ESBD_379720_1729031266148_Attachment E - UHC Plan Documents.pdf

GROUP BASIC LIFE

ACCIDENTAL DEATH AND DISMEMBERMENT

CERTIFICATE OF COVERAGE

FOR

TRAVIS COUNTY HEALTHCARE DISTRICT

POLICY NUMBER: 305532

EFFECTIVE DATE: March 1, 2018

TX–UHIC/2008

Full Time Employees (3-18)

UHCLD-CERT-2/2008-TX

UnitedHealthcare Insurance Company

185 Asylum Street, Hartford, Connecticut

(Home Office)

Policyholder: Travis County Healthcare District

Effective Date: March 1, 2018

Policy Number: 305532

Beneficiary: As on file with the Administrator

We, UnitedHealthcare Insurance Company, issue this Certificate to the Covered Person as evidence of insurance under the Policy We issued to the Policyholder shown above. This Certificate describes the benefits and other important provisions of the Policy. Please read it carefully.

The Policy may be amended, changed, cancelled or discontinued without the consent of the Covered Person or the Covered Person’s beneficiary.

The benefits described in this Certificate insure the Covered Person. This Certificate becomes effective at 12:01 A.M. Eastern Standard time on the Effective Date shown above.

Read the Group Certificate Carefully

This is a legal contract between the Policyholder and Us. If the Policyholder has any questions or problems with the Policy, We will be ready to help the Policyholder. The Policyholder may call upon his agent or Our Home Office for assistance at any time.

If the Policyholder or the Covered Person have questions, need information about their insurance, or need assistance in resolving complaints, call 1-866-615-8727.

It is signed at the Home Office of UnitedHealthcare Insurance Company as of the Effective Date shown above.

Secretary President

Group Term Life, Accidental Death and Dismemberment Insurance Policy Non-Participating

Administrative Office:

9900 Bren Road East Minnetonka, MN 55343

Death benefits will be reduced if an acceleration-of-life insurance benefit is paid.

DISCLOSURE: Receipt of Acceleration Death Benefits may affect You, Your spouse or Your family’s eligibility for public assistance programs such as medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), supplementary social security income (SSI), and drug assistance programs. You are advised to consult with a qualified tax advisor and with social service agencies concerning how receipt of such payment will affect You, Your spouse and Your family’s eligibility for public assistance.

DISCLOSURE: The Accelerated Death Benefits offered under this Policy may or may not qualify for favorable tax treatment under the Internal Revenue Code of 1986. Whether such benefits qualify depends on factors such as Your life expectancy at the time benefits are accelerated or whether you use the benefits to pay necessary long-term care expense, such as nursing home care. If the Accelerated Death Benefits qualify for favorable tax treatment, the benefits will be excludable from Your income and to subject to federal taxation. Tax laws relating to Accelerated Death Benefits are complex. You are advised to consult with a qualified tax advisor about circumstances under which You could receive Accelerated Death Benefits excludable from income under federal law.

ACN-TX-MP (8/95)

IMPORTANT NOTICE

To obtain information or make a complaint:

You may call UnitedHealthcare Insurance Company’s toll-free telephone number for information or to make a complaint at

1-866-615-8727

You may also write to UnitedHealthcare Insurance Company at:

UnitedHealthcare Insurance Company Administrative Offices 9900 Bren Road East Minnetonka, MN 55343

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

800-252-3439

You may write the Texas Department of Insurance at:

P.O. Box 149104 Austin, TX 78714-9104

FAX #(512) 490-1007

Web: http://www.tdi.texas.gov E-Mail: ConsumerProtection@tdi.texas.gov

PREMIUM OR CLAIM DISPUTES:

Should you have a dispute concerning your premium or about a claim you should contact the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance.

ATTACH THIS NOTICE TO YOUR POLICY:

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

Form No. AA-2068 (Rev. 6/15)

AVISO IMPORTANTE

Para obtener información o para presentar una queja:

Usted puede llamar al número de teléfono gratuito de UnitedHealthcare Insurance Company's para obtener información o para presentar una queja al:

1-866-615-8727

Usted también puede escribir a UnitedHealthcare Insurance Company:

UnitedHealthcare Insurance Company Administrative Offices 9900 Bren Road East Minnetonka, MN 55343

Usted puede comunicarse con el Departamento de Seguros de Texas para obtener información sobre compañías, coberturas, derechos, o quejas al:

1-800-252-3439

Usted puede escribir al Departamento de Seguros de Texas a:

P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 490-1007 Sitio web: http://www.tdi.texas.gov E-mail: ConsumerProtection@tdi.texas.gov

DISPUTAS POR PRIMAS DE SEGUROS O

RECLAMACIONES:

Si tiene una disputa relacionada con su prima de seguro o con una reclamación, usted debe comunicarse con (el agente) (la compañía) (el agente o la compañía) primero. Si la disputa no es resuelta, usted puede comunicarse con el Departamento de Seguros de Texas.

ADJUNTE ESTE AVISO A SU PÓLIZA: Este aviso es solamente para propósitos informativos y no se convierte en parte o en condición del documento adjunto.

