Short_Term_Disability_Policy_CITY_OF_ROSENBERG_EMPLOYEE_TRUST_GVDI_CONTRACT.pdf

AMERICAN HERITAGE LIFE INSURANCE COMPANY

HOME OFFICE:

1776 AMERICAN HERITAGE LIFE DRIVE

JACKSONVILLE, FLORIDA 32224-6687

(904) 992-1776

A Stock Company

GROUP DISABILITY INSURANCE POLICY

NON-PARTICIPATING

American Heritage Life Insurance Company (referred to as we, us, or our) will provide benefits under this policy. We make this promise subject to all of the provisions of this policy.

The policyholder should read this group policy carefully and contact us promptly with any questions. This group policy is delivered in and is governed by the laws of the governing jurisdiction and, to the extent applicable, by the Employee Retirement Income Security Act of 1974 (ERISA), and consists of:

1. all policy provisions and any amendments and/or attachments issued; and

2. the employer’s signed application.

This policy may be changed in whole or in part. The approval must be in writing, signed by one of our executive officers and endorsed on or attached to this policy. No other person, including an agent, may change this policy or waive any part of it.

Signed for American Heritage Life Insurance Company at its Home Office in Jacksonville, Florida on the policy effective date.

Secretary President

THIS IS A GROUP DISABILITY ONLY POLICY WHICH PROVIDES

BENEFITS FOR DISABILITIES AS STATED WITHIN THIS POLICY

THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER

TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON- SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS'

COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS COMPENSATION LAW AS IT PERTAINS TO

NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

GVDIEPTX Page 1

IMPORTANT NOTICE AVISO IMPORTANTE

TO OBTAIN INFORMATION OR MAKE A

COMPLAINT:

PARA OBTENER INFORMACION O PARA

SOMETER UNA QUEJA:

YOU MAY CALL AMERICAN HERITAGE LIFE

INSURANCE COMPANY'S TOLL-FREE

TELEPHONE NUMBER FOR INFORMATION

OR TO MAKE A COMPLAINT AT

1-800-535-8086

USTED PUEDE LLAMAR AL NUMERO DE

TELEFONO GRATIS DE AMERICAN

HERITAGE LIFE INSURANCE COMPANY'S

PARA INFORMACION O PARA SOMETER

UNA QUEJA AL

YOU MAY CONTACT THE TEXAS

DEPARTMENT OF INSURANCE TO OBTAIN

INFORMATION ON COMPANIES,

COVERAGES, RIGHTS OR COMPLAINTS AT

1-800-252-3439

PUEDE COMUNICARSE CON EL

DEPARTAMENTO DE SEGUROS DE TEXAS

PARA OBTENER INFORMATION ACERCA

DE COMPANIAS, COBERTURAS,

DERECHOS O QUEJAS AL

YOU MAY WRITE THE TEXAS

DEPARTMENT OF INSURANCE

P. O. BOX 149104

AUSTIN, TX 78714-9104

FAX #(512) 475-1771

PUEDE ESCRIBAR AL DEPARTAMENTO

DE SEGUROS DE TEXAS

P. O. BOX 149104

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.

DISPUTAS SOBRE PRIMAS O RECLAMOS:

SI TIENE UNA DISPUTA CONCERNIENTE A

SU PRIMA O A UN RECLAMO, DEBE

COMUNICARSE CON EL COMPANIA

PRIMERO. SI NO SE RESUELVE LA

DISPUTA, PUEDE ENTONCES

COMUNICARSE CON EL DEPARTAMENTO

(TDI).

ATTACH THIS NOTICE TO YOUR POLICY:

THIS NOTICE IS FOR INFORMATION ONLY

AND DOES NOT BECOME A PART OR

CONDITION OF THE ATTACHED

DOCUMENT.

UNA ESTE AVISO A SU POLIZA: ESTE

AVISO ES SOLO PARA PROPOSITO DE

INFORMACION Y NO SE CONVIERTE EN

PARTE O CONDICION DEL DOCUMENTO

ADJUNTO.

NENSPTX-GV

TABLE OF CONTENTS

POLICY SPECIFICATIONS ........................................................................................................3 – 4

POLICYHOLDER PROVISIONS..................................................................................................5 – 7

CERTIFICATE PROVISIONS MADE PART OF THE GROUP POLICY

GVDIEPTX Page 2

POLICY SPECIFICATIONS

POLICYHOLDER: CITY OF ROSENBERG EMPLOYEE TRUST

POLICY NUMBER: 81606

POLICY EFFECTIVE DATE: October 1, 2017

POLICY ANNIVERSARY DATE: October 1, 2018 and the first day of October each calendar year thereafter.

GOVERNING JURISDICTION: The state of Texas and subject to the laws of that jurisdiction.

ELIGIBLE CLASS(ES):

All full-time active employees who work 30 or more hours a week for the employer.

ELIGIBILITY WAITING PERIOD:

None

MAXIMUM MONTHLY BENEFIT:

The amount* elected by each insured employee, not to exceed 60% of monthly earnings, subject to a minimum of $400 and a maximum of $5,000.

*Payment may be reduced by deductible sources of income and disability earnings. Some disabilities may not be covered under this policy. This policy does not cover disabilities due to an occupational sickness or injury.

