Life_Plan_Design_-_Retirees.pdf

Basic Term Life

YOUR

BENEFIT

PLAN

CITY OF TUCSON

Maryland

The group insurance policy providing coverage under this certificate was issued in a jurisdiction other than Maryland and may not provide all of the benefits required by Maryland law.

Version: February 2021

State Notices

IMPORTANT INFORMATION FOR RESIDENTS OF CERTAIN STATES: There are state-specific requirements that may change the provisions described in the group insurance certificate. If you live in a state that has such requirements, those requirements will apply to your coverage. State-specific requirements that may apply to your coverage are summarized below. In addition, updated state-specific requirements are published on our website.

You may access the website at https://www.thehartford.com/. If you are unable to access this website, want to receive a printed copy of these requirements, or have any questions or complaints regarding any of these requirements or any aspect of your coverage, please contact your Employee Benefits Manager; or you may contact us as follows:

The Hartford Group Benefits Division, Customer Service P.O. Box 2999 Hartford, CT 06104-2999 1-800-523-2233

If you have a complaint and contacts between you, us, your agent, or another representative have failed to produce a satisfactory solution to the problem, some states require we provide you with additional contact information. If your state requires such disclosure, the contact information is listed below with the other state requirements and notices.

We are providing notice that Hartford Life and Accident Insurance Company is subject to economic and trade sanctions laws and regulations. These laws and regulations, including the laws and regulations administered and enforced by the United States Department of the Treasury’s Office of Foreign Assets Control (“OFAC”), prevent Hartford Life and Accident from providing coverage to, and from paying benefits to, entities and individuals where prohibited by applicable law. In addition, these laws and regulations prohibit certain activities with respect to certain countries.

We have included this information to make you aware of the existence and potential impact of these economic and trade sanctions programs on your benefit program.

The Hartford complies with applicable Federal civil rights laws and does not unlawfully discriminate on the basis of race, color, national origin, age, disability, or sex. The Hartford does not exclude or treat people differently for any reason prohibited by law with respect to their race, color, national origin, age, disability, or sex.

If your policy is governed under the laws of Maryland, any of the benefits, provisions or terms that apply to the state you reside in as shown below will apply only to the extent that such state requirements are more beneficial to you.

Alaska:

1. If notice of Your Conversion Right is not received by You on the date Your or Your Dependent’s coverage terminates, You have 15 days from the date You receive the notice.

2. The Policy Interpretation provision, if shown in the General Provisions section of the Certificate, is not applicable.

3. The Spouse definition will always include domestic partners, civil unions, and any other legal union recognized by state law.

Arizona:

1. NOTICE: The Certificate may not provide all benefits and protections provided by law in Arizona. Please read the Certificate carefully.

Arkansas:

1. NOTICE: You have the right to file a complaint with the Arkansas Insurance Department (AID). You may call AID to request a complaint form at (800) 852-5494 or (501) 371-2640 or write the Department at:

Arkansas Insurance Department 1 Commerce Way, Suite 102 Little Rock, AR 72202

California:

1. The Policy Interpretation provision, if shown in the General Provisions section of the Certificate, does not apply to you. The following requirement applies to you:

Eligibility Determination: How will We determine Your or Your Dependent’s eligibility for benefits?

We, and not Your Employer or plan administrator, have the responsibility to fairly, thoroughly, objectively and timely investigate, evaluate and determine Your or Your Dependent’s eligibility for benefits for any claim You or Your beneficiaries make on The Policy. We will:

1) obtain with Your or Your beneficiaries’ cooperation and authorization if required by law, only such information that is necessary to evaluate Your or Your beneficiaries’ claim and decide whether to accept or deny Your or Your beneficiaries’ claim for benefits. We may obtain this information from Your or Your beneficiaries’ Notice of Claim, submitted proofs of loss, statements, or other materials provided by You or others on Your behalf; or, at Our expense We may obtain necessary information, or have You or Your Dependent’s physically examined when and as often as We may reasonably require while the claim is pending. In addition, and at Your or Your beneficiaries’ option and at Your or Your beneficiaries’ expense, You or Your beneficiaries may provide Us and We will consider any other information, including but not limited to, reports from a Physician or other expert of Your or Your beneficiaries’ choice. You or Your beneficiaries should provide Us with all information that You or Your beneficiaries want Us to consider regarding Your or Your beneficiaries’ claim;

2) As part of Our routine operations, We will apply the terms of The Policy for making decisions, including decisions on eligibility, receipt of benefits and claims or explaining policies, procedures and processes;

3) if We approve Your claim, We will review Our decision to approve Your or Your beneficiaries claim for benefits as often as is reasonably necessary to determine Your or Your Dependent’s continued eligibility for benefits;

4) if We deny Your or Your beneficiaries’ claim, We will explain in writing to You or Your beneficiaries the basis for an adverse determination in accordance with The Policy as described in the provision entitled Claim Denial.

In the event We deny Your or Your beneficiaries’ claim for benefits, in whole or in part, You or Your beneficiaries can appeal the decision to Us. If You or Your beneficiaries choose to appeal Our decision, the process You or Your beneficiaries must follow is set forth in The Policy provision entitled Claim Appeal. If You or Your beneficiaries do not appeal the decision to Us, then the decision will be Our final decision.

