Universal_Life_Policy_CITY_OF_ROSENBERG_GUL_CONTRACT.pdf

AMERICAN HERITAGE LIFE INSURANCE COMPANY

A Stock Company

FLEXIBLE PREMIUM ADJUSTABLE GROUP LIFE INSURANCE POLICY

This group policy is issued in consideration of the group policyholder’s application and payment of the premiums when due.

The group policy is effective as of the date shown below.

Group Policyholder: CITY OF ROSENBERG EMPLOYEE TRUST

Group Policy Number: 81606

Group Policy Effective Date: October 1, 2017

Governing Jurisdiction: Texas

The group policy is issued in the governing jurisdiction shown above and will be governed by its laws.

These agreements are subject to all terms of this group policy on this and the following pages. The group policy replaces any prior one issued to the group policyholder.

PLEASE READ YOUR GROUP POLICY CAREFULLY!

This policy is a contract between you, the group policyholder, and us, American Heritage Life Insurance Company.

20 DAY RIGHT TO EXAMINE GROUP POLICY

If for any reason you are not satisfied with this policy, return it to us or to our agent. If the policy is returned within 20 days after you receive it, we will return all premiums paid and the policy is void. If you have a complaint, an inquiry or need to obtain information regarding this policy, you may call us toll-free at 1-800-521-3535.

Signed for American Heritage Life Insurance Company at its Home Office in Jacksonville, Florida.

Secretary President

FLEXIBLE PREMIUM ADJUSTABLE GROUP LIFE INSURANCE

FLEXIBLE PREMIUMS PAYABLE DURING THE LIFE OF THE INSURED UNTIL MATURITY DATE

NET SURRENDER VALUE, IF ANY, PAID TO THE CERTIFICATE HOLDER ON THE MATURITY DATE IF THE

INSURED IS LIVING ON THAT DATE

DEATH BENEFIT PAYABLE AT DEATH OF INSURED PRIOR TO MATURITY DATE

NON-PARTICIPATING – NO DIVIDENDS

Home Office American Heritage Life Insurance Company

1776 American Heritage Life Drive Jacksonville, Florida 32224-6687

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TABLE OF CONTENTS

Page

INSURANCE SCHEDULE

POLICYHOLDER APPLICATION

DEFINITIONS

PREMIUMS

Group Policy Premiums Grace Period for Paying Premiums Change in Premium Rate

POLICY CHANGES AND TERMINATION

Change in the Group Policy Effective Date of Changes Termination of the Group Policy

POLICYHOLDER PROVISIONS

Group Policyholder Application Duties Inspection of the Group Policy Continuation of the Certificate or Conversion ................ 6-7

GENERAL PROVISIONS

Entire Group Policy Incontestability Clerical Errors Money Payable Time Periods

CERTIFICATE PROVISIONS MADE PART OF

GROUP POLICY

RIDERS AND ENDORSEMENTS (IF APPLICABLE)

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INSURANCE SCHEDULE

Eligibility to Participate in the Insurance Program

In order for the employee or his/her eligible family members to participate in the insurance program, the employee must meet the following requirements:

1. Initial Enrollment: The employee must be actively at work performing the regular duties of his/her job in the usual manner and the usual place of employment on the date the enrollment form is signed.

2. The employee is actively at work for 30 hours or more per week as of the date of the enrollment form.

3. Additional Enrollments: Must be a new employee of the employer and not eligible for the insurance program in a prior enrollment.

4. Employee must be at least age 18 but not older than age 80, age last birthday as of the certificate date.

Spouse/Domestic Partner

To qualify as the employee’s spouse, he/she must be legally married to the employee.

To qualify as the employee’s domestic partner, the relationship must meet the definition and requirements described in the Definitions section of the group policy.

To qualify as the employee’s domestic partner, civil union (or similar state designated term) partner, the relationship must qualify as such according to the laws of the insured’s state of residence.

He/she does not qualify as a spouse if he/she is individually eligible as an employee under the group policy.

He/she does not qualify as a domestic partner, civil union (or similar state designated term partner), if he/she is individually eligible as an employee under the group policy.

Spouse/domestic partner must be at least age 18 but not older than age 80.

Dependent Child

To qualify as the employee’s dependent child, he/she must be no older than age 24 on the date of the enrollment form; and must be:

1. a natural child of the employee; or

2. a legally adopted child of the employee; or

3. a stepchild who lives with the employee; or

4. a child for whom the employee has been appointed legal guardian and who lives with the employee; or

5. a child of the employee’s spouse/domestic partner.