OPTIONAL RIDERS:

None

GUARANTEED ISSUE LIMIT:

We may ask for evidence of insurability if a person proposed for insurance applies for a monthly benefit amount over $5,000.

ELIMINATION PERIOD:

14 days for disability due to an injury

14 days for disability due to a sickness

Benefits begin the day after the elimination period is completed.

MAXIMUM PERIOD OF PAYMENT:

PLAN I - 3 months;PLAN II – 6 months

GVDIEPTX Page 3

POLICY SPECIFICATIONS (Continued)

WAIVER OF PREMIUM:

Premium payments are required while the insured employee is receiving payments under this policy during the first 30 days of disability.

INITIAL RATE:

Monthly rate is determined on the certificate effective date based on the insured employee’s issue age on such dates, as follows:

PLAN I PLAN II

Issue Age

Monthly rate per $100 of monthly benefit

Monthly rate per $100 of monthly benefit

18 to 49 $2.21 $2.95 50 to 59 $2.73 $3.94 60 to 64 $3.58 $5.29 65 to 69 $3.79 $5.69 70 and over $4.20 $6.26

RATE GUARANTEE DATE:

10/01/2018

PREMIUM DUE:

The initial date agreed to between American Heritage Life Insurance Company and the Policyholder and each specified date thereafter.

The policyholder must send all premiums on or before the premium due date to us. The premium must be paid in United States dollars.

COST OF COVERAGE:

The insured employee pays the cost of coverage.

DIVISIONS, SUBSIDIARIES OR AFFILIATED COMPANIES

These are the policyholder’s divisions, subsidiaries, or affiliates listed below. The policyholder may act for and on behalf of any and all of these in all matters that pertain to this policy. Every act done by, agreement made with, or notice given to the policyholder will be binding on them.

Name Location (City and State)

None

GVDIEPTX Page 4

POLICYHOLDER PROVISIONS

RATE GUARANTEE

A change in premium rate will not take effect before the Rate Guarantee Date, except for reasons which affect the risk assumed, including the reasons shown below:

1. a change occurs in this policy design; or

2. a division, subsidiary, or affiliated company is added or deleted; or

3. the number of insured employees increases or decreases by 25% or more; or

4. a new law or a change in any existing law is enacted which applies to this policy; or

5. less than 25% of those eligible for coverage are participating.

We will notify the policyholder in writing at least 31 days before a premium rate is changed. A change may take effect on an earlier date when both we and the policyholder agree.

PREMIUM INCREASES OR DECREASES

Premium increases or decreases may take effect any time subject to the RATE GUARANTEE provision. If they take effect during a policy month, they are adjusted and due on the next premium due date following the change.

Changes will not be pro-rated daily.

If premiums are paid on other than a monthly basis, premiums for increases and decreases will result in a monthly pro-rated adjustment on the next premium due date.

WAIVER OF PREMIUM

We do not require premium payment for an insured employee after being disabled the longer of 30 days or completion of the elimination period for the duration of that disability. The waiver of the premium will not exceed the maximum benefit period.

We do not require premium payment for an insured employee while he or she is receiving disability payments.

INFORMATION REQUIRED FROM THE POLICYHOLDER

The policyholder must provide us with the following on a regular basis:

1. information about employees:

a. who are eligible to become insured; and

b. whose amounts of coverage change; and

c. whose coverage ends; and

2. occupational information and any other information that may be required to manage a claim; and

3. any other information that may be reasonably required.

Policyholder records that have a bearing, in our opinion, on this policy must be made available for review by us at any reasonable time.

WHEN EVIDENCE OF INSURABILITY IS REQUIRED

Evidence of insurability is required if the employee:

1. voluntarily canceled coverage and is reapplying; or

2. is applying for an amount of coverage over the Guaranteed Issue Limit; or

3. is applying for the coverage at any time after the initial enrollment period; or

4. is applying for an increase in the amount of coverage, during the re-enrollment period.

INCONTESTABILITY

After 2 years from the effective date of this policy, no misstatement of the policyholder, made in any applications, can be used to void the policy.

GVDIEPTX Page 5

POLICYHOLDER PROVISIONS (Continued)

CLERICAL ERROR

Clerical error on the part of the policyholder or us will not invalidate insurance otherwise in force nor continue insurance otherwise terminated. Upon discovery of any error, an adjustment will be made in the premiums and/or benefits available. Complete proof must be supplied by the policyholder documenting any clerical errors.

CANCELING POLICY

This policy can be canceled:

1. by us; or

2. by the policyholder.

We may cancel or offer to modify this policy, with at least 31 days written notice to the policyholder, if:

1. less than 25% of those eligible for coverage are participating; or

2. this policy has been in effect more than 12 months; or

3. the policyholder does not promptly provide us with information that is reasonably required; or

4. the policyholder fails to perform any of its obligations that relate to this policy; or

5. fewer than 10 people are insured; or

6. the policyholder fails to pay any premium within the 31 day grace period.

If the premium is not paid during the grace period, the policy will terminate automatically at the end of the grace period. The policyholder is liable for the premium for coverage during the grace period. The policyholder must send us all premiums due for the full period this policy is in force.

The policyholder may cancel this policy by written notice delivered to us at least 31 days prior to the cancellation date. When both we and the policyholder agree, this policy can be canceled on an earlier date. If canceled, coverage will end at 12:00 midnight on the last day of coverage.

If this policy is canceled, the cancellation will not affect a payable claim incurred prior to cancellation.