TABLE OF CONTENTS

TOC-UHC

Schedule of Benefits

General Definitions

Certificate General Provisions

Covered Person Eligibility, Effective Date and Termination Provisions

Life Insurance Benefit for Covered Person

Waiver of Premium – Total Disability For Covered Person

Accelerated Death Benefit for Covered Person

Accidental Death and Dismemberment Benefit for Covered Person

Child Care Expense Benefit under the Accidental Death and Dismemberment Benefit

Spouse Training Benefit under the Accidental Death and Dismemberment Benefit

Repatriation Benefit for Covered Persons under the Accidental Death and Dismemberment Benefit

Education Benefit for Covered Person under the Accidental Death and Dismemberment Benefit

Common Carrier Hazard Benefit for Covered Persons under the Accidental Death and Dismemberment Benefit

Felonious Assault Benefit For Covered Persons Under the Accidental Death and Dismemberment Benefit

SCHEDULE OF BENEFITS

SCH-UHC-TX

Class of Employees This schedule covers the following class(es) of Employees of companies and affiliates controlled by the Policyholder:

All active full-time Employees residing in the United States, excluding temporary and seasonal employees

Description of Class:

Employees are considered full-time if they customarily work: 30 hours per week

Employee Waiting Period:

An Employee is eligible for insurance on the later of the following dates:

1. The Group Policy’s Effective Date, March 1, 2018.

2. The first day of the month following the date the Employee begins continuous employment with the Policyholder.

Cost of Insurance: The Covered Person is not required to contribute to the cost of his Basic Life and Accidental Death and Dismemberment insurance.

Covered Person Insurance:

Basic Life Insurance Benefit:

One times basic Annual Earnings to a maximum of $350,000

Basic Life Insurance Benefit will reduce to 65% at age 65, 40% at age 70, 25% at age 75, 15% at age 80 and terminate at retirement.

Annual Earnings Definition: The Annual Earnings received from the Covered Person’s Employer.

Annual Earnings includes commissions for the year ending prior to the Policy Anniversary period. It does not include bonuses, overtime pay and other extra compensation. Annual Earnings will be rounded to the next higher thousand.

Any change to Annual Earnings that will increase the Covered Person's insurance is subject to the requirements stated in the Effective Date of Change in Amount of Insurance provision.

Basic Accidental Death and Dismemberment Benefit:

One times basic Annual Earnings to a maximum of $350,000

Basic Accidental Death and Dismemberment Benefit will reduce to 65% at age 65, 40% at age 70, 25% at age 75, 15% at age 80 and terminate at retirement.

Basic Accidental Death and Dismemberment Benefits are issued on a:

24 hour basis non-occupational basis

Accelerated Death Benefit: Up to 75% of the combined Basic Life Insurance and Supplemental Life Insurance amount in force to a maximum of $825,000. Employee must have at least $10,000 in Life Insurance in-force to qualify for this benefit.

GENERAL DEFINITIONS

DEF-UHC-TX

The male pronoun, whenever used in the Policy, includes the female.

Active Work or Actively at Work: The Covered Person reports for work at his usual place of employment or any other business location where he is required to travel and is able to perform the material and substantial duties of his regular occupation for the entire normal workday. The Covered Person must be working at least the minimum number of hours per week in an Eligible Class, as shown in the Schedule of Benefits.

Unless Disabled on the prior workday or on the day of absence, a Covered Person will be considered Actively at Work on the following days:

1. a Saturday, Sunday or holiday which is not a scheduled workday;

2. a paid vacation day, or other scheduled or unscheduled non-workday; or

3. an excused or emergency leave of absence (except medical leave).

Contributory or Non-Contributory Insurance: Contributory Insurance is insurance for which the Covered Person must apply and agree to make the required premium contributions. Non- Contributory Insurance is insurance for which the Covered Person does not have to make any premium contributions.

Covered Person: The Employee insured under the Policy. References to “Covered Person,” “Covered Persons” and “Covered Person’s” throughout this Certificate are references to a Covered Person.

Employee: A person who is:

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

2. paid for services by the Policyholder; and

3. Actively at Work for the Policyholder, or any subsidiary or affiliate insured under the Policy.

No director or officer of an Policyholder will be considered an Employee unless he meets the above conditions.

Employer: The Policyholder and includes any division, subsidiary, or affiliated company named in the Policy. Employer does not include Employers of other related areas of practice for which the Covered Person may also work.

Hospital or Medical Facility: A legally operated, accredited facility licensed to provide full-time care and Treatment for the condition for which benefits are payable under the Policy. It is operated by a full-time staff of licensed physicians and registered nurses. It does not include facilities that primarily provide custodial, education or rehabilitative care, or long-term institutional care on a residential basis.

Injury: A bodily Injury resulting directly from an accident and independently of all other causes.

Physician: A practitioner of the healing arts who is:

1. duly licensed in the state in which the Treatment is received; and

2. practicing within the scope of that license.

The term Physician does not include the Covered Person, the Covered Person’s Spouse, children, parents, parents-in-law, or siblings.

GENERAL DEFINITIONS (continued)

Regular Care: The Covered Person personally visits a Physician as often as is medically required to effectively manage and treat his disabling condition(s), according to generally accepted medical standards. The Covered Person is receiving appropriate Treatment and care, according to generally accepted medical standards, by a Physician whose specialty or experience is appropriate for the disabling condition(s).

Sickness: An illness, disease, pregnancy or complication of pregnancy.