He/she does not qualify as a dependent child, if he/she is individually eligible as an employee under the group policy.

Grandchild

To qualify as the employee’s grandchild, he/she must be no older than age 24 on the date of the enrollment form.

He/she does not qualify as a grandchild, if he/she is individually eligible as an employee under the group policy.

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INSURANCE SCHEDULE (continued)

Evidence of Insurability

We may ask for evidence of insurability if a person proposed for insurance:

1. applies for this insurance after 31 days of becoming eligible for coverage or if the amount of insurance coverage is increased; or

2. applies for an amount of insurance in excess of the guaranteed issue limit, if applicable; or

3. applies for an amount of insurance in excess of the contingent guarantee issue limit, if applicable; or

4. applies for reinstatement of life insurance coverage after such coverage has terminated; or

5. does not otherwise meet the eligibility requirements.

ISSUE LIMITS:

Guaranteed Issue Limits: (subject to eligibility requirements)

Employee/Member Spouse/Domestic Partner Dependent Child N/A N/A N/A

Subject to a minimum face amount of $10,000

Contingent Guaranteed Issue Limits: (subject to contingent guarantee issue eligibility requirements)

Employee/Member Working Spouse/Domestic Partner

Dependent Child

$5.00 - $20.00 per week subject to an overall maximum amount of

$150,000 Issue Ages: 18 - 65

$5.00 - $8.00 per week subject to an overall maximum amount of

$100,000 Issue Ages: 18 - 65

$3.00 per week subject to an overall maximum amount of

$50,000 Issues Ages: 0 - 18

Simplified Issue Limits: (subject to simplified issue eligibility requirements and evidence of insurability)

Employee/Member Spouse/Domestic Partner Dependent Child or Grandchild

Subject to an overall maximum amount of

$250,000 Issue Ages: 18 - 80

Subject to an overall maximum amount of

$150,000 Issue Ages: 18 - 80

Subject to an overall maximum amount of

$150,000 Issue Ages: 0 - 24

Group Policy and Optional Riders

The group policy provides for a Flexible Premium Adjustable Group Life Insurance Plan.

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INSURANCE SCHEDULE (continued)

The group policy provides for the following optional riders:

1. Accelerated Death Benefit for Long-Term Care Rider

Any or all of the optional riders may be declined by the certificateholder. A combination of riders may be chosen.

Minimum Participation Requirement

A minimum of ten insured employees is required to issue this group policy.

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Policyholder Application

American Heritage Life Insurance Company 1776 American Heritage Life Dr., Jacksonville, FL 32224-6687

Group Name: CITY OF ROSENBERG EMPLOYEE TRUST

Group Policy Number: 81606

Address (No., Street, City, State & ZIP Code): 2110 Fourth St., Rosenberg, TX 77471

Policy Effective Date: October 1, 2017

Contact Name, Phone # and Fax #: Lori Remington (832) 595-3320 FAX (832) 595-3321

This is to advise American Heritage Life Insurance Company (AHL) that w e w ould like to participate in your Insurance Program for the benefit of our employees/members. We authorize AHL, its authorized agents or enrollers, to offer each of the eligible employees/members, as defined below , the opportunity to purchase the Insurance Program.

1. We w ill allow agents or enrollers to conduct an annual enrollment of all eligible persons. Eligible Persons are described as employees/members of the Policyholder, and their dependents, w ho meets the eligibility requirements show n in the Insurance Schedule:

a. An eligible employee/member must be actively at w ork on the date the enrollment form is signed.

2. We w ill provide AHL w ith employment census data in order that they may, based on their rules, determine proper enrollment eligibility.

3. We w ill provide AHL’s authorized agents or enrollers direct access to its employees to solicit enrollment forms through group meetings and individual interview s in a suitable location on our property during normal business hours, or through any other means mutually agreed upon by both AHL and us. AHL reserves the right to w ithdraw from the enrollment and w ithdraw any applications already solicited should these conditions not be satisf ied.

4. We w ill honor all Deduction Authorization forms signed by our current employees, if any, for payment of the premium to AHL w hen due. The bills w ill normally be sent once each month for any premiums due and w e shall forw ard all deductions to AHL’s administrative off ice w ithin 15 days of the receipt of the monthly billing. We shall maintain records of all premiums w ithheld on behalf of our employees. These records shall alw ays remain open to inspection and audit by AHL during normal business hours and for tw o years after the program has been terminated.