ENTIRE CONTRACT

The contract consists of the following items:

1. the group policy; and

2. any amendments and endorsements; and

3. the applications and other written statements of the policyholder; and

4. any individual applications, enrollments, evidence of insurability or other statements of the insured employee.

Any statements made by the policyholder or by an insured employee in the absence of fraud, are representations and not warranties. Only written statements signed by the policyholder or insured employee will be used in defense of a claim. A copy of any written statement, if applicable, will be furnished to the policyholder or the insured employee or his or her personal representative, if any, if such written statement will be used in defense of a claim.

If any of the statements are not complete and/or not true at the time they are made, we can:

1. reduce or deny any claim; or

2. cancel coverage from the original effective date.

GVDIEPTX Page 6

POLICYHOLDER PROVISIONS (Continued)

CERTIFICATES OF INSURANCE

We will furnish to the policyholder a certificate of insurance for delivery to each insured employee. The certificate will provide a description of the insurance provided by this policy and will state:

1. the essential features of the insurance coverage; and

2. to whom benefits are payable.

If there is any discrepancy between the provisions of any certificate and the provisions of this policy, the provisions of this policy govern.

WORKERS’ COMPENSATION OR STATE DISABILITY INSURANCE

This policy does not replace or affect the requirements for coverage by any workers’ compensation or state disability insurance.

CERTIFICATE PROVISIONS MADE PART OF THIS GROUP POLICY

The remainder of this group policy consists of the provisions that will appear in the group certificate, including any optional riders or endorsements or amendments. The group certificate describes the insurance made available under this group policy to insured employees.

(This space intentionally left blank.)

GVDIEPTX Page 7

1776 AMERICAN HERITAGE LIFE DRIVE

JACKSONVILLE, FLORIDA 32224-6687

THIS IS A GROUP DISABILITY ONLY POLICY WHICH PROVIDES

BENEFITS FOR DISABILITIES AS STATED WITHIN THIS POLICY

THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A

SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE

ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE

WORKERS COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED

NOTIFICATIONS THAT MUST BE FILED AND POSTED.

1776 AMERICAN HERITAGE LIFE DRIVE

JACKSONVILLE, FLORIDA 32224-6687

CERTIFICATE OF INSURANCE

This certificate of insurance (“certificate”) describes your insurance coverage under the policy.

In this certificate, the words:

“You” and “your” mean the named insured employee shown on the Certificate Specifications page who is a member of an eligible class as described in the policy and for whom premiums are remitted.

“We”, “us” and “our” mean American Heritage Life Insurance Company.

“The policy” means the policy of insurance issued by us to the policyholder.

The policy alone makes up the agreement under which insurance coverage is provided and benefits are determined. If the terms of your certificate and the policy differ, the policy will govern. The policy may be inspected at the office of the policyholder during normal business hours.

Coverage under the policy is issued in consideration of your enrollment or other form of application and the payment of the first premium.

We certify that coverage under the policy is in effect for persons who have satisfied all eligibility requirements and for whom the required premium has been paid when due.

The policy is delivered in and is governed by the laws of the governing jurisdiction and, to the extent applicable, by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments.

The policy and this certificate may be changed in whole or in part or cancelled by agreement between us and the policyholder. Such an action may be taken without the consent or notice to you or anyone covered under the policy. Only an authorized officer at our home office can approve a change. The approval must be in writing and endorsed on or attached to the policy. No other person, including an agent, may change the policy or certificate or waive any of its provisions. Premiums are subject to periodic changes.

This certificate supersedes and replaces any certificate previously issued to you under the policy.

Secretary President

THIS IS GROUP DISABILITY ONLY COVERAGE WHICH PROVIDES

BENEFITS FOR DISABILITIES AS STATED WITHIN THIS CERTIFICATE

SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS

A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS COMPENSATION LAW AS IT

PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

GVDIECTX Page 1

IMPORTANT NOTICE AVISO IMPORTANTE

TO OBTAIN INFORMATION OR MAKE A

COMPLAINT:

PARA OBTENER INFORMACION O PARA

SOMETER UNA QUEJA:

YOU MAY CALL AMERICAN HERITAGE

LIFE INSURANCE COMPANY'S TOLL-

FREE TELEPHONE NUMBER FOR

INFORMATION OR TO MAKE A

COMPLAINT AT

USTED PUEDE LLAMAR AL NUMERO DE

TELEFONO GRATIS DE AMERICAN

HERITAGE LIFE INSURANCE COMPANY'S

PARA INFORMACION O PARA SOMETER

UNA QUEJA AL

YOU MAY CONTACT THE TEXAS

DEPARTMENT OF INSURANCE TO

OBTAIN INFORMATION ON COMPANIES,

COVERAGES, RIGHTS OR COMPLAINTS

AT

PUEDE COMUNICARSE CON EL

DEPARTAMENTO DE SEGUROS DE

TEXAS PARA OBTENER INFORMATION

ACERCA DE COMPANIAS, COBERTURAS,

DERECHOS O QUEJAS AL

YOU MAY WRITE THE TEXAS

DEPARTMENT OF INSURANCE

P. O. BOX 149104

PUEDE ESCRIBAR AL DEPARTAMENTO

DE SEGUROS DE TEXAS

P. O. BOX 149104

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.

