ESBD_503812_1775238468231_PI THE TEXAS A&M UNIVERSITY SYSTEM 681835.pdf

Form GBD-1000 A (10/08) GOV (Rev-2) (TX)

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

One Hartford Plaza, Hartford, Connecticut 06155

(A stock insurance company, herein called The Company) will pay benefits according to the terms and conditions of The Policy.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries.

AMENDMENT TO GROUP POLICY GL-681835 PROCESSED ON JUNE 24, 2024. ANY CHANGES BETWEEN THIS POLICY AND THE PREVIOUSLY ISSUED POLICY ARE EFFECTIVE OCTOBER 1, 2024. ALL OTHER TERMS

CONDITIONS AND DATES REMAIN UNCHANGED.

Name of Policyholder: The Texas A&M University System

Policy Number: Policy Effective Date: Place of Delivery:

GL-681835 September 1, 2020 Texas

Anniversary Date: Premium Due Dates:

September 1 of each year, beginning in

Monthly, on the first day of each policy month

Signed for The Company

THIRTY DAY RIGHT TO EXAMINE POLICY

The Company urges you to examine this Policy closely. If you are not satisfied with it, you may send it back to The Company for any reason within 30 days after the date you receive it. If so returned, your insurance will be canceled, and any premium paid will be refunded in full.

Countersigned by.............................……………………………………..

Licensed Resident Agent or Registrar

Table of Contents Schedule of Insurance Premium Provisions Premium Schedule Policy Provisions Incorporation Provision

Form GBD-1000 C.5 (10/08) 2

SCHEDULE OF INSURANCE

The Schedule(s) of Insurance for The Policy benefits listed below are shown in the Certificate(s) of Insurance, as incorporated into The Policy.

1) Supplemental Life Insurance

2) Dependent Life Insurance

The Schedule(s) of Insurance will address the:

1) benefit amounts and maximum limits;

2) eligibility and effective date requirements; and

3) other schedule amounts and limits;

which apply to the employees of the Policyholder.

Form GBD-1000 D.2 (10/08) (Rev-2) (TX) 3

PREMIUM PROVISIONS

Initial Monthly Premium Rates The initial monthly premium rates to be charged for employee coverage and/or child/spouse coverage, if applicable, are shown on the following page(s).

The first premium is due and payable on the effective date of The Policy. Subject to The Policy's grace period provision, all premiums after the first must be paid when or before they are due.

Premiums are based on the employee's age on his or her effective date and thereafter on the first day of the month following the month in which his or her birthday occurs.

The Initial Monthly Premium Rates may be converted as follows:

To Convert Rates to: Use a Conversion Factor of:

--annual rates 11.8227 --semi-annual rates 5.9557 --quarterly rates 2.9852

Grace Period The Company will allow the Policyholder a 60 day grace period for the payment of all premiums after the first. During this 60 day period, The Policy will stay in force. If the owed premium is not paid by the 60th day, The Policy will automatically terminate. If the Policyholder gives The Company written advance notice of an earlier cancellation date, The Policy will terminate on the earlier date. Premium is due for each day The Policy is in force.

Monthly Premium Rate Guarantee Initial Monthly Premium Rates are guaranteed as follows:

Benefit Rate Guarantee Period Supplemental Life Insurance until September 01, 2023 Supplemental Dependent Life Insurance until September 01, 2023

Subject to the Rate Guarantee Period shown above, The Company has the right to change premium rates on any premium due date if:

1) written notice is delivered to the Policyholder's last address on record; and

2) the change is effective at least 61 days after the date of notice.

The Rate Guarantee Period supersedes only those provisions appearing elsewhere in this Policy which give The Company the right to change the premium rates, and then, only for the period of time for which the rates are guaranteed.

However, The Company may change the premium rates during the Rate Guarantee Period if:

1) there is a change in The Policy;

2) there is any change to state or federal law or inaction by state or federal law makers which affects The Company's liability under The Policy on a temporary or permanent basis;

3) there is a 10% increase or decrease in the number of insured Employees;

4) the Policyholder adds or deletes a subsidiary or affiliated business entity; or

5) there has been a material misstatement in the reported experience during the pre-sale process.

The Rate Guarantee Period in no way affects, amends or supersedes any other provision in The Policy.

Form GBD-1000 D.3 (10/08) (Rev-1) 4

PREMIUM PROVISIONS

Calculation Premiums may be calculated by multiplying the rate times the applicable number of units of coverage.

If any insurance is added, increased or becomes effective after The Policy is in force, the premium charges will begin on:

1) the day the coverage is effective, if it is also the first day of a policy month; or

2) the first day of the next policy month.

For insurance which is terminated, premium charges will stop as of the first day of the next policy month.