Treatment: consultation, advice, tests, attendance or observation, supplies or equipment, including the prescription or use of prescription drugs or medicines.

We, Our and Us: UnitedHealthcare Insurance Company.

CERTIFICATE GENERAL PROVISIONS

GEN-UHC-TX-1

Conformity With State or Federal Statutes: If any provision of the Certificate conflicts with any applicable law, the provision will be deemed to conform to the minimum requirements of the law.

Authority: When making a benefit determination under the Policy, We have the authority to determine the Covered Person’s or Dependent’s eligibility, if applicable, for benefits and to interpret the terms, conditions, limitations, and exclusions, and all other provisions of the Policy including the Certificate of Coverage and any riders or amendments. We may delegate this authority to other entities or persons who provide services in regard to the administration of the Policy. This provision does not prevent the bringing of a legal action under the time limit for Legal Action provision, nor does it serve to deprive any insurance department of its statutory rights and obligations.

Fraud: We will focus on all means necessary to support fraud detection, investigation, and prosecution. It may be a crime if the Covered Person or the Employer knowingly, and with intent to injure, defraud or deceive Us, files a claim containing any false, incomplete, or misleading information. These actions, as well as submission of false information, will result in denial of the Covered Person’s claim, and are subject to prosecution and punishment to the full extent under state and/or federal law. We will pursue all appropriate legal remedies in the event of insurance fraud.

Incontestability: We may not contest the validity of the Policy, except for the non-payment of premiums after it has been in force for two years from its date of issue. No statement made by any Covered Person relating to his insurability shall be used in contesting the validity of the insurance with respect to which such statement was made after such insurance has been in force prior to the contest for a period of two years during such person’s lifetime, nor unless it is contained in a written instrument signed by him. This clause will not affect Our right to contest claims made for accidental death or accidental dismemberment benefits.

Information To Be Furnished: The Policyholder may be required to furnish any information needed to administer the Policy. Clerical error by the Policyholder will not:

1. affect the amount of insurance which would otherwise be in effect; or

2. continue insurance which otherwise would be terminated; or

3. result in the payment of benefits not otherwise payable.

Once an error is discovered, an equitable adjustment in premium will be made. If the premium adjustment involves the return of unearned premium, the amount of the return will be limited to the 12-month period, which precedes the date We receive proof such an adjustment should be made.

We may inspect any of the Policyholder’s records which relate to the Policy.

Misstatement of Age: If a Covered Person’s age has been misstated, premiums will be subject to an equitable adjustment. If the amount of the benefit depends upon age, then the benefit will be that which would have been payable, based upon the person’s correct age.

Workers’ Compensation: The Policy is not to be construed to provide benefits required by Workers’ Compensation laws.

COVERED PERSON ELIGIBILITY, EFFECTIVE DATE AND TERMINATION PROVISIONS

EELIG-UHC

Covered Person’s Eligibility: Employees who work on a full-time basis for a Policyholder are eligible for insurance after completion of the required Employee Waiting Period, provided they are in a class of Employees who are included. Employees will be considered to work on a full-time basis if they customarily work at least the number of hours per week shown in the Schedule of Benefits.

An Employee will become eligible for insurance on the latest of the following dates:

1. the Effective Date of the Policy;

2. the end of the Employee Waiting Period shown in the Schedule of Benefits;

3. the date the Policy is changed to include the Employee’s class; or

4. the date the Employee enters a class eligible for insurance.

Effective Date of Covered Person Insurance: If an Employee is not Actively at Work on the date his insurance is scheduled to take effect, it will take effect on the day after the date he returns to Active Work. If the Employee’s insurance is scheduled to take effect on a non-working day, his Active Work status will be based on the last working day before the scheduled Effective Date of his insurance.

An Employee must use forms provided by Us when applying for insurance.

The Employee’s insurance will be effective at 12:01 A.M. Eastern Standard time as follows:

1. if it is Non-contributory, on the date the Employee becomes eligible for insurance, regardless of when he applies, or

2. if it is Contributory, and the Employee makes application within 31 days after the date he first became eligible, on the later of:

a. the date the Employee is eligible for insurance, regardless of when he applies; or

b. the date the Employee’s application is approved by Us if evidence of insurability is required.

Effective Date of Change in Amount of Insurance: If there is an increase in the amount of the Covered Person’s insurance, the increase will take effect on:

1. the policy anniversary date on or next following the date of the increase, if the Covered Person is Actively at Work on the date of increase;

2. the date the Covered Person returns to Active Work if the Covered Person is not Actively at Work on the policy anniversary date on or next following the date of the increase;

3. the policy anniversary date on or next following the date of the increase, if the policy anniversary date is a non-working day and the Covered Person was Actively at Work on his last scheduled working day before the non-working day;

4. the policy anniversary date on or next following the date of the increase if the Covered Person is on an approved layoff or leave of absence, for reasons other than a Sickness or Injury.

If evidence of insurability is required, the increase will take effect on the later of the dates indicated above or the date We approve his application.

Neither an increase nor a decrease in insurance will affect a Payable Claim that occurs prior to the increase or decrease.

A decrease in the amount of the Covered Person’s insurance will take effect on the policy anniversary date on or next following the date of the decrease.