DISPUTAS SOBRE PRIMAS O

RECLAMOS: SI TIENE UNA DISPUTA

CONCERNIENTE A SU PRIMA O A UN

RECLAMO, DEBE COMUNICARSE CON EL

COMPANIA PRIMERO. SI NO SE

RESUELVE LA DISPUTA, PUEDE

ENTONCES COMUNICARSE CON EL

DEPARTAMENTO (TDI).

ATTACH THIS NOTICE TO YOUR POLICY:

THIS NOTICE IS FOR INFORMATION

ONLY AND DOES NOT BECOME A PART

OR CONDITION OF THE ATTACHED

DOCUMENT.

UNA ESTE AVISO A SU POLIZA: ESTE

AVISO ES SOLO PARA PROPOSITO DE

INFORMACION Y NO SE CONVIERTE EN

PARTE O CONDICION DEL DOCUMENTO

ADJUNTO.

NENSPTX-GV

TABLE OF CONTENTS

CERTIFICATE SPECIFICATIONS

GENERAL PROVISIONS .............................................................................................................................. 4 - 5

LIMITATIONS AND EXCLUSIONS............................................................................................................... 6 - 7

BENEFIT INFORMATION ........................................................................................................................... 8 - 10

CLAIM INFORMATION ............................................................................................................................. 11 - 12

GLOSSARY ............................................................................................................................................... 13 - 15

GVDIECTX Page 2

1776 American Heritage Life Drive, Jacksonville, Florida 32224

CERTIFICATE SPECIFICATIONS

ANNUAL

PREMIUM

FORM NO. DESCRIPTION OF BENEFITS AMOUNT

MAXIMUM

MAXIMUM MONTHLY

ELIMINATION BENEFIT BENEFIT

PERIOD PERIOD AMOUNT

GVDIC SHORT TERM DISABILITY 14 days for injury 24 months $1500.00 $XX.XX 14 days for sickness

The effective date of each benefit is the Effective Date unless otherwise specified.

TOTAL PREMIUMS

The Total Premiums include the charge for any additional benefits.

ANNUAL SEMI-ANNUAL QUARTERLY MONTHLY BILLABLE PREMIUM

$000.00 $000.00 $00.00 $00.00 $00.00

Premium Payment Method: PAYROLL – MONTHLY Premium Class: INDUSTRY A

INSURED: JOHN DOE ISSUE AGE: 35

EFFECTIVE DATE: JANUARY 01, 2011 CERTIFICATE NUMBER: 123456

POLICY NUMBER: GROUP106

BENEFICIARY: AS NAMED AT ENROLLMENT OR LATER CHANGED

GROUP DISABILITY COVERAGE

GVDIC Page 3

GENERAL PROVISIONS

EFFECTIVE DATE OF COVERAGE

Your coverage will be effective at 12:01 a.m. on the effective date shown on the Certificate Specifications page provided you are an active employee on that date.

If you are not an active employee on that date due to disability, injury, sickness, temporary layoff, leave of absence or Family and Medical Leave of Absence, coverage begins on the date you return to active employment. This applies to your initial coverage, as well as any increase or addition to coverage that occurs after your initial coverage is effective.

For any change in coverage that is subject to evidence of insurability, the change in coverage is effective on the date we approve such change.

For any change in coverage that is not subject to evidence of insurability, the change in coverage is effective on the date we receive such request for change.

Any decrease in coverage will take effect on the first day of the calendar month that next follows the date you apply for the decrease, but will not affect a payable claim that occurs prior to the effective date of the decrease.

CERTIFICATE OF INSURANCE

This certificate of insurance provides a description of the insurance provided by the policy issued to the policyholder. It describes the essential features of the insurance coverage and to whom benefits are payable.

If there is any discrepancy between the provisions of this certificate and the provisions of the policy, the provisions of the policy govern.

WHEN YOU CAN ENROLL, CHANGE OR DISCONTINUE COVERAGE

1. You may apply for coverage during:

a. the initial enrollment period; or

b. a re-enrollment period or at any time, subject to evidence of insurability.

2. You may increase coverage at any time, subject to evidence of insurability.

3. You may decrease coverage at any time.

4. You may discontinue coverage at any time.

WHEN EVIDENCE OF INSURABILITY IS REQUIRED

Evidence of insurability is required if you:

1. voluntarily canceled coverage and are reapplying; or

2. are applying for an amount of coverage over the Guaranteed Issue Limit; or

3. are applying for coverage, or for an increase in the amount of coverage, during the re-enrollment period; or

4. are applying for the coverage at any time after the initial enrollment period.

TERMINATION OF COVERAGE

Your coverage under the policy ends on the earliest of:

1. the date the policy is canceled; or

2. the last day of the period for which any required premium payment was made; or

3. the last day you are an active employee with your employer, except as provided under the TEMPORARY LAYOFF, LEAVE OF

ABSENCE OR FAMILY AND MEDICAL LEAVE OF ABSENCE provision; or 4 the date you are no longer in an eligible class; or

5. the date your class is no longer eligible; or

6. upon our discovery of fraud or material misrepresentation in the presentation of a claim under this certificate.

If we accept a premium for coverage extending beyond the date, age or event specified for termination, such premium will be refunded, coverage will terminate and claims will not be paid. We will provide coverage for a payable claim which occurs while you are covered under the policy.

