONS

def as amended by GCR09-07 dp 27

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

Actively at Work or Active Work means that You are performing all of the usual and customary duties of Your job on a Full-Time or Part-Time basis. This must be done at:

• the Policyholder’s place of business;

• an alternate place approved by the Policyholder; or

• a place to which the Policyholder’s business requires You to travel.

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

Cast Restoration means an inlay, onlay, or crown.

Child means the following (See Notice for Louisiana, Minnesota, Montana, New Mexico, Texas, and Utah Residents):

Your natural or adopted child; Your stepchild (including the child of a Domestic Partner) who resides with You;

or a child who resides with and is fully supported by You; and who, in each case, is:

• under age 22; or

• between ages 22 and 25; and

• a full-time student at an accredited school, college or university that is licensed in the jurisdiction where it is located;

• supported by You; and

• not employed on a full-time basis.

The definition of Child includes:

• newborns; and

• the Employee’s grandchild, niece or nephew if such:

• Child is under Your Primary Care;

• Child is under 22; and

• Child's legal guardian is not covered by an accident or sickness policy.

If You provide Us notice, a Child also includes a child for whom You must provide Dental Insurance due to a Qualified Medical Child Support Order as defined in the United States Employee Retirement Income Security Act of 1974 as amended.

The term does not include any person who:

• is on active duty in the military of any country or international authority; however, active duty for this purpose does not include weekend or summer training for the reserve forces of the United States, including the National Guard; or

• is insured under the Group Policy as an employee.

Covered Percentage means:

• for a Covered Service performed by an In-Network Dentist, the percentage of the Maximum Allowed

Charge that We will pay for such services after any required Deductible is satisfied; and

• for a Covered Service performed by an Out-of-Network Dentist, the percentage of the Reasonable and Customary Charge that We will pay for such services after any required Deductible is satisfied.

DEFINITIONS (continued) def as amended by GCR09-07 dp 28

Covered Service means a dental service used to treat Your or Your Dependent's dental condition which is:

• prescribed or performed by a Dentist while such person is insured for Dental Insurance;

• Dentally Necessary to treat the condition; and

• described in the SCHEDULE OF BENEFITS or DENTAL INSURANCE sections of this certificate.

Deductible means the amount You or Your Dependents must pay before We will pay for Covered Services.

Dental Hygienist means a person trained to:

• remove calcareous deposits and stains from the surfaces of teeth; and

• provide information on the prevention of oral disease.

Dentally Necessary means that a dental service or treatment is performed in accordance with generally accepted dental standards as determined by Us and is:

• necessary to treat decay, disease or injury of the teeth; or

• essential for the care of the teeth and supporting tissues of the teeth.

Dentist means:

• a person licensed to practice dentistry in the jurisdiction where such services are performed; or

• any other person whose services, according to applicable law, must be treated as Dentist’s services for purposes of the Group Policy. Each such person must be licensed in the jurisdiction where the services are performed and must act within the scope of that license. The person must also be certified and/or registered if required by such jurisdiction.

For purposes of Dental Insurance, the term will include a Physician who performs a Covered Service.

Dentures means fixed partial dentures (bridgework), removable partial dentures and removable full dentures.

Dependent(s) means Your Spouse and/or Child.

Domestic Partner means each of two people, one of whom is an Employee of the Policyholder, who:

• have registered as each other’s domestic partner, civil union partner or reciprocal beneficiary with a government agency where such registration is available; or

• are of the same or opposite sex and have a mutually dependent relationship so that each has an insurable interest in the life of the other. Each person must be:

1. 18 years of age or older;

2. unmarried;

3. the sole domestic partner of the other person and have been so for the immediately preceding 6 months;

4. sharing a primary residence with the other person and have been so sharing for the immediately preceding 6 months; and

5. not related to the other in a manner that would bar their marriage in the jurisdiction in which they reside.

A Domestic Partner declaration attesting to the existence of an insurable interest in one another’s lives must be completed and Signed by the Employee.

Full-Time means Active Work on the Policyholder's regular work schedule for the eligible class of employees to which You belong. The work schedule must be at least 60 hours on a bi-weekly basis.

In-Network Dentist means a Dentist who participates in the Preferred Dentist Program and has a contractual agreement with Us to accept the Maximum Allowed Charge as payment in full for a dental service.

def as amended by GCR09-07 dp 29

Maximum Allowed Charge means the lesser of:

• the amount charged by the Dentist; or

• the maximum amount which the In-Network Dentist has agreed with Us to accept as payment in full for the dental service.

Out-of-Network Dentist means a Dentist who does not participate in the Preferred Dentist Program.

Part-Time means Active Work on the Policyholder's regular work schedule for the eligible class of employees to which You belong. The work schedule must be at least 60 hours on a bi-weekly basis.

Physician means:

• a person licensed to practice medicine in the jurisdiction where such services are performed; or

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

Primary Care means that You provide food, clothing, and shelter, on a regular basis and continuous basis, for a grandchild, niece or nephew during the time that the District of Columbia public schools are in regular session and such Child is under age 22.

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

• the nature and extent of the loss or condition;

• Our obligation to pay the claim; and

• the claimant’s right to receive payment.

Proof must be provided at the claimant's expense.

Reasonable and Customary Charge is the lowest of:

• the Dentist’s actual charge for the services or supplies (or, if the provider of the service or supplies is not a Dentist, such other provider’s actual charge for the services or supplies) (the 'Actual Charge'); or

• the usual charge by the Dentist or other provider of the services or supplies for the same or similar services or supplies (the 'Usual Charge'); or

• the usual charge of other Dentists or other providers in the same geographic area equal to the 90th percentile of charges as determined by MetLife based on charge information for the same or…