2. For Your Questions and Complaints:

State of California Insurance Department Consumer Communications Bureau 300 South Spring Street, South Tower Los Angeles, CA 90013 Toll Free: 1(800) 927-HELP TDD Number: 1(800) 482-4833 Web Address: www.insurance.ca.gov

Colorado:

1. The Suicide provision will only exclude amounts of life insurance in effect within the first year of coverage or within the first year following an increase in coverage.

2. The Dependent Child(ren) definition will always include children related to You by civil union.

3. The Spouse definition will always include civil unions.

4. Entering a civil union, terminating a civil union, the death of a party to a civil union or a party to a civil union losing employment, which results in a loss of group insurance, will all constitute as a Change in Family Status.

Florida:

1. Legal Actions cannot be taken against Us more than 5 years after the date Proof of Loss is required to be furnished according to the terms of The Policy.

2. NOTICE: The benefits of the policy providing you coverage may be governed primarily by the laws of a state other than Florida.

Georgia:

1. NOTICE: 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 abuse.

Idaho:

1. For Your Questions and Complaints:

Idaho Department of Insurance

Consumer Affairs 700 W State Street, 3rd Floor PO Box 83720 Boise, ID 83720-0043 Toll Free: 1-800-721-3272 Web Address: www.DOI.Idaho.gov

Illinois:

1. For Your Questions and Complaints:

Illinois Department of Insurance Consumer Services Station Springfield, Illinois 62767 Consumer Assistance: 1(866) 445-5364 Officer of Consumer Health Insurance: 1(877) 527-9431

2. In accordance with Illinois law, insurers are required to provide the following NOTICE to applicants of insurance policies issued in Illinois.

STATE OF ILLINOIS

The Religious Freedom Protection and Civil Union Act

Effective June 1, 2011

The Religious Freedom Protection and Civil Union Act (“the Act”) creates a legal relationship between two persons of the same or opposite sex who form a civil union. The Act provides that the parties to a civil union are entitled to the same legal obligations, responsibilities, protections and benefits that are afforded or recognized by the laws of Illinois to spouses. The law further provides that a party to a civil union shall be included in any definition or use of the terms “spouse,” “family,” “immediate family,” “dependent,” “next of kin,” and other terms descriptive of spousal relationships as those terms are used throughout Illinois law. This includes the terms “marriage” or “married,” or variations thereon. Insurance policies are required to provide identical benefits and protections to both civil unions and marriages. If policies of insurance provide coverage for children, the children of civil unions must also be provided coverage. The Act also requires recognition of civil unions or same sex civil unions or marriages legally entered into in other jurisdictions.

For more information regarding the Act, refer to 750 ILCS 75/1 et seq. Examples of the interaction between the Act and existing law can be found in the Illinois Insurance Facts, Civil Unions and Insurance Benefits document available on the Illinois Department of Insurance’s website at www.insurance.illinois.gov.

Indiana:

1. For Your Questions and Complaints:

Public Information/Market Conduct Indiana Department of Insurance 311 W. Washington St. Suite 300 Indianapolis, IN 46204-2787 1(317) 232-2395

Louisiana:

1. The age limit stated in the Continuation for Dependent Child(ren) with Disabilities provision is increased to 21, if less than 21.

2. The following requirement applies to you:

Reinstatement after Military Service: Can coverage be reinstated after return from active military service?

If Your or Your Dependents’ coverage ends because You or Your Dependents enter active military service, coverage may be reinstated, provided You request such reinstatement upon Your or Your Dependents’ release from active military service.

The reinstated coverage will:

1) be the same coverage amounts in force on the date coverage ended;

2) not be subject to any Eligibility Waiting Period for Coverage or Evidence of Insurability; and

3) be subject to all the terms and provisions of The Policy.

Maine:

1. NOTICE: The laws of the State of Maine require notification of the right to designate a third party to receive notice of cancellation, to change such a designation and, to have the Policy reinstated if the insured suffers from cognitive impairment or functional incapacity and the ground for cancellation was the insured's nonpayment of premium or other lapse or default on the part of the insured.

Within 10 days after a request by an insured, a Third Party Notice Request Form shall be mailed or personally delivered to the insured.

Massachusetts:

1. The definition of Terminal Illness or Terminally Ill shown in the Accelerated Benefit cannot exceed 24 months.

2. NOTICE: As of January 1, 2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen (18) years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement based on affordability or individual hardship. For more information call the Connector at 1-877-MA-ENROLL or visit the Connector website (www.mahealthconnector.org).

This plan is not intended to provide comprehensive health care coverage and does not meet Minimum Creditable Coverage standards, even if it does include services that are not available in the insured’s other health plans.

If you have questions about this notice, you may contact the Division of Insurance by calling (617) 521- 7794 or visiting its website at www.mass.gov/doi.

Michigan:

1. The Policy Interpretation provision, if shown in the General Provisions section of the Certificate, is not applicable.

Minnesota:

1. You or Your Dependents must be on a documented military leave of absence in order to qualify for the Military

Leave of Absence continuation shown in the Continuation Provisions.