GVDIECTX Page 4

GENERAL PROVISIONS (Continued)

TEMPORARY LAYOFF, LEAVE OF ABSENCE OR FAMILY AND MEDICAL LEAVE OF ABSENCE

If you cease active employment with your current employer due to a temporary layoff or leave of absence, and if premiums are paid, coverage will be continued for 3 months following the date active employment ceased.

We will continue your coverage in accordance with your employer’s written human resource policy on temporary layoff, leave of absence or family and medical leave of absence, if premium payments continue and the employer approved your leave in writing, for the following periods:

1. If you are on temporary layoff or leave of absence, coverage will be continued for 3 months following the date you ceased active employment.

2. If you are on a Family and Medical Leave of Absence as defined by the Federal Family and Medical Leave Act of 1993, and any amendments, coverage will continue as though you are in active employment. Coverage will continue up to the greater of the leave period required under the:

a. Federal Family and Medical Leave Act of 1993, and any amendments; or

b. applicable state law.

If your employer’s human resource written policy does not provide for continuation of coverage during a family and medical leave of absence, coverage will be reinstated when you return to active employment.

We will not:

1. apply a new eligibility waiting period; or

2. apply a new pre-existing condition exclusion; or

3. require evidence of insurability.

DISCRETIONARY AUTHORITY, IF GOVERNED BY ERISA

The following applies only when the administration of the policy is governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq.:

We have the discretion and authority to construe disputed or seemingly inconsistent provisions of the policy and to make all decisions regarding eligibility and/or entitlement to coverage or benefits. Whenever we make reasonable determinations which are not arbitrary or capricious in the administration of the policy, such determinations shall be final and conclusive.

LEGAL ACTION

No legal action may be brought to obtain benefits under the policy:

1. for at least 60 days after proof of loss has been furnished; or

2. after the expiration of 3 years from the time written proof of loss is required to have been furnished.

INCONTESTABILITY

After 2 years from the effective date of your coverage, no misstatement, made in writing, can be used to void coverage or deny a claim for a disability incurred.

CLERICAL ERROR

Clerical error on the part of the policyholder or us will not invalidate insurance otherwise in force nor continue insurance otherwise terminated. Upon discovery of any error, an adjustment will be made in the premiums and/or benefits available. Complete proof must be supplied by us or the policyholder documenting any clerical errors.

WORKERS’ COMPENSATION OR STATE DISABILITY INSURANCE

This certificate does not replace or affect the requirements for coverage by any workers’ compensation or state disability insurance.

AGENCY

For purposes of the policy, the policyholder acts on its own behalf or as your agent. Under no circumstances will the policyholder be deemed the agent of American Heritage Life Insurance Company.

GVDIECTX Page 5

PRE-EXISTING CONDITION LIMITATION

We will not pay for disabilities during the first 12 months of coverage due to a pre-existing condition.

You have a pre-existing condition if:

1. your disability begins in the first 12 months after your effective date of coverage; and

2. you received medical treatment, consultation, care or services, including diagnostic measures, took or were prescribed drugs or medicines, took over the counter medications or followed treatment recommendations in the 12 months just prior to your effective date of coverage or the date an increase in benefits would otherwise be effective; or

3. you had symptoms in the 12 months just prior to your effective date of coverage or the date an increase in benefits would otherwise be effective.

WAIVER OF PRE-EXISTING CONDITION LIMITATION FOR PRIOR GROUP INSURANCE

We will waive the pre-existing condition limitation for a claim made by you not to exceed the amount you were insured under a prior group policy if:

1. the claim would have satisfied the pre-existing condition limitation of the prior group policy; and

2. you:

a. were in active employment on the policy date of this policy; and

b. had been continuously insured under this policy since the policy date; and

c. were insured under the prior group policy when it terminated; and

3. the prior group policy:

a. had the same policyholder as this policy; and

b. provided coverage substantially similar to this policy; and

c. was issued before the policy date of this policy; and

d. terminated within 60 days of the policy date of this policy.

WAIVER OF PRE-EXISTING CONDITION LIMITATION FOR PRIOR INDIVIDUAL INSURANCE

We will waive the pre-existing condition limitation for a claim made by you not to exceed the amount you were insured under a prior individual policy if:

1. the claim would have satisfied the pre-existing condition limitation of the prior individual policy; and

2. you:

a. were in active employment on the policy date of this policy; and

b. had been continuously insured under this policy since the policy date; and

c. were insured under the prior individual policy when it terminated; and

3. the prior individual policy:

a. provided coverage substantially similar to this policy; and

b. was issued before the policy date of this policy; and

c. terminated within 60 days of the policy date of this policy.

GVDIECTX Page 6

EXCLUSIONS

We will not pay benefits for any disabilities that are caused by, contributed to by or result from:

1. Bipolar affective disorder (manic depressive syndrome), delusional (paranoid) disorders, psychotic disorders, somatoform disorders (psychosomatic illness), eating disorders, schizophrenia, anxiety disorders, depression or mental illness. We will pay, however, for covered disabilities resulting from Alzheimer’s disease or similar forms of senility or senile dementia first manifested while coverage is in force.

2. War, declared or undeclared, participation in a riot, insurrection or rebellion.

3. Illegal activities or participation in an illegal occupation.

4. Intentionally self-inflicted injury or action.

5. Substance abuse, to include abuse of alcohol, alcoholism, drug addiction or dependence upon any controlled substance.

6. Participation in any form of aeronautics except as a fare paying passenger in a licensed aircraft provided by a common carrier and operating between definitely established airports.