With respect to Dependent Life Insurance only, the premium rate per Dependent unit or per $1,000 of insurance, whichever is applicable, will be based on actuarial assumptions, due to the difficulty in obtaining the ages of all Dependents who are covered under this benefit. The actuarial assumptions will produce, in the opinion of The Company, the same total amount of premium as would be obtained by the use of the actual ages of the Dependents covered.

Premiums may be calculated by any other method which both The Company and the Policyholder agree to in writing.

Premium Payments Premium payments are due and payable in full to a place designated by The Company or, with respect to the initial premium payment, premium payments may be made to an authorized agent of The Company. The pre-payment of premiums for a particular period by the Policyholder is not a guarantee that The Policy will remain in force.

Form GBD-1000 D.4 (10/08) 5

PREMIUM SCHEDULE

Supplemental Life Insurance Plan 3 For each $1,000 of Supplemental Life Insurance the monthly premium rate shall be determined in accordance with the employee's age as follows:

Employee Age Smoker Non-smoker Less than 25 $.10 $.05 25-29 $.10 $.05 30-34 $.10 $.05 35-39 $.12 $.06 40-44 $.14 $.07 45-49 $.24 $.12 50-54 $.40 $.20 55-59 $.72 $.36 60-64 $1.12 $.56 65-69 $1.52 $.76 70-74 $2.86 $1.43 75 or over $4.00 $2.00

Supplemental Life Insurance Plan 4 For each $1,000 of Supplemental Life Insurance the monthly premium rate shall be determined in accordance with the employee's age as follows:

Employee Age Smoker Non-smoker Less than 25 $.10 $.05 25-29 $.10 $.05 30-34 $.10 $.05 35-39 $.12 $.06 40-44 $.14 $.07 45-49 $.24 $.12 50-54 $.40 $.20 55-59 $.72 $.36 60-64 $1.12 $.56 65-69 $1.52 $.76 70-74 $2.86 $1.43 75 or over $4.00 $2.00

Supplemental Life Insurance Plan 8 For each $1,000 of Supplemental Life Insurance the monthly premium rate shall be determined in accordance with the employee's age as follows:

Employee Age Smoker Non-smoker Less than 25 $.10 $.05 25-29 $.10 $.05 30-34 $.10 $.05 35-39 $.12 $.06 40-44 $.14 $.07 45-49 $.24 $.12 50-54 $.40 $.20 55-59 $.72 $.36 60-64 $1.12 $.56 65-69 $1.52 $.76 70-74 $2.86 $1.43 75 or over $4.00 $2.00

Supplemental Dependent Life Insurance Plan 5

TEXAS A&M UNIVERSITY-OPTION A

Form GBD-1000 D.4 (10/08) 6

Spouse For each $1,000 of Supplemental Dependent Life Insurance the monthly premium rate shall be determined in accordance with the Spouse's age as follows:

Spouse Age Smoker Non-smoker Less than 25 $.06 $.05 25-29 $.072 $.06 30-34 $.096 $.08 35-39 $.108 $.09 40-44 $.12 $.10 45-49 $.18 $.15 50-54 $.276 $.23 55-59 $.516 $.43 60-64 $.792 $.66 65-69 $1.524 $1.27 70-74 $2.472 $2.06 75 or over $2.472 $2.06

Child(ren) $.06 per $1,000

TEXAS A&M UNIVERSITY-OPTION B

Spouse $.20 per $1,000

Child(ren) $.054 per $1,000

TEXAS A&M UNIVERSITY-OPTION C

Spouse $15.625 spouse

Child(ren) $3.125 per child unit

TEXAS A&M-OPTION A RETIREES

Spouse For each $1,000 of Supplemental Dependent Life Insurance the monthly premium rate shall be determined in accordance with the Spouse's age as follows:

Spouse Age Smoker Non-smoker Less than 25 $.06 $.05 25-29 $.072 $.06 30-34 $.096 $.08 35-39 $.108 $.09 40-44 $.12 $.10 45-49 $.18 $.15 50-54 $.276 $.23 55-59 $.516 $.43 60-64 $.792 $.66 65-69 $1.524 $1.27 70-74 $2.472 $2.06 75 or over $2.472 $2.06

Child(ren) $.06 per $1,000

TEXAS A&M-OPTION B RETIREES

Spouse $.20 per $1,000

Child(ren) $.054 per $1,000

Form GBD-1000 D.4 (10/08) 7

TEXAS A&M-OPTION C RETIREES

Spouse $15.625 spouse

Child(ren) $3.125 per child unit

Supplemental Dependent Life Insurance Plan 9

INTL-TEXAS A&M-OPTION A

Spouse For each $1,000 of Supplemental Dependent Life Insurance the monthly premium rate shall be determined in accordance with the Spouse's age as follows:

Spouse Age Smoker Non-smoker Less than 25 $.06 $.05 25-29 $.072 $.06 30-34 $.096 $.08 35-39 $.108 $.09 40-44 $.12 $.10 45-49 $.18 $.15 50-54 $.276 $.23 55-59 $.516 $.43 60-64 $.792 $.66 65-69 $1.524 $1.27 70-74 $2.472 $2.06 75 or over $2.472 $2.06

Child(ren) $.06 per $1,000

INTL-TEXAS A&M-OPTION B

Spouse $.20 per $1,000

Child(ren) $.054 per $1,000

INTL-TEXAS A&M-OPTION C

Spouse $15.625 spouse

Child(ren) $3.125 per child unit

Supplemental Dependent Life Insurance Plan 10

TEXAS A&M-OPTION A RETIREES

Spouse For each $1,000 of Supplemental Dependent Life Insurance the monthly premium rate shall be determined in accordance with the Spouse's age as follows:

Spouse Age Smoker Non-smoker Less than 25 $.06 $.05 25-29 $.072 $.06 30-34 $.096 $.08 35-39 $.108 $.09 40-44 $.12 $.10 45-49 $.18 $.15 50-54 $.276 $.23

Form GBD-1000 D.4 (10/08) 8

55-59 $.516 $.43 60-64 $.792 $.66 65-69 $1.524 $1.27 70-74 $2.472 $2.06 75 or over $2.472 $2.06

Child(ren) $.06 per $1,000

Form GBD-1000 F.1 (10/08) (Rev-1) (TX) 9

POLICY PROVISIONS

Entire Contract The contract between the parties consists of:

1) The Policy;

2) any Certificate(s) of Insurance incorporated and made a part of The Policy;

3) any riders issued in connection with such Certificate(s) of Insurance;

4) the Policyholder's application, if any, a copy of which is attached to and made a part of The Policy when issued;

and

5) any individual application submitted by the Employee and accepted by The Company in connection with The

Policy.

In the absence of fraud, all statements made by the Policyholder, or persons insured under The Policy will be deemed representations and not warranties. No statement made to affect this insurance will be used in any contest unless it is in writing and a copy of it is given to the person who made it, or to his or her beneficiary or personal representative.

Incontestability Except for non-payment of premium, the insurance provided by The Policy cannot be contested after such insurance has been in effect for a period of 2 years.

Changes The Company reserves the right to make changes in The Policy, after The Policy has been in force for 12 months. The Company will give the Policyholder 31 days advance written notice of any change. No agent has authority to change or waive any part of The Policy. To be valid, any change or waiver must be in writing, approved by one of our officers and made a part of The Policy.

Clerical Error Clerical error (whether by the Policyholder, the Plan Administrator, or The Company) in keeping the records having to do with The Policy, or delays in making entries on the records, will not void the insurance of any person if that insurance would otherwise have been in effect. A clerical error will not extend the insurance of any person if that insurance would otherwise have ended or been reduced as provided by The Policy. When a clerical error is found, premiums and benefits will be adjusted based on the true facts and The Policy.

Conformity with Law If any provision of The Policy is contrary to the law of the jurisdiction in which it is delivered, such provision is hereby amended to conform to that law. If any change to state or federal law, including but not limited to the Federal Social Security Act, affects The Company's liability under The Policy, The Company may change The Policy, the premiums or both. Such change:

1) will be effective as of the date of the change to the state or federal law; and

2) will not be made until The Company gives the Policyholder 61 days notice.

Termination of Policy The Company may terminate The Policy for the following reasons by giving the Policyholder 31 days written notice:

1) the Policyholder fails to furnish any information which The Company may reasonably require;

2) the Policyholder fails to perform any of its other obligations pertaining to this Policy;

3) Less than 100% of the persons eligible for coverage on a Non-contributory basis are insured;

4) Less than 25% of the persons eligible for coverage on a Contributory basis are insured; or

5) Fewer than 10 persons are insured.

In addition, The Company may terminate this Policy on any premium due date after The Policy has been in force for 12 months by providing 31 days written notice. If The Policy is terminated, the Policyholder is responsible for providing notice to insureds of their right to convert under The Policy.

The Company reserves the right to terminate Dependent Life Insurance Benefits on any premium due date on which:

1) there are fewer than 10 persons insured for Dependent coverage; or

2) less than 25% of the persons eligible for Dependent coverage on a Contributory basis are insured.

The Company shall give the Policyholder 31 days notice of its intent to terminate the Dependent Life Insurance Benefit.

Form GBD-1000 F.2 (10/08) (TX) 10

POLICY PROVISIONS

Certificate(s) of Insurance The Company will give individual Certificate(s) of Insurance to:

1) the Policyholder; or

2) any other person according to a mutual agreement among the other person, the Policyholder, and The Company;

for delivery to persons covered under The Policy and which will explain the important features of The Policy.