2. If there are 25 or more residents of Minnesota who are covered under The Policy, or there are fewer than 25 residents and those residents constitute 25% or more of the total number of people covered under The Policy, the Lay Off continuation shown in the Continuation Provisions shall not apply to you. The following requirement applies to you:

Minnesota Coverage Continuation: If You are voluntarily or involuntarily terminated or Laid Off by the Employer, You may elect to continue Your Life Insurance coverage (including Dependent Life coverage) by making premium payments to the Employer for the cost of continued coverage. Continued coverage will take effect on the date Your coverage would otherwise have ended and must be elected within 60 days from:

1) the date Your coverage would otherwise terminate; or

2) the date You receive a written notice of Your right to continue coverage from the Employer;

whichever is later.

The amount of premium charged may not exceed 102% of the premium paid for other similarly situated employees who are Actively at Work. The Employer will inform You of:

1) Your right to continue coverage;

2) the amount of premium; and

3) how, where and by when payment must be made.

Upon request, the Employer will provide You Our written verification of the cost of coverage.

Coverage will be continued until the earliest of:

1) the date You are covered under another group policy;

2) the date the required premium is due but not paid; or

3) the last day of the 18th month following the date of termination or Lay Off.

Upon the termination of continued coverage, You may:

1) exercise Your Conversion Right; or

2) continue coverage under a group Portability policy; and

3) qualify for Retiree coverage.

Minnesota law requires that if Your coverage ends because the Employer fails to notify You of Your right to continue coverage or fails to pay the premium after timely receipt, the Employer will be liable for benefit payments to the extent We would have been liable had You still been covered.

3. If the following paragraph appears in the Accelerated Benefit provision, it does not apply to you:

In the event:

1) You are required by law to accelerate benefits to meet the claims of creditors; or

2) if a government agency requires You to apply for benefits to qualify for a government benefit or entitlement;

You will still be required to satisfy all the terms and conditions herein in order to receive an Accelerated Benefit

4. If there are 25 or more residents of Minnesota who are covered under The Policy and those 25 residents constitute 25% or more of the total number of people covered under The Policy, You are not required to be insured under The Policy for a specified period of time in order to exercise the Conversion Right.

Missouri:

1. The period in which You must remain Disabled to qualify for Waiver of Premium cannot exceed 180 days.

2. If Waiver of Premium is approved and You have completed the elimination period, We will retroactively refund to

You, or to Your estate if You have died, any premiums paid during the period You have been continuously Disabled.

3. The Suicide provision will only exclude amounts of life insurance in effect within the first year of coverage or within the first year following an increase in coverage.

Montana:

1. The time period in which You are required to be insured under The Policy in order to exercise the Conversion

Right cannot exceed 3 years.

2. If You are eligible to receive the Felonious Assault Benefit, We will not exclude for losses that result from a

Felonious Assault committed by a member of Your family or a member of the household in which You live.

3. NOTICE: Conformity with Montana statutes: The provisions of the certificate conform to the minimum requirements of Montana law and control over any conflicting statutes of any state in which the insured resides on or after the effective date of the certificate

New Hampshire:

1. Your Spouse may be eligible to continue his or her Life Insurance coverage in the event of divorce or separation as shown in the Spouse Continuation below:

Spouse Continuation: Can coverage for my Spouse be continued in the event of divorce or separation?

If:

1) You are a resident of New Hampshire;

2) You get a divorce or legal separation from a Spouse that is covered under The Policy; and

3) the final decree of divorce or legal separation does not expressly prohibit it;

Your former Spouse may continue his or her coverage.

We must receive Your Spouse's written request and the required premium to continue his or her coverage within 30 days of the final decree of divorce or legal separation.

Solely for the purpose of continuing the coverage, Your Spouse will be considered the insured person. However, Your former Spouse’s coverage will not continue beyond the earliest of:

1) the 3-year anniversary of the final decree of divorce or legal separation;

2) the remarriage of the former Spouse;

3) Your death;

4) an earlier time as provided by the final decree of divorce or legal separation; or

5) a date the coverage would otherwise have ended under the Dependent Termination Provision.

New Mexico:

1. For Your Questions and Complaints:

Office of Superintendent of Insurance Consumer Assistance Bureau

P.O. Box 1689 Santa Fe, NM 87504-1689 1(855) 427-5674

New York:

1. If the definition of Spouse requires the completion of a domestic partner affidavit, the requirement applies to you:

The domestic partner affidavit must be notarized and requires that You and Your domestic partner meet all of the following criteria:

1) you are both legally and mentally competent to consent to contract in the state in which you reside;

2) you are not related by blood in a manner that would bar marriage under laws of the state in which you reside;

3) you have been living together on a continuous basis prior to the date of the application;

4) neither of you have been registered as a member of another domestic partnership within the last six months; and

5) you provide proof of cohabitation (e.g., a driver’s license, tax return or other sufficient proof).