COVERED PERSON ELIGIBILITY, EFFECTIVE DATE AND TERMINATION

PROVISIONS (continued)

Family and Medical Leave of Absence: If the Covered Person is on a Family or Medical Leave of Absence, his insurance will be governed by his Employer’s policy on Family and Medical Leaves of Absence.

We will continue the Covered Person’s insurance if the cost of his insurance continues to be paid and his Leave of Absence is approved in advance and in writing by his Employer.

The Covered Person’s insurance will continue for up to the greater of:

1. the leave period required by the Federal Family and Medical Leave Act of 1993; or

2. the leave period required by applicable state law.

While the Covered Person is on a Family or Medical Leave of Absence, We will use earnings from his Employer just prior to the date his Leave of Absence started to determine Our payments to him.

If the Covered Person’s insurance does not continue during a Family or Medical Leave of Absence, then when he returns to Active Work:

1. he will not have to meet a new Employee Waiting Period including a Waiting Period for insurance of a Pre-Existing Condition, if applicable; and

2. he will not have to give Us evidence of insurability to reinstate the insurance he had in effect before his Leave of Absence began.

However, time spent on a Leave of Absence, without insurance, does not count toward satisfying his Employee Waiting Period.

Termination of Covered Person Insurance: The Covered Person’s insurance will terminate at 12:00 midnight Eastern Standard time on the earliest of the following dates:

1. the last day of the period for which a premium payment is made, if the next payment is not made;

2. the last day of the month during which he ceases to be a member of a class eligible for insurance;

3. the date the Policy terminates, or a specific benefit terminates; or

4. the last day of the month during which he ceases to be Actively at Work, unless

a. Active work ceases during an approved layoff, medical leave or non-medical leave of absence, the Life Insurance Benefit and the Accidental Death and Dismemberment Benefit will continue for up to 3 months from the date he stopped active work.

b. Active work ceases as a result of a disability due to a sickness or accidental injury and:

i. that disability began before age 60; and

ii. the Covered Person remains continuously disabled.

The Life Insurance and the Accidental Death and Dismemberment Benefit may be continued for up to 12 months from the date he stopped active work.

5. the date he is no longer Actively at Work due to a labor dispute, including but not limited to a strike, work slow down or lock out.

LIFE INSURANCE BENEFIT FOR COVERED PERSON

ELIFE-UHC-TX

Death Benefits: We will pay the Covered Person’s beneficiary the amount of insurance in force on the date of death. We will make the payment in the form of a lump sum within two months of receipt by Us of satisfactory proof of the Covered Person’s death. The benefit will be paid in accordance with the beneficiary section.

Assignment: Life insurance as provided by the Policy may be assigned as an absolute assignment only. In making an assignment, the Covered Person must transfer all his present and future ownership rights to the person to whom he assigned the insurance. This includes the right to change the beneficiary and to convert the insurance. The Covered Person may not make a collateral or partial assignment of his insurance.

Beneficiary: The Covered Person’s beneficiary will be the person(s) he names in writing to receive any amount of insurance payable due to his death.

The Covered Person may name or change a beneficiary by giving Us written notice at Our Home Office on a form acceptable to Us. When We receive the notice, it will be effective on the date made, subject to any payment We may have made before We receive it.

If the Covered Person names more than one beneficiary, those who survive will share equally unless the Covered Person specifies otherwise. If there is no named beneficiary living at the time of the Covered Person’s death, We will pay any amount due in the following order:

1. to his legal Spouse; or

2. to his natural or legally adopted children in equal shares; or

3. to his estate.

Notice of Claim: Written notice of a claim for death must be given to Us at Our Home Office by the Covered Person’s beneficiary within 30 days of the date of death. If it is not possible, written notice must be given as soon as it is reasonably possible to do so.

The claim form is available from the Covered Person’s Employer, or can be requested from Us. If the form is not received from Us within 15 days of a request, written proof of claim should be sent to Us without waiting for the form. Written proof must show the cause of death. Also, a certified copy of the death certificate must be given to Us.

Proof of Claim: Written proof of claim must be filed within 90 days of the loss. However, if it is not possible to give proof within 90 days, it must be given no later than one year after the time proof is otherwise required, except in the absence of legal capacity.

Payment of Claim: Payment of Claim for loss of life will be paid in accordance with the beneficiary section. All other benefits under the Policy are paid to the Covered Person.

If the Covered Person has chosen an option, no one may change it unless the Covered Person consents in writing. The Covered Person’s beneficiary may choose an option within 60 days after death if one has not been chosen.

Legal Action: The Covered Person may not bring suit to recover under this section until 60 days after he has given Us written proof of loss. No suit may be brought more than three years after the date the proof of loss is required to be filed.

Physical Examination and Autopsy: We have the right to have a Physician of Our choice examine the Covered Person as often as necessary, but not more often than once each three months, while the claim is pending. We may also have an autopsy made in case of death, unless not allowed by law. We will pay the cost of the exam and autopsy.

LIFE INSURANCE BENEFIT FOR COVERED PERSON (continued)

Settlement Options: Instead of a single payment, the Covered Person may choose to have all or part of the insurance paid under one of the settlement options We have available. We will give the Covered Person full information about the options upon request.