7. Voluntary inhalation of fumes or gases.

8. Cosmetic surgery (except complications from such surgery will be covered).

9. Pre-existing conditions during the first 12 months of coverage.

10. Occupational sickness or injury, unless covered by an on-the-job disability rider.

We will not pay a benefit for any period of disability during which you are incarcerated.

As used in this provision, mental illness means a psychiatric or psychological condition regardless of cause such as schizophrenia, depression, manic depressive or bipolar illness, anxiety, post traumatic stress disorder, personality disorders and/or adjustment disorders or other conditions. These conditions are usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment.

As used in this provision, substance abuse means the consuming of alcohol or taking of other drugs at dosages that place your psychological and physical welfare in danger or which habitual influence of such substance (except as prescribed and directed by a doctor) endangers public health, safety or welfare.

As used in this provision, occupational sickness or injury means a sickness or injury that was caused by, contributed to by or aggravated by any employment for pay or profit.

GVDIECTX Page 7

BENEFIT INFORMATION

GENERAL

The following are shown on the Certificate Specifications page:

1. the elimination period(s); and

2. the monthly benefit amount.

You must be an active employee on the date your disability occurs for disability benefits to be payable.

We may require an exam by a doctor, 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. We may also require an interview by our authorized representative.

The loss of a professional or occupational license or certification does not, in itself, constitute a disability.

A. Elimination Period You must be totally disabled continuously throughout the elimination period.

If your covered disability is the result of an injury or sickness that occurs while covered under the policy, the elimination period is the time period stated on the Certificate Specifications page.

If, because of your covered disability, you are hospital confined, benefits begin on the first day of hospital confinement, if this is earlier than the end of the elimination period.

B. Monthly Benefit Amount We pay the monthly benefit amount (or part of the monthly benefit amount, if less than a full month) for a covered disability at the end of the month for which it is due. You will receive benefits as long as you remain totally disabled, except:

1. we pay only up to the maximum benefit period for any one total disability; and

2. any monthly benefit we pay is subject to the DEDUCTIBLE SOURCES OF INCOME provision.

If a monthly benefit is payable for any period less than a full month, we pay 1/30th of the applicable monthly benefit for each day.

When a benefit is due for a payable claim, we will send you a payment each month up to the maximum benefit period. The maximum benefit period during a continuous period of disability is shown on the Certificate Specifications page.

We will stop sending payments and your claim will end on the earliest of the following:

1. when you are able to return to work in your own occupation on a part-time or full-time basis but choose not to do so; or

2. the end of the maximum benefit period; or

3. the date you are no longer disabled under the terms of the policy; or

4. the date proof of your continuing disability is not submitted; or

5. the date of your death.

C. Amount of Payment When you are totally disabled and not working we will follow the process described below to determine your amount of payment:

1. Multiply your monthly earnings by 60%.

2. Subtract any deductible sources of income from item 1.

3. Determine the lesser of the amount listed on the Certificate Specifications page and the result of item 2.

4. Compare item 3 with the $100 minimum monthly payment and we will pay the greater of the two.

The amount calculated in item 4 is your monthly payment.

After the elimination period, if you continue to be disabled for less than 1 month, we will send 1/30th of your payment for each day of disability.

We may apply this amount toward an outstanding overpayment.

D. Deductible Sources of Income Deductible sources of income include:

The amount that you receive, or are eligible to receive, as disability income payments under any:

1. individual disability income policies; or

2. other group insurance coverage.

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BENEFIT INFORMATION (Continued)

DISABILITY BENEFITS

A. Total Disability Benefit We pay the monthly benefit amount after the elimination period if we receive sufficient proof that you are totally disabled.

Benefits will not continue beyond the maximum benefit period for total disability.

You are totally disabled when we determine that due to a sickness or injury you are:

1. unable to perform the material and substantial duties of your own occupation; and

2. under the regular care of a doctor; and

3. not working in any job for wage or profit.

B. Partial Disability Benefit We pay 50% of the monthly benefit if we receive sufficient proof that you are partially disabled, subject to the following:

1. the total disability benefit must have been payable for at least one full month immediately prior to being partially disabled; and

2. the maximum benefit period for a partial disability is 3 months; and

3. for a given period of disability, you may receive either a partial disability benefit, or a total disability benefit, but not both.

Benefits paid under this benefit count towards your maximum benefit period.

You are partially disabled when we determine that due to a sickness or injury you are:

1. unable to perform the material and substantial duties of your own occupation on a full-time basis, but you are able to work on a part-time basis; and

2. under the regular care of a doctor.

C. Concurrent Disability During any period in which you are disabled due to more than one cause, benefits will be paid as if you are disabled due to only one cause. In no event will being disabled due to more than one cause extend the time for which benefits will be paid under the maximum benefit period.

D. Recurrent Disability If you have a recurrent disability, we will treat the disability as part of the prior claim and another elimination period will not have to be completed if you were continuously insured under the policy for the period between the prior claim and the recurrent disability and:

1. your recurrent disability occurs within 6 months of the end of your prior claim; or

2. you fully performed any occupation for your employer on a full-time basis for less than 30 full days and your current disability is unrelated to your prior disability for which we made a payment.