The domestic partner affidavit further requires that You and Your domestic partner provide proof of financial interdependence in the form of at least two of the following:

1) a joint bank account;

2) a joint credit card or charge card;

3) joint obligation on a loan;

4) status as an authorized signatory on the partner’s bank account, credit card or charge card;

5) joint ownership of holdings or investments, residence, real estate other than residence, major items of personal property (e.g., appliances, furniture), or a motor vehicle;

6) listing of both partners as tenants on the lease of the shared residence;

7) shared rental payments of residence (need not be shared 50/50)

8) listing of both partners as tenants on a lease, or shared rental payments, for property other than residence;

9) a common household and shared household expenses (e.g., grocery bills, utility bills, telephone bills, etc.

and need not be shared 50/50);

10) shared household budget for purposes of receiving government benefits;

11) status of one as representative payee for the other’s government benefits;

12) joint responsibility for child care (e.g., school documents, guardianship);

13) shared child-care expenses (e.g., babysitting, day care, school bills, etc. and need not be shared 50/50);

14) execution of wills naming each other as executor and/or beneficiary;

15) designation as beneficiary under the other’s life insurance policy;

16) designation as beneficiary under the other’s retirement benefits account;

17) mutual grant of durable power of attorney;

18) mutual grant of authority to make health care decisions (e.g., health care power of attorney);

19) affidavit by creditor or other individual able to testify to partners’ financial interdependence;

20) other item(s) of proof sufficient to establish economic interdependency under the circumstances of the particular case.

North Carolina:

1. NOTICE: UNDER NORTH CAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON,

EMPLOYER, FINANCIAL AGENT, TRUSTEE, OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE

FOR THE PAYMENT OF GROUP LIFE INSURANCE, GROUP HEALTH OR GROUP HEALTH PLAN

PREMIUMS, SHALL:

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

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 PERSON 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 WRITTEN NOTICE OF THE

PERSON'S INTENTION TO STOP PAYMENT OF PREMIUMS. 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.

IMPORTANT TERMINATION INFORMATION

YOUR INSURANCE MAY BE CANCELLED BY THE COMPANY. PLEASE READ THE TERMINATION

PROVISION IN THE CERTIFICATE.

THE CERTIFICATE OF INSURANCE PROVIDES COVERAGE UNDER A GROUP MASTER POLICY.

THE CERTIFICATE PROVIDES ALL OF THE BENEFITS MANDATED BY THE NORTH CAROLINA

INSURANCE CODE, BUT YOU MAY NOT RECEIVE ALL OF THE PROTECTIONS PROVIDED BY A POLICY

ISSUED IN NORTH CAROLINA AND GOVERNED BY ALL OF THE LAWS OF NORTH CAROLINA.

North Dakota:

1. The Suicide provision will only exclude amounts of life insurance in effect within the first year of coverage or within the first year following an increase in coverage.

Ohio:

1. Any references to the Accelerated Benefit shall be changed to the Accelerated Death Benefit.

Oregon:

1. The Spouse definition will include Your domestic partner provided You have registered as domestic partners with a government agency or office where such registration is available. You will not be required to provide proof of such registration.

2. The Dependent Child(ren) definition will include children related to You by domestic partnership.

3. The following Jury Duty continuation applies for Employers with 10 or more employees:

Jury Duty: If You are scheduled to serve or are required to serve as a juror, Your coverage may be continued until the last day of Your Jury Duty, provided You:

1) elected to have Your coverage continued; and

2) provided notice of the election to Your Employer in accordance with Your Employer’s notification policy.

Rhode Island:

1. The Policy Interpretation provision, if shown in the General Provisions section of the Certificate, is not applicable.

South Carolina:

1. The dollar amount stated in the third paragraph of the Claims to be Paid provision is changed to $2,000, if greater than $2,000.

2. If the Continuity from a Prior Policy for Disability Extension provision is included in the Certificate and You qualify for continued coverage, Your Amount of Insurance will be the greater of the amount of life insurance and accidental death and dismemberment principal sum that You had under the Prior Policy or the amount shown in the Schedule of Insurance. This Amount of Insurance will be reduced by any coverage amount that is in force, paid or payable under the Prior Policy or that would have been payable under the Prior Policy had timely election been made.

3. If The Policy Terminates or Your Employer ceases to be a Participating Employer and You have been approved for the Waiver of Premium, Your coverage under the terms of this provision will not be affected. Your Dependent coverage will continue for a period of 12 months from the date of Policy termination and will be subject to the terms and conditions of The Policy.

4. If The Policy Terminates or Your Employer ceases to be a Participating Employer and You have been approved for the Disability Extension, Your and Your Dependent’s coverage will be continued for a period of up to 12 months from the date The Policy terminated or Your Employer ceased to be a Participating Employer, as long as premiums are paid when due. Coverage during this period will be subject to the other terms and conditions of the Disability Extension Ceases provision. When this extension period is exhausted, You may be eligible to exercise the Conversion Right for You and Your Dependent’s coverage. Portability Benefits will not be available

South Dakota:

1. The definition of Physician can include You or a person Related to You by blood or marriage in the event that the

Physician is the only one in the area and is acting within the scope of their normal employment.

Texas:

1. The Policy Interpretation provision, if shown in the General Provisions section of the Certificate, is not applicable.

2. NOTICE:

Have a complaint or need help?

If you have a problem with a claim or your premium, call your insurance company first. If you can't work out the issue, the Texas Department of Insurance may be able to help.

Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company. If you don't, you may lose your right to appeal.

Hartford Life and Accident Insurance Company To get information or file a complaint with your insurance company:

Call: Customer Service at 860-547-5000

Toll-free: 1-800-523-2233

Online: https://www.thehartford.com/contact-the-hartford Email: GBD.Customerservice@hartfordlife.com Mail: The Hartford, Group Benefits Division, P.O. Box 2999, Hartford, CT 06104-2999

The Texas Department of Insurance To get help with an insurance question or file a complaint with the state:

Call with a question: 1-800-252-3439

File a complaint: www.tdi.texas.gov Email: ConsumerProtection@tdi.texas.gov Mail: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091

¿Tiene una queja o necesita ayuda?

Si tiene un problema con una reclamación o con su prima de seguro, llame primero a su compañía de seguros. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department of Insurance, por su nombre en inglés) pueda ayudar.

Aun si usted presenta una queja ante el Departamento de Seguros de Texas, también debe presentar una queja a través del proceso de quejas o de apelaciones de su compañía de seguros. Si no lo hace, podría perder su derecho para apelar.

Hartford Life and Accident Insurance Company Para obtener información o para presentar una queja ante su compañía de seguros:

Llame a: servicio al cliente al 860-547-5000

Teléfono gratuito: 1-800-523-2233

En línea: https://www.thehartford.com/contact-the-hartford Correo electrónico: GBD.Customerservice@hartfordlife.com Dirección postal: The Hartford, Group Benefits Division, P.O. Box 2999, Hartford, CT 06104-2999

El Departamento de Seguros de Texas Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una queja ante el estado:

Llame con sus preguntas al: 1-800-252-3439

Presente una queja en: www.tdi.texas.gov Correo electrónico: ConsumerProtection@tdi.texas.gov Dirección postal: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091

Utah:

1. We will send Claim Forms within 15 days of receiving a Notice of Claim. If We do not send the forms within 15 days, any other written proof which fully describes the nature and extent of the claim may be submitted.

2. If the Sending Proof of Loss provision provides a timeframe in which proof must be submitted before it affects

Your claim, this time limitation shall not apply to You.

3. When We determine that benefits are payable, We will make Claim Payments within no more than 45 days after

Proof of Loss is received.

4. Any reference to fraud within the Incontestability provision does not apply to You.

5. A Sickness or Injury continuation of at least 6 months must be included in the Continuation Provisions.

Vermont:

1. The following requirement applies:

Purpose: This requirement is intended to provide benefits for parties to a civil union. Vermont law requires that insurance contracts and policies offered to married persons and their families be made available to parties to a civil union and their families. In order to receive benefits in accordance with this requirement, the civil union must have been established in the state of Vermont according to Vermont law.

General Definitions, Terms, Conditions and Provisions: The general definitions, terms, conditions or any other provisions of the policy, contract, certificate and/or riders and endorsements are hereby superseded as follows:

1) Terms that mean or refer to a marital relationship or that may be construed to mean or refer to a marital relationship: such as "marriage", "spouse", "husband", "wife", "dependent", "next of kin", "relative", "beneficiary", "survivor", "immediate family" and any other such terms include the relationship created by a civil union.

2) Terms that mean or refer to a family relationship arising from a marriage such as "family", "immediate family", "dependent", "children", "next of kin", "relative", "beneficiary", "survivor" and any other such terms include the family relationship created by a civil union.

3) Terms that mean or refer to the inception or dissolution of a marriage, such as "date of marriage", "divorce decree", "termination of marriage" and any other such terms include the inception or dissolution of a civil union.

4) "Dependent" means a spouse, a party to a civil union, and/or a child or children (natural, stepchild, legally adopted or a minor who is dependent on the insured for support and maintenance) who is born to or brought to a marriage or to a civil union.

5) "Child or covered child" means a child (natural, step-child, legally adopted or a minor who is dependent on the insured for support and maintenance) who is born to or brought to a marriage or to a civil union.

Cautionary Disclosure: THIS NOTICE IS ISSUED TO MEET THE REQUIREMENTS OF VERMONT LAW AS

EXPLAINED IN THE "PURPOSE" PARAGRAPH OF THE NOTICE. THE FEDERAL GOVERNMENT OR

ANOTHER STATE GOVERNMENT MAY NOT RECOGNIZE THE BENEFITS GRANTED UNDER THIS

NOTICE. YOU ARE ADVISED TO SEEK EXPERT ADVICE TO DETERMINE YOUR RIGHTS UNDER THIS

CONTRACT

2. Interest on a Claim Payment is payable from the date of death until the date payment is made at an interest rate of 6% annually or Our corporate interest rate, whichever is greater.

Virginia:

1. For Your Questions and Complaints:

Life and Health Division Bureau of Insurance P.O. Box 1157 Richmond, VA 23209 1(804) 371-9741 (inside Virginia) 1(800) 552-7945 (outside Virginia)

Washington:

1. The following Disputed Diagnosis requirement applies to You:

Disputed Diagnosis: What happens if a dispute occurs over whether I am Terminally Ill or my Dependent is Terminally Ill?