Conversion Privilege: The Covered Person may convert:

1. all or part of his Life Insurance to an individual policy of life insurance, other than term insurance, if his insurance terminated because he ceases to be a member of a class eligible for insurance;

2. the amount of insurance to an individual policy of life insurance, other than term insurance, that is lost due to a reduction of insurance because of age;

3. a limited amount of insurance to an individual policy of life insurance, other than term insurance, if he has been continuously insured under the Policy (or the policy it replaced) for five years and the insurance terminated due to termination or amendment of the Policy. The amount the Covered Person may convert in this case is the smaller of the following:

a. the amount of Life Insurance which terminates, less the amount he became eligible for under any Policy within 31 days after this insurance terminated; or

b. $10,000.

The Covered Person may convert to any policy, other than term insurance, We are issuing for the purpose of conversions. The conversion policy will not have disability or other supplementary benefits. No evidence of insurability will be required. The Covered Person must submit a written application and the first premium payment for the conversion policy to Our Home Office within 31 days after his insurance terminates. It is the Covered Person’s responsibility to pay the premiums for the conversion policy. The premium will be based on the amount and the form of the conversion policy, and on his class of risk and age on the date the conversion takes effect.

If the Covered Person dies within the 31 days allowed for making application to convert, We will pay the amount he was entitled under this Policy if the individual policy has not yet taken effect. We will do this whether or not application was made.

A conversion policy is in lieu of benefits under this section of the Policy. However, if the Covered Person is qualified for the Waiver of Premium-Total Disability provision, the converted policy will be cancelled. Premiums paid for the converted policy will be returned.

The conversion policy will take effect on the later of:

1. its date of issue; or

2. 31 days after the date this insurance terminates.

The insurance under the Policy may be reinstated within one year after termination of employment, if the Covered Person has converted and he:

1. gives Us proof that he was Totally Disabled when his insurance terminated and that his insurance would have continued in force under the Waiver of Premium-Totally Disabled provision if he had not converted; and

2. surrenders the conversion policy to Us without claim in return for premiums paid less any unpaid policy loans.

Employees rehired after converting insurance must either lapse that insurance or provide evidence of insurability to keep that individual policy.

WAIVER OF PREMIUM – TOTAL DISABILITY FOR COVERED PERSON

WAIVER-UHC-TX

We will continue the Covered Person’s Basic Life Insurance in force without premium payment while he remains Totally Disabled if he:

1. becomes Totally Disabled before age 60;

2. remains Totally Disabled continuously for at least six consecutive months;

3. gives Us proof of Total Disability, as required.

We will waive the Covered Person’s premium payment on a monthly basis, beginning the first day of the month after the month he became Totally Disabled. We will refund any premium paid for the Basic Life Insurance after that day. We will not refund premiums for any period more than 12 months before the date proof of disability was furnished. This Waiver of Premium will continue to be effective even if the Policy terminates after the Covered Person becomes Totally Disabled.

Amount of Life Insurance Under the Total Disability Benefit: The amount of insurance continued would be the amount in force on the date the Covered Person became Totally Disabled. This amount will be reduced or terminated, based on the Schedule of Benefits in effect on the date of Total Disability. This amount will not be increased while the Covered Person remains Totally Disabled. All other Benefits will be terminated.

Death While Totally Disabled: If the Covered Person dies while his Basic Life Insurance is being continued under Waiver of Premium, We will pay the amount of insurance if We receive proof:

1. of the Covered Person’s death; and

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

Proof of Total Disability: We will provide forms which the Covered Person must use when giving Us proof of Total Disability. The Covered Person must give Us proof no later than 12 months after the date he became Totally Disabled. We may at any time require proof that Total Disability continues. The Covered Person must give Us proof within 60 days after Our request. After the Covered Person has been Totally Disabled for more than two years from the date of Total Disability, We will not request proof any more than once a year. We may require the Covered Person to be examined, at Our expense, by a Physician of Our choice.

Total Disability or Totally Disabled: For purposes of this section, the Covered Person will be considered Totally Disabled if he is unable to perform each and every duty of his occupation at his usual place of employment and he is unable to do the material and substantial duties of any job suited to his education, training or experience.

We may require the Covered Person to be examined by a Physician, other medical practitioner or vocational expert of Our choice. We will pay for this examination. We can require an examination as often as it is reasonable to do so, but not more often than once each three months.

WAIVER OF PREMIUM – TOTAL DISABILITY FOR COVERED PERSON (continued)

WAIVER-UHC-TX

Termination of the Total Disability Benefit: The Covered Person will no longer be eligible for the Total Disability Benefit and his Basic Life Insurance will terminate on the earlier of the following dates:

1. the date the Covered Person ceases to be Totally Disabled. However, if he is still eligible for Basic Life Insurance when he returns to Active Work, his Basic Life Insurance may be continued in force if premium payments are resumed. If this is done, any increased amount of Basic Life Insurance he may then be eligible for will take effect as described in the Effective Date of insurance provision; or

2. the last day of the 60-day period following Our request for proof of Total Disability, if he does not give Us proof or refuses to take a medical exam;

3. the date the Covered Person reaches Normal Retirement Age;

4. the date premium has been waived for 12 months and the Covered Person is considered to reside outside the United States. The Covered Person is considered to reside outside the United States when he has been outside the United States for a total period of 6 months or more during any 12 consecutive months for which premium has been waived.

If the Covered Person’s Total Disability ends and he does not return to Active Work, then the Covered Person may exercise the Conversion Privilege.