Your recurrent disability will be subject to the same terms as your prior claim.

Any disability which occurs after 6 months from the date your prior claim ended will be treated as a new claim. Your new claim will be subject to all of the policy provisions.

If you become entitled to payments under any other group disability policy, you will not be eligible for payments under our policy.

As used in this provision, recurrent disability means a disability which is:

1. caused by a worsening in condition; or

2. due to the same cause(s) or related cause(s) as the prior disability for which we made a payment.

As used in the provision, any occupation means any gainful occupation for which you are suited by education, training or experience.

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BENEFIT INFORMATION (Continued)

DISABILITY BENEFITS (Continued)

E. Pregnancy Benefit Pregnancy or childbirth will be covered the same as any covered sickness if you meet the definition of total disability, as outlined in the TOTAL DISABILITY BENEFIT provision, provided that your coverage has been in effect for a period of 9 months or more from your effective date of coverage.

F. Organ Donor Benefit If your disability is the result of your serving as an organ donor in an organ transplant procedure performed while covered under the policy, we will pay the monthly benefit you would receive if you are totally or partially disabled. Sufficient proof that you are totally or partially disabled must be received by us.

As used in this provision, organ transplant means the surgical transplantation of a:

1. kidney; or

2. lung; or

3. portion of the liver, pancreas, or intestines; or

4. bone marrow.

A procedure to have bone marrow removed and stored for your own future use is not considered organ donation.

G. Waiver of Premium After you have been totally or partially disabled as the result of a covered sickness or injury for 30 or more consecutive days while covered under the policy, or after the elimination period shown on the Certificate Specifications page, whichever is greater, we will waive the premium for this coverage and any attached rider(s) for as long as you remain disabled. The waiver of the premium will not exceed the maximum benefit period shown on the Certificate Specifications page. You must pay all premiums to keep your coverage and any attached rider(s) in force until you have qualified for waiver of premium as described in this provision.

You must send us written notice as soon as you are no longer disabled. We will assume that you are no longer disabled if you:

1. do not send us satisfactory proof of loss when we request it; or

2. notify us that you are no longer disabled.

You must pay all premiums to keep your coverage and any attached rider(s) in force beginning with the first premium due after you are no longer disabled.

Waiver of premium does not apply to any period that you are totally or partially disabled as a result of sickness or injury which is excluded by name or specific description under the policy.

There is no limit to the number of times that you can receive a waiver of premium.

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CLAIM INFORMATION

NOTICE OF A CLAIM

We encourage you to notify us of a claim as soon as possible so that a claim decision can be made in a timely manner. Written notice of a claim should be sent within 30 days after the date your disability begins. However, written proof of your claim must be sent to us no later than 90 days after the elimination period. If it is not possible to give proof within 90 days, it must be given no later than 1 year after the time proof is otherwise required except in the absence of legal capacity. Notice given to us by, or on behalf of, you or the beneficiary at 1776 American Heritage Life Drive, Jacksonville, Florida 32224-6687, or to any authorized agent of ours, with your name and certificate number, is notice to us.

The claim form can be requested from us. If the claim form is not received within 15 days of the request, written proof of your claim may be sent to us without waiting for the form.

We must be notified immediately when you return to work in any capacity.

FILING A CLAIM

You and the policyholder must complete your own sections of the claim form and then give it to the attending doctor. The doctor should complete the attending physician statement on the form and send it directly to us. The form will include an additional section for completion by your employer, if different from the policyholder. In this event, the claim form should be forwarded to your employer before it is given to the doctor for completion.

PROOF OF CLAIM

Proof of claim, provided at your expense, must show:

1. proof that you are under the regular care of a doctor whose specialty or expertise is the most appropriate for treating the disabling condition(s) according to generally accepted medical practice;

2. the date your disability began;

3. the cause of your disability;

4. the extent of your disability, including restrictions and limitations preventing you from performing your own occupation;

5. the prognosis of your disability;

6. the name and address of any hospital or institution where treatment was received, including all attending doctors;

7. objective medical findings which support your disability. Objective medical findings include but are not limited to tests, procedures, or clinical examinations accepted as standard in the practice of medicine, for the disabling condition(s); and

8. the appropriate documentation of monthly earnings; and

9. proof of active employment on the date your disability began.

We may request that proof of continuing disability be sent to us indicating that you are under the regular care of a doctor. This proof, provided at your expense, must be received within 30 days of a request by us.

In some cases, you will be required to give us authorization to obtain additional medical information, and to provide non-medical information as part of the proof of claim, or proof of continuing disability. We will deny a claim, or stop sending payments, if any appropriate information is not submitted.

As used in this provision, generally accepted medical practice means care and treatment which is consistent with relevant guidelines of national medical, research and health care coverage organizations and governmental agencies.

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CLAIM INFORMATION (Continued)

PAYMENT OF CLAIMS

After receiving written proof of claim, we will pay all benefits then due under this certificate and we will make payments to you. Any amounts unpaid at your death may, at our option, be paid either to the named beneficiary or to your estate.

If benefits are payable to your estate or a beneficiary who cannot execute a valid release, we can pay benefits up to $1,000, to someone related to you or your beneficiary by blood or marriage whom we consider to be entitled to the benefits. We will be discharged to the extent of any such payment made in good faith. There may be cases where a law requires any benefits be paid to an agency of government. We will abide by any such law that may apply. We will not be liable to you or anyone else for such law that may apply. We will not be liable to you or anyone else for such benefits to the extent we are required by law to pay them to such agency.