If Your or Your Dependent's attending Physician, and a Physician appointed by Us, disagree on whether You or Your Dependent are Terminally Ill, Our Physician’s opinion will not be binding upon You or Your Dependent. The two parties shall attempt to resolve the matter promptly and amicably. If the disagreement is not resolved, You or Your Dependent have the right to mediation or binding arbitration conducted by a disinterested third party who has no ongoing relationship with either You or Your Dependent or Us. Any such arbitration shall be conducted in accordance with the laws of the State of Washington. As part of the final decision, the arbitrator or mediator shall award the costs of the arbitrator to one party or the other, or may divide the costs equally or otherwise.

2. A Labor Dispute continuation of at least 6 months must be included in the Continuations Provisions.

3. The Dependent Child(ren) definition will always include children related to You by domestic partnership.

4. The definition of Spouse will always include domestic partners.

5. The provision titled Suicide does not apply to you.

Wisconsin:

1. For Your Questions and Complaints:

To request a Complaint Form:

Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 1(800) 236-8517 (outside of Madison) 1(608) 266-0103 (in Madison)

Form GBD-1100 (10/08) (681052) 3.09

Group Term Life Insurance

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

One Hartford Plaza

Hartford, Connecticut 06155 (A stock insurance company)

CERTIFICATE OF INSURANCE

Policyholder: CITY OF TUCSON Policy Number: GL-681052 Policy Effective Date: July 1, 2017 Policy Anniversary Date: July 1, 2021

We have issued The Policy to the Policyholder. Our name, the Policyholder's name and the Policy Number are shown above. The provisions of The Policy, which are important to You, are summarized in this certificate consisting of this form and any additional forms which have been made a part of this certificate. This certificate replaces any other certificate We may have given to You earlier under The Policy. The Policy alone is the only contract under which payment will be made.

Any difference between The Policy and this certificate will be settled according to the provisions of The Policy on file with Us at Our home office. The Policy may be inspected at the office of the Policyholder.

Signed for the Company

A note on capitalization in this Certificate:

Capitalization of a term, not normally capitalized according to the rules of standard punctuation, indicates a word or phrase that is a defined term in The Policy or refers to a specific provision contained herein.

TABLE OF CONTENTS

SCHEDULE OF INSURANCE

Cost of Coverage Eligible Class(es) for Coverage Eligibility Waiting Period for Coverage Benefit Amounts

ELIGIBILITY AND ENROLLMENT

Eligible Persons Eligibility for Coverage Enrollment

PERIOD OF COVERAGE

Deferred Effective Date

BENEFITS

Life Insurance Benefit Conversion Right

GENERAL PROVISIONS

DEFINITIONS

SCHEDULE OF INSURANCE

The benefits described herein are those in effect as of January 1, 2020.

Cost of Coverage:

Non-Contributory Coverage: Retiree Life Insurance

Eligible Class(es) For Coverage: All Retirees who were hired prior to January 1, 2016 or laid off on or after January 1, 2016 and then later rehired from a lay-off rehire list, excluding medical retirees, who are citizens or legal residents of the United States, its territories and protectorates.

Eligibility Waiting Period for Coverage:

None

Life Insurance Benefit

Amount of Life Insurance:

Retiree Life Insurance

Maximum Amount

$7,500

Reduction in Amount of Life Insurance We will reduce the Amount of Life Insurance for You by any Amount of Life Insurance in force, paid or payable in accordance with the Conversion Right.

ELIGIBILITY AND ENROLLMENT

Eligible Persons: Who is eligible for coverage?

All persons in the class or classes shown in the Schedule of Insurance will be considered Eligible Persons.

Eligibility for Coverage: When will I become eligible?

You are eligible for Retiree coverage on the later of:

1) the date You meet the definition of Retiree; or

2) the Policy Effective Date.

Enrollment: How do I enroll for coverage?

Your Employer will automatically enroll You for coverage. However, You will be required to complete a beneficiary designation form.

You must enroll for Retiree Coverage within 31 days of the date You retire.

PERIOD OF COVERAGE

Effective Date of Retiree Coverage: When does my Retiree Coverage start?

Coverage will start on the date You become eligible.

Deferred Effective Date provisions will only apply to increases in coverage or new benefits.

Deferred Effective Date: When will my effective date for coverage or a change in my coverage be deferred?

If, on the date You are to become covered:

1) for increased benefits; or

2) for a new benefit;

You are:

1) confined in a hospital; or

2) Confined Elsewhere;

such coverage will not start until You:

1) are discharged from the hospital; or

2) are no longer Confined Elsewhere;

and have engaged in all the normal and customary activities of a person of like age and gender, in good health, for at least 15 consecutive days.

Confined Elsewhere means You are unable to perform, unaided, the normal functions of daily living, or leave home or other place of residence without assistance.

Retiree Coverage Termination: When will my Retiree Coverage End?

Your coverage will end on the earliest of the following:

1) the date The Policy Terminates;

2) the date You are no longer in a class eligible for coverage, or the class is cancelled; or

3) the date the required premium is due but not paid.

BENEFITS

Life Insurance Benefit: When is the Life Insurance Benefit payable?

If You die while covered under The Policy, We will pay Your Life Insurance Benefit after We receive Proof of Loss, in accordance with the Proof of Loss provision.