ACCELERATED DEATH BENEFIT FOR COVERED PERSON

EACD-UHC-TX

If while insured under the Policy, the Covered Person becomes terminally ill (called the “qualifying event”) with a life expectancy of less than 12 months and the Covered Person has met all of the conditions set forth below, We will pay the Covered Person the amount of insurance shown in the Schedule of Benefits.

The Covered Person may elect to receive an Accelerated Death Benefit amount that is stated on the Schedule of Benefits. However, an Accelerated Death Benefit payment against the Covered Person’s Life Insurance Benefit can only be made once in the Covered Person’s lifetime.

The Life Insurance Benefit amount will be reduced by the amount paid under this provision.

The Covered Person must submit written medical evidence signed by the treating Physician and acceptable to Us that he is:

1. under a Physician’s care for that condition, and

2. has a life expectancy of less than 12 months.

The Accelerated Death Benefit amount will be paid to the Covered Person after the Covered Person meets all of the conditions listed above.

We reserve the right to ask for a medical exam in connection with a claim. In the event that the Physician’s examinations result in conflict with the medical evidence signed by the treating Physician, a second examination from a Physician of Our choice (at Our expense) will be requested.

This second exam will determine if the Covered Person has met the conditions stated above.

The Covered Person must continue to pay any applicable premium for the amount of Life Insurance Benefits remaining after the reduction.

Upon the Covered Person’s death, the amount of Life Insurance Benefits paid to the Covered Person’s beneficiary will be reduced by the amount already paid under this provision and this payment shall constitute full settlement of the death benefit payable under the Policy.

At the time of payment of the Accelerated Death Benefit, We will send a statement to the Covered Person specifying:

1. the amount of benefits paid;

2. the affect of the Accelerated Death Benefit payment on the death benefit face amount and future premiums; and

3. the amount of Life Insurance benefits remaining.

Limitations: Accelerated Death Benefits will not be payable if:

1. the Covered Person has assigned his Life Insurance Benefits; or

2. We have been notified that all or a portion of the Life Insurance Benefits are to be paid to the Covered Person’s former Spouse as part of a divorce agreement; or

3. the Covered Person is required by law to accelerate benefits in order to meet the claims of creditor(s); or

4. the Covered Person is required by a government agency to accelerate benefits in order to qualify for a government benefit or entitlement.

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT FOR COVERED PERSON

EADD-UHC-TX

If the Covered Person suffers a loss described below, We will pay the amount of insurance that applies. The Covered Person, or the Covered Person’s beneficiary, must give Us proof that:

1. Injury occurred while the insurance was in force under this section;

2. loss occurred within 365 days after the Injury; and

3. loss was due to Injury independent of all other causes.

Amount of Insurance: The amount of insurance shown in the Schedule of Benefits will be paid according to the following table:

Loss of life 100%

Loss of both hands or both feet 100%

Loss of sight of both eyes 100%

Loss of one hand and sight of one eye 100%

Loss of one foot and sight of one eye 100%

Quadriplegia 100%

Paraplegia 50%

Hemiplegia 50%

Loss of one hand 50%

Loss of one foot 50%

Loss of sight of one eye 50%

Loss of speech 25%

Loss of hearing 25%

Loss of Thumb and Index Finger of the Same Hand

25%

Loss of sight means total and irrecoverable loss of sight. Loss of hands or feet means severance at or above the wrist or ankle. Loss of thumb and index finger means the actual, complete and permanent severance through or above the metacarpophalangeal joints. Loss of speech means the total and irrecoverable loss of speech. Loss of hearing means total and irrecoverable loss of hearing. Quadriplegia means total and permanent Paralysis of both upper and lower limbs.

Paraplegia means total and permanent Paralysis of both lower limbs. Hemiplegia means total and permanent Paralysis of upper and lower limbs on one side of the body. Paralysis means permanent impairment and loss of the ability to voluntarily move or to have sensation in any entire extremity.

Paralysis must be the result of an Injury to the brain or spinal cord and without the severance of a limb.

In paying this benefit, We will consider only losses sustained while insured under this section of the Policy. We will pay no more than the full amount shown in the Schedule of Benefits for losses resulting from any one Injury.

(continued)

Seat Belt and Air Bag Benefit for Covered Person: We will pay an additional benefit for the loss of the Covered Person’s life that results from injuries sustained while driving or riding in a private Passenger Car if such Covered Person’s Seat Belt was properly fastened. A benefit is not payable under this provision, if:

1. the Covered Person is either a driver or passenger, and the driver was legally intoxicated or under the influence of drugs at the time of the accident; or

2. the driver of the private Passenger Car does not hold a current and valid driver’s license at the time of the accident.

An additional Air Bag Benefit will be paid if:

1. Seat Belt Benefit is payable; and

2. the private Passenger Car is equipped with a single Air Bag and the Covered Person is the driver; or

3. the private Passenger Car is equipped with an Air Bag for both the driver and for the front passenger seat and the Covered Person is the driver or front seat passenger; or

4. the private Passenger Car is equipped with an Air Bag for the driver seat, for the front passenger seat and for all rear passenger seats and the Covered Person is the driver, front seat passenger or rear seat passenger; and

5. the police report or other evidence establishes that the Air Bag inflated properly upon impact.