Data To Be Furnished The Policyholder, or any other person designated by the Policyholder, will give The Company all information The Company needs regarding matters pertaining to the insurance. At any reasonable time while The Policy is in force and for 12 months after that, The Company may inspect any of the Policyholder's documents, books, or records which may affect the insurance or premiums of The Policy.

The Policyholder will, upon our request, give The Company:

1) the names of all persons initially eligible for coverage;

2) the names of all additional persons who become eligible for coverage;

3) the names of all persons whose amount of insurance is to be changed;

4) the names of all persons whose eligibility or insurance is terminated; and

5) any data necessary to administer the insurance provided by The Policy.

If the Policyholder gives The Company any incorrect information, the relevant facts will be determined to establish if insurance is in effect and in what amount.

No person will be deprived of insurance to which he is otherwise entitled or have insurance to which he is not entitled, because of any misstatement of fact by the Policyholder. Any required adjustment may be made in premiums or benefits.

Right to Audit The Company reserves the right to audit, once every 2 years, the Policyholder's billing records and premium accounting practices. If The Company discovers:

1) an underpayment of premium by the Policyholder, the Policyholder will be obligated to remit, in a timely manner, the underpayment amount; or

2) an overpayment of premium, The Company will return any overpayment amount in a timely manner;

for the previous 2 year period.

Not in Lieu of Worker's Compensation This Policy does not satisfy any requirement for worker's compensation insurance.

Time Period All periods begin and end at 12:01 A.M., standard time, at the Policyholder's address.

Form GBD-1000 G.1 (10/08) (Rev-1) 11

INCORPORATION PROVISION

The Certificate(s) of Insurance and Rider(s) listed below are attached to, incorporated in and made a part of, The Policy.

Certificate(s) of Insurance Rider(s) Form GBD-1100 (10/08) GOV (Rev-1) (TX) (681835) 1.40 Form PA-9394 (10/08) (Rev-1) (681835) 1.01

Form PA-9394 (10/08) (Rev-1) (681835) 8.0 Form PA-10385 (Life) GOV (TX)

Form GBD-1100 (10/08) GOV (Rev-1) (TX) (681835) 2.31 Form PA-10385 (Life) GOV (TX)

The provisions found in the Certificate(s) of Insurance will address the benefit plan, period of coverage, exclusions, claims and other general policy provisions pertaining to state insurance law requirements.

Printed in U.S.A TX v.3

How you’re protected if your life or health insurance company fails

The Texas Life and Health Insurance Guaranty Association protects you by paying your covered claims if your life or health insurance company is insolvent (can’t pay its debts). This notice summarizes your protections.

The Association will pay your claims, with some exceptions required by law, if your company is licensed in Texas and a court has declared it insolvent. You must live in Texas when your company fails. If you don’t live in Texas, you may still have some protections.

For each insolvent company, the Association will pay a person’s claims only up to these dollar limits set by law:

· Accident, accident and health, or health insurance (including HMOs):

Up to $500,000 for health benefit plans, with some exceptions.

Up to $300,000 for disability income benefits.

Up to $300,000 for long-term care insurance benefits.

Up to $200,000 for all other types of health insurance.

· Life insurance:

Up to $100,000 in net cash surrender or withdrawal value.

Up to $300,000 in death benefits.

· Individual annuities:

Up to $250,000 in the present value of benefits, including cash surrender and net cash withdrawal values.

· Other policy types: Limits for group policies, retirement plans and structured settlement annuities are in Chapter 463 of the Texas Insurance Code.

· Individual aggregate limit: Up to $300,000 per person, regardless of the number of policies or contracts. A limit of $500,000 may apply for people with health benefit plans.

· Parts of some policies might not be protected: For example, there is not protection for parts of a policy or contract that the insurance company doesn’t guarantee, such as some additions to the value of variable life or annuity policies.

To learn more about the Association and your protections, contact:

Texas Life and Health Insurance Guaranty Association 515 Congress Avenue, Suite 1875 Austin, Texas 78701 1-800-982-6362 or www.txlifega.org

For questions about insurance, contact:

Texas Department of Insurance

P.O. Box 12030 Austin, Texas 78711-2030 1-800-252-3439 or www.tdi.texas.gov

Note: You’re receiving this notice because Texas law requires your insurance company to send you a summary of your protections under the Texas Life and Health Insurance Guaranty Association Act (Insurance Code, Chapter 463). These protections apply to insolvencies that occur on or after September 1, 2019. There may be other exceptions that aren’t included in this notice. When choosing an insurance company, you should not rely on the Association’s coverage.

Texas law prohibits companies and agents from using the Association as an inducement to buy insurance or HMO coverage.

Chapter 463 controls if there are differences between the law and this summary.