The Life Insurance Benefit will be paid according to the General Provisions of The Policy.

Conversion Right: If coverage under The Policy ends, do I have a right to convert?

If Life Insurance coverage or any portion of it under The Policy ends for any reason, You have the right to convert the coverage that terminated to an individual conversion policy without providing Evidence of Insurability. Conversion is not available for any Amount of Life Insurance for which You were not eligible and covered under The Policy.

If coverage under The Policy ends because:

1) The Policy is terminated; or,

2) coverage for an Eligible Class is terminated;

then You must have been insured under The Policy for 5 years or more, in order to be eligible to convert coverage. The amount which may be converted under these circumstances is limited to the lesser of:

1) $10,000; or

2) the Life Insurance Benefit under The Policy less any Amount of Life Insurance for which You may become eligible under any group life insurance policy issued or reinstated within 31 days of termination of group life coverage.

If coverage under The Policy ends for any other reason, the full amount of coverage which ended may be converted.

Insurer, as used in this provision, means Us or another insurance company which has agreed to issue conversion policies according to this Conversion Right.

Conversion: How do I convert my coverage?

To convert Your coverage You must:

1) complete a Notice of Conversion Right form; and

2) have Your Employer sign the form.

The Insurer must receive this within:

1) 31 days after Life Insurance terminates; or

2) 15 days from the date Your Employer signs the form;

whichever is later. However, We will not accept requests for Conversion if they are received more than 91 days after Life Insurance terminates.

After the Insurer verifies eligibility for coverage, the Insurer will send You a Conversion Policy proposal. You must:

1) complete and return the request form in the proposal; and

2) pay the required premium for coverage;

within the time period specified in the proposal.

Any individual policy issued to You under the Conversion Right:

1) will be effective as of the 32nd day after the date coverage ends; and

2) will be in lieu of coverage for this amount under The Policy.

Conversion Policy Provisions: What are the Conversion Policy provisions?

The Conversion Policy will:

1) be issued on any one of the Life Insurance policy forms the Insurer is issuing for this purpose at the time of conversion; and

2) base premiums on the Insurer's rates in effect for new applicants of Your class and age at the time of conversion.

The Conversion Policy will not provide:

1) the same terms and conditions of coverage as The Policy;

2) any benefit other than the Life Insurance Benefit; and

3) term insurance.

Death within the Conversion Period: What if I die before coverage is converted?

We will pay Your Amount of Life Insurance You would have had the right to apply for under this provision if:

1) coverage under The Policy terminates; and

2) You die within 31 days of the date coverage terminates; and

3) We receive Proof of Loss.

If the Conversion Policy has already taken effect, no Life Insurance Benefit will be payable under The Policy for the amount converted.

GENERAL PROVISIONS

Notice of Claim: When should I notify the Company of a claim?

You, or the person who has the right to claim benefits, must give Us, written notice of a claim within 30 days after the date of death.

If notice cannot be given within that time, it must be given as soon as reasonably possible after that. Such notice must include the claimant’s name, address, and the Policy Number.

Claim Forms: Are special forms required to file a claim?

We will send forms to the claimant to provide Proof of Loss, within 15 days of receiving a Notice of Claim. If We do not send the forms within 15 days, the claimant may submit any other written proof which fully describes the nature and extent of the claim.

Proof of Loss: What is Proof of Loss?

Proof of Loss may include, but is not limited to, the following:

1) a completed claim form;

2) a certified copy of the death certificate (if applicable);

3) Your Beneficiary Designation (if applicable);

4) documentation of:

a) the date Your disability began;

b) the cause of Your disability; and

c) the prognosis of Your disability;

5) any and all medical information, including x-ray films and photocopies of medical records, including histories, physical, mental or diagnostic examinations and treatment notes;

6) the names and addresses of all:

a) Physicians or other qualified medical professionals You have consulted;

b) hospitals or other medical facilities in which You have been treated; and

c) pharmacies which have filled Your prescriptions within the past three years;

7) Your signed authorization for Us to obtain and release medical, employment and financial information (if applicable); or

8) any additional information required by Us to adjudicate the claim.

All proof submitted must be satisfactory to Us.

Sending Proof of Loss: When must Proof of Loss be given?

Written Proof of Loss should be sent to Us or Our representative within 365 day(s) after the loss. However, all claims should be submitted to Us within 90 days of the date coverage ends.

If proof is not given by the time it is due, it will not affect the claim if:

1) it was not reasonably possible to give proof within the required time; and

2) proof is given as soon as reasonably possible; but

3) not later than 1 year after it is due unless You, or the person who has the right to claim benefits, are not legally competent.

Physical Examination and Autopsy: Can We have a claimant examined or request an autopsy?

While a claim is pending We have the right at Our expense:

1) to have the person who has a loss examined by a Physician when and as often as We reasonably require; and

2) to have an autopsy performed in case of death where it is not forbidden by law.

Claim Payment: When are benefit payments issued?

When We determine that benefits are payable, We will pay the benefits in accordance with the Claims to be Paid provision, but not more than 30 days after such Proof of Loss is received.

Benefits may be subject to interest payments as required by applicable law.