We will pay:

1. A Seat Belt benefit of an amount equal to 10% of the full amount of Accidental Death and Dismemberment Benefit; or

2. A Seat Belt and Air Bag Benefit of an amount equal to 10% of the full amount of Accidental Death and Dismemberment Benefit.

However, the amount payable will not exceed $10,000 for the Seat Belt Benefit or $15,000 for the combined Seat Belt and Air Bag Benefit.

The accident causing the Covered Person’s death must occur while the Covered Person is insured under the Policy.

Passenger Car means, for the purposes of this Accidental Death and Dismemberment Benefit, any validly registered four-wheel private Passenger Car. Seat Belt means any restraint device which meets published federal safety standards, has been installed by the car manufacturer or reinstalled according to the manufacturer’s specifications and has not been altered after such installation. The investigating officer must certify the correct position of the Seat Belt. A copy of the police report must be submitted with the claim.

Air Bag means, for the purposes of this Accidental Death and Dismemberment Benefit, a supplemental restraint system that inflates for added protection to the head and chest areas. The Air Bag must meet published federal safety standards, be installed by the car manufacturer or consist of proper replacement parts as required by the car manufacturer’s specifications and not have been altered after such installation.

Limitations: We will not pay a benefit for a loss caused directly or indirectly by:

1. disease, bodily or mental infirmity, or medical or surgical Treatment of these;

2. suicide or intentionally self-inflicted Injury, while sane or insane;

3. participation in a riot or insurrection, or commission of an assault or felony;

(continued)

4. war or any act of war, declared or undeclared while the Covered Person is serving in the armed services;

5. use of any drug, hallucinogen, controlled substance, or narcotic unless prescribed by a Physician;

6. driving while intoxicated, as defined by the applicable state law where the loss occurred;

7. engaging in the following hazardous activities, including skydiving, hang gliding, auto racing, mountain climbing, Russian Roulette, autoerotic asphyxiation or bungee jumping;

8. Injury arising out of or in the course of any occupation or employment for pay or profit, or any Injury or Sickness for which the Covered Person is entitled to benefits under any Workers Compensation Law, Employers Liability Law or similar law, unless this insurance is issued on an 24 hour basis as shown in the Schedule of Benefits;

9. travel or flight in, or descent from any aircraft, unless as a fare-paying passenger on a commercial airline flying between established airports on: a) a scheduled route; or b) a charter flight seating 15 or more people.

Notice of Claim: Written notice of a claim for death or Injury must be given to Us at Our Home Office by the Covered Person or his beneficiary within 30 days of the date of death or the date the Injury occurred. If it is not possible, written notice must be given as soon as it is reasonably possible to do so.

The claim form is available from the Covered Person’s Employer, or can be requested from Us. If the Covered Person does not receive the form from Us within 15 days of his request, written proof of claim should be sent to Us without waiting for the form. Written proof should establish facts about the claim such as date of occurrence, nature, and extent of the loss involved.

Proof of Claim: Written proof of claim must be filed within 90 days of the loss. However, if it is not possible to give proof within 90 days, it must be given no later than one year after the time proof is otherwise required, except in the absence of legal capacity.

Payment of Claim: Payment of Claim for loss of life will be paid in a lump sum within two months of receipt by Us of satisfactory Proof of Claim. The benefit will be paid in accordance with the beneficiary section. All other benefits under the Policy are paid to the Covered Person.

If the Covered Person has chosen an option, no one may change it unless the Covered Person consents in writing. The Covered Person’s beneficiary may choose an option within 60 days after death if one has not been chosen.

Legal Action: The Covered Person may not bring suit to recover under this section until 60 days after he has given Us written proof of loss. No suit may be brought more than three years after the date the proof of loss is required to be filed.

Physical Examination and Autopsy: We have the right to have a Physician of Our choice examine the Covered Person as often as necessary, but not more often than once each three months, while the claim is pending. We may also have an autopsy made in case of death, unless not allowed by law. We will pay the cost of the exam and autopsy.

Assignment: Accidental Death and Dismemberment insurance provided by the Policy cannot be assigned.

CHILD CARE EXPENSE BENEFIT UNDER THE ACCIDENTAL DEATH AND

DISMEMBERMENT BENEFIT

CCARE-ADD-UHC

We will pay a Child Care Expense Benefit if:

1. a Covered Person and his Children are insured under the Policy; and

2. the Covered Person dies as a result of an Injury; and

3. a Loss of Life benefit is payable for the Covered Person under the Accidental Death and Dismemberment provision.

This benefit will be paid on behalf of any Child under age of 13 or any Child age 13 or older who needs ongoing personal care assistance, who is receiving child care from a licensed child care provider at the time of the Covered Person’s death, or within 365 days of the Covered Person’s death. Payment will be made to the Child’s parent or legal guardian.

The benefit is equal to the lesser of the following amounts:

1. the actual cost charged for the Child Care Expenses per year;

2. 25% of the Covered Person’s Loss of Life benefit payable under the Accidental Death and Dismemberment provision, not to exceed $1,250 per year per Child.

However, We will not pay more than the overall maximum amount of $5,000 per year for all Child Care Expenses combined.

This Child Care Expense Benefit is payable each year for each Dependent Child who qualifies for Child Care Benefits. No more than two Child Care Benefits will be payable for each Dependent.