OVERPAID CLAIM

We have the right to recover any overpayments due to:

1. fraud; or

2. any error we make in processing a claim; or

3. your receipt of deductible sources of income.

You must reimburse us in full. We will work with you to develop a reasonable method of repayment if you are financially unable to repay us in a lump sum.

We will not recover more money than the amount we overpaid.

UNPAID PREMIUM

Any unpaid premium that is due from you may be deducted from the payment of your claim.

CLAIM REVIEW

If your claim is denied, we will provide written notice of:

1. the reason for denial; and

2. the policy provision that relates to the denial; and

3. the right to ask for a review of your claim; and

4. the right to submit any additional information that might allow us to change our decision.

You may, upon written request, read any reports that are not confidential. For a small fee, we will make copies of those reports.

APPEALS PROCEDURE

Prior to filing any lawsuit and within 60 days after denial of a claim, you or your beneficiary must appeal any denial of benefits under the policy by making a written request for review of the denial.

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GLOSSARY

Active Employment means you are working for your employer for earnings that are paid regularly and that you are performing the material and substantial duties of your own occupation. For the purposes of this coverage:

1. you must be working at least the minimum number of hours as described under Eligible Class(es); and

2. you will be deemed to be in active employment on a day which is not your employer’s scheduled work days only if you were an active employee on the preceding scheduled work day.

Your work site must be:

1. your employer’s usual place of business; or

2. an alternative work site at the direction of your employer; or

3. a location to which your job requires you to travel.

Normal vacation is considered active employment. However, if vacation days are used to cover disability, sickness or injury, those days are not considered active employment. Temporary and seasonal workers are excluded from coverage.

Complications of Pregnancy means (1) conditions, requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy, including but not limited to acute nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and (2) non-elective cesarean section, termination of ectopic pregnancy and spontaneous termination of pregnancy, occurring during a period of gestation in which a viable birth is not possible.

Deductible Sources of Income means income from deductible sources listed in this certificate which you receive while disabled.

This income will be subtracted from the gross monthly disability payment.

Doctor means:

1. a person performing tasks that are within the limits of his or her medical license; and

2. a person who is licensed to practice medicine and prescribe and administer drugs or to perform surgery; or

3. a person with a doctoral degree in Psychology (Ph.D. or Psy.D.) whose primary practice is treating patients; or

4. a person who is a legally qualified medical practitioner according to the laws and regulations of the governing jurisdiction.

We will not recognize you, your spouse, children, parents or siblings as a doctor for a claim that is sent to us.

Eligibility Waiting Period means the continuous period of time that you must be in active employment in an eligible class before eligible for coverage under the policy.

Elimination Period means a period of continuous total disability which must be satisfied before you are eligible to receive benefits from us.

Employee means a person who is a citizen or resident of the United States or Canada in active employment with his or her employer.

Employer means the individual, company or corporation under which you are in active employment, and includes any division, subsidiary, or affiliated company of such employer.

Evidence of Insurability means a statement of your medical history which we will use to determine if you are approved for coverage. Evidence of insurability will be provided at your expense.

Full-Time Basis means a job at which you have worked 25 or more hours a week for pay or profit.

Gainful Occupation means an occupation that is or can be expected to provide you with an income of the lesser of the gross monthly disability payment or $6,000 per month within 12 months of your return to work.

Grace Period means the 31 day period of time following the premium due date during which premium payment may be made.

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GLOSSARY (Continued)

Gross Monthly Disability Payment means the monthly benefit amount before we subtract deductible sources of income.

Hospital or Institution means an accredited facility licensed to provide care and treatment for the condition causing your disability.

Initial Enrollment Period means one of the following periods during which you may first apply in writing for coverage under the policy:

1. if eligible for coverage on the policy effective date, a period before the policy effective date as set by us and the policyholder; or

2. if you become eligible for coverage after the policy effective date, the period ending 31 days after the date first eligible to apply for coverage.

Injury means a bodily injury that is the direct result of an accident and not related to any other cause. Injury which occurs before you are insured under the policy will be treated as a sickness. Disability must begin while you are insured under the policy.

Insured Employee means the employee covered under the policy.

Material and Substantial Duties means duties that:

1. are normally required for the performance of your own occupation; and

2. cannot be reasonably omitted or modified, except if required to work on average in excess of 40 hours per week, we will consider you able to perform that requirement if working or having the capacity to work 40 hours per week.

Maximum Benefit Period means the longest period of time we will make payments to you for any one period of disability.

Monthly Benefit Amount means the total benefit amount listed on the Certificate Specifications page for which you are insured under the policy subject to the maximum benefit period.

Monthly Earnings means your gross monthly income from your employer in effect just prior to the date of disability. Gross monthly income is the total income before taxes and any pre-tax deductions made under a qualified deferred compensation plan recognized by the Internal Revenue Service. It will always be considered to be 1/12th of the basic annual wage payable by your employer at the start of the term of continuous disability. Regardless of your timing of payment from your employer, it will be considered to be received over a 12 month period. It does not include income received from commissions, bonuses, overtime pay, or other extra compensation. It does not include income received from sources other than your employer.

If you become disabled while on a covered layoff or leave of…