Claims to be Paid: To whom will benefits for my claim be paid?

Life Insurance Benefits will be paid in accordance with the life insurance Beneficiary Designation.

If no beneficiary is named, or if no named beneficiary survives You, We may, at Our option, pay:

1) the executors or administrators of Your estate;

2) all to Your surviving spouse;

3) if Your spouse does not survive You, in equal shares to Your surviving children; or

4) if no child survives You, in equal shares to Your surviving parents.

In addition, We may, at Our option, pay a portion of Your Life Insurance Benefit up to $250 to any person equitably entitled to payment by reason of having incurred expenses on Your behalf or because of expenses from Your burial.

Payment to any person, as shown above, will release Us from liability for the amount paid.

If any beneficiary is a minor, We may pay his or her share, until a legal guardian of the minor’s estate is appointed, to a person who at Our option and in Our opinion is providing financial support and maintenance for the minor. We will pay:

1) $200 at Your death; and

2) monthly installments of not more than $200.

Payment to any person as shown above will release Us from all further liability for the amount paid.

If benefits are payable and meet Our guidelines, then You, or your Beneficiary, may elect to receive benefits in a lump sum payment or may elect to receive benefits through a draft book account. The draft book account will be owned by:

1) You, if living; or

2) Your beneficiary, in the event of Your death.

However, an account will not be established for a benefit payable to Your estate.

We will make any payments, other than for loss of life, to You. We may make any such payments owed at Your death to Your estate. If any payment is owed to:

1) Your estate;

2) a person who is a minor; or

3) a person who is not legally competent, then We may pay up to $1,000 to a person who is related to You and who, at Our sole discretion, is entitled to it. Any such payment shall fulfill Our responsibility for the amount paid.

Beneficiary Designation: How do I designate or change my beneficiary?

You may designate or change a beneficiary by doing so in writing on a form satisfactory to Us and filing the form with the Employer. Only satisfactory forms sent to the Employer prior to Your death will be accepted.

Beneficiary designations will become effective as of the date You signed and dated the form, even if You have since died.

We will not be liable for any amounts paid before receiving notice of a beneficiary change from the Employer.

In no event may a beneficiary be changed by a power of attorney.

Claim Denial: What notification will my beneficiary or I receive if a claim is denied?

If a claim for benefits is wholly or partly denied, You or Your beneficiary will be furnished with written notification of the decision. This written notification will:

1) give the specific reason(s) for the denial;

2) make specific reference to the provisions upon which the denial is based;

3) provide a description of any additional information necessary to perfect a claim and an explanation of why it is necessary; and

4) provide an explanation of the review procedure.

Claim Appeal: What recourse do my beneficiary or I have if a claim is denied?

On any claim, the claimant or his or her representative may appeal to Us for a full and fair review. To do so, he or she:

1) must request a review upon written application within:

a) 180 days of receipt of claim denial if the claim requires Us to make a determination of disability; or

b) 60 days of receipt of claim denial if the claim does not require Us to make a determination of disability; and

2) may request copies of all documents, records, and other information relevant to the claim; and

3) may submit written comments, documents, records and other information relating to the claim.

We will respond in writing with Our final decision on the claim.

Policy Interpretation: Who interprets the terms and conditions of The Policy?

We have full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of The Policy.

Incontestability: When can the Life Insurance Benefit of The Policy be contested?

Except for non-payment of premiums, Your Life Insurance Benefit cannot be contested after two years from its effective date.

In the absence of fraud, no statement made by You relating to Your insurability will be used to contest Your insurance for which the statement was made after Your insurance has been in force for two years. In order to be used, the statement must be in writing and signed by You.

All statements made by the Policyholder, the Employer or You 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 Your representative.

Assignment: Are there any rights of assignment?

You have the right to absolutely assign all of Your rights and interest under The Policy including, but not limited to the following:

1) the right to make any contributions required to keep the insurance in force;

2) the right to convert; and

3) the right to name and change a beneficiary.

We will recognize any absolute assignment made by You under The Policy, provided:

1) it is duly executed; and

2) a copy is acknowledged and on file with Us.

We and the Policyholder assume no responsibility:

1) for the validity or effect of any assignment; or

2) to provide any assignee with notices which We may be obligated to provide to You.

You do not have the right to collaterally assign Your rights and interest under The Policy.

Legal Actions: When can legal action be taken against Us?

Legal action cannot be taken against Us:

1) sooner than 60 days after the date written Proof of Loss is furnished; or

2) more than 6 years after the date Proof of Loss is required to be furnished according to the terms of The Policy.

Workers' Compensation: How does The Policy affect Workers' Compensation coverage?

The Policy does not replace Workers' Compensation or affect any requirement for Workers' Compensation coverage.

Insurance Fraud: How does the Company deal with fraud?

Insurance fraud occurs when You, and/or the Employer provide Us with false information or file a claim for benefits that contains any false, incomplete or misleading information with the intent to injure, defraud or deceive Us. It is a crime if You, and/or the Employer commit insurance fraud. We will use all means available to Us to detect, investigate, deter and prosecute those who commit insurance fraud. We will pursue all available legal remedies if You and/or the Employer perpetrate insurance fraud.

Misstatements: What happens if…