To receive this benefit, the Child’s parent or legal guardian must provide satisfactory proof that he is incurring expenses that entitle him to the Child Care Expenses Benefit. Expenses must be charged by a child care provider who is licensed to provide such services in the jurisdiction in which the services are provided.

The Child Care Expense Benefit will end on the earlier of the following:

1. the date the Child’s parent or legal guardian is no longer incurring child care expenses;

2. the date the maximum number of Child Care Benefits have been paid;

3. the date the Child reaches 13 years of age unless the Child needs ongoing personal care assistance.

SPOUSE TRAINING BENEFIT UNDER THE ACCIDENTAL DEATH AND

STRN-ADD-UHC

When We receive proof that a Covered Person dies as a result of an Injury and an Accidental Death and Dismemberment Loss of Life benefit is payable, then We will pay an additional Spouse Training Benefit to the Covered Person’s Spouse if:

The Spouse is insured under the Policy on the date of the Covered Person’s accident, and is enrolled in a post secondary institution, professional or trade school training program:

1. for the purpose of obtaining an independent source of support and maintenance; and

2. within 3 months of the date of the Covered Person’s death.

The Spouse Education Benefit payable is the lesser of:

1. expenses incurred for the training which includes tuition charged and the costs of materials needed, but does not include room and board costs;

2. 25% of the Covered Person’s Spouse’s full Accidental Death and Dismemberment Benefit;

3. $5,000.

REPATRIATION BENEFIT FOR COVERED PERSONS UNDER THE ACCIDENTAL DEATH

AND DISMEMBERMENT BENEFIT

REPAT-ADD-UHC

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

1. an Accidental Death and Dismemberment Loss of Life benefit as the result of an Injury is payable on behalf of the Covered Person’s death;

2. The Covered Person’s death occurs more than 100 miles from his primary place of residence and occurs outside the state or country of the Covered Person’s place of permanent residence; and

3. Covered Expenses are incurred for the preparation and transportation of the Covered Person’s body to a mortuary near the primary place of residence.

The amount of the Repatriation Benefit is the lesser of:

1. the Covered Expenses incurred; or

2. 10% of the Covered Person’s Accidental Death & Dismemberment Loss of Life benefit; or

3. $5,000.

The Repatriation Benefit is payable to the person who incurs the expenses.

Covered Expenses include, but are not limited to the usual and customary fee or charge for the services rendered and supplies furnished in the area where services are rendered or the supplies are furnished. Such services and supplies include, but are not limited to, embalming, cremation, coffins, and transportation.

EDUCATION BENEFIT FOR COVERED PERSON UNDER THE ACCIDENTAL DEATH AND

DED-ADD-UHC

We will pay a yearly Education Benefit to each of the Covered Person’s Qualified Children if:

1. an Accidental Death and Dismemberment Loss of Life benefit is payable for the Covered Person;

2. the Covered Person dies within 365 days after the date of the accident causing the accidental bodily Injury;

3. proof is given to Us that the Child is a Qualified Child; and

4. the Qualified Child continues to be enrolled as a full-time student in an accredited post-secondary institution of higher learning beyond the 12th grade level.

The maximum yearly Education Benefit amount is the lesser of:

1. 10% of the Covered Person’s Accidental Death and Dismemberment Loss of Life benefits; or

2. $1,250.

However, We will not pay more than $5,000 per year for all Qualified Children combined.

This Education Benefit is payable in addition to any other benefits provided under the Policy. We will not pay more than one Education Benefit per Qualified Child during any one school year.

If the Covered Person has no surviving Children, or the Children are not insured under the Policy, or the Children do not meet the Education Benefit requirements, then no Education Benefit will be paid.

The Education Benefit will terminate for each Qualified Child on the earliest of the following dates:

1. the date the Qualified Child fails to furnish proof as required by Us;

2. the date the Qualified Child no longer qualifies as a Dependent Child for any reason except the Covered Person’s death; or

3. the date on which the fourth Education Benefit has been paid.

The following term is defined for the purposes of this Education Benefit:

Qualified Child is any of the Covered Person’s unmarried children under the age shown in the General Definitions section who, on the date of the Covered Person’s death as a result of an Injury, was either:

1. enrolled as a full-time student in an accredited post-secondary institution of higher learning beyond the 12th grade level; or

2. at the 12th grade level and enrolls as a full-time student in an accredited post-secondary institution of higher learning beyond the 12th grade level within 365 days following the date of the Covered Person’s death.

COMMON CARRIER HAZARD BENEFIT FOR COVERED PERSONS UNDER THE

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT

COMCARE-ADD-UHC 19

If an Accidental Death and Dismemberment Loss of Life benefit is payable under the Policy, We will pay an additional benefit amount for a loss that is the result of a hazard while the Covered Person is on business for the Employer or on personal travel. A hazard is a situation or activity that places the Covered Person at risk of loss. We will pay the Common Carrier Hazard Benefit for the following hazards if the Covered Person’s loss of life occurs:

1. while riding as a passenger (not as a pilot or crew member) in or getting into or out of:

a. any common public passenger carrier, including air, that is licensed for the transportation of passengers for hire, excluding an aircraft owned, operated, chartered or leased by or for the Employer; or

b. any transport type aircraft operated by the Military Airlift Command (MAC) of the United States…