5. We w ill maintain eligibility records and, on behalf of our employees, report changes and terminations on a timely basis to AHL.

6. The follow ing riders may be made available to our employees/members subject to state and/or underw riting approval:

Accelerated Death Benefit for Long-Term Care Rider

We may, upon w ritten notice to AHL and to our employees/members, discontinue our participation in AHL’s Insurance Program. In such event, the continued payment of premiums w ill be coordinated betw een AHL and each employee/member.

In the event of any misappropriation by us, our employees/members or agents, of funds ow ed to AHL, w e shall reimburse AHL for their entire loss including attorney fees and expenses incurred in collection.

Will you pay for any of the premium for the coverage elected? Ye s No Will you pay for all of the premium for the coverage elected? Ye s No

Enrollment Period: from______________________to______________________.

Executed on this ______________ day of ________________________________, __________.

Signature of Officer/Representative

Print Name and Title of Officer/Representative

Signature of Witness (Licensed Resident Agent as Required)

Print Name of Licensed Resident Agent License Identification Number (as Required)

Please complete, sign and date this document. Return this document to AHL at the address above. Make a photocopy for your records.

GULAPP

DEFINITIONS

Certificate. A document that describes the terms of the insurance made available to the eligible employees/members of the group policyholder and their eligible family members. It provides evidence of the coverage provided to the insured under the group policy.

Certificateholder. The person who is allowed to exercise the rights given by the group policy. The certificateholder may be someone other than the insured. The certificateholder is shown on the certificate specifications page.

Domestic Partner. The insured’s same-sex or opposite-sex partner who is eligible for coverage providing the domestic partner is mentally competent to consent to the contract and the requirements listed below have been met for the last 12 months.

Both must:

1. have resided together in the same permanent residence; and

2. be at least 18 years of age; and

3. intend to remain each other’s sole domestic partner indefinitely; and

4. be emotionally committed to one another and share joint responsibilities for the common welfare and financial obligations of one another; or the domestic partner must be chiefly dependent upon the employee/member for care and financial assistance; and

5. not be legally married to or the legal domestic partner of anyone else; and

6. not be related to each other by blood closer than would prohibit marriage under applicable state law.

If requested by us, satisfactory proof must be submitted that supports the domestic partner’s eligibility for coverage.

Group Policy. The group contract whose provisions govern the insurance provided to the eligible employees/members of the group policyholder and their eligible family members.

Group Policyholder. The entity through which we make this insurance available to eligible employees/members and their eligible family members. The group policyholder is shown on page 1.

Insured. The person whose life is insured under the group policy. The insured is shown on the certificate specifications page.

Rider. An amendment to the group policy and may include optional benefits. All riders elected by the group policyholder are attached to the group policy. No certificate is available under the rider unless elected and attached as an optional benefit to the certificate.

We, Our, or Us. American Heritage Life Insurance Company.

You, Your. The group policyholder as shown on the group policyholder application.

PREMIUMS

Group Policy Premiums. You must pay to us the sum of all premiums collected and due for each insured covered under the group policy. Premiums are due and payable to us on each premium due date. The first premium due date is the group policy effective date.

Grace Period for Paying Premiums. You have a grace period of 61 days from each premium due date, except the first, in which to pay the premium then due. Coverage will continue during the grace period. You are liable for the premium due during the grace period.

Change in Premium Rates. We have the right to change the premium rates on any premium due date after the first, subject to any premium rate guarantee you have with us. We will provide you with a 60 day advance written notice of any change in premium rates.

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POLICY CHANGES AND TERMINATION

Change in the Group Policy. The terms of this group policy may not be changed unless our officer approves it in writing. Any approved change will be added to the group policy in writing.

The group policy will automatically comply with any state or federal law as of the mandated effective date of the law, even if we have not notified the group policyholder of the change or the group policy has not been amended.

Effective Date of Changes. Unless we and the group policyholder agree otherwise in writing, the effective date of any change in benefits offered under this group policy will be the first day of the month that next follows the date we send notice of the change in benefits and corresponding change in premium rates.

Termination of the Group Policy. The group policy, together with all riders, will terminate at the earliest of the following events:

1. if any premium payable by you is not paid within the grace period, the group policy will terminate the day after the 61 day grace period; or

2. if you submit a 60 day advance notice to us to terminate the group policy, the group policy, together with all optional riders will terminate on the date specified in such request; or

3. if we give you a 60 day advance written notice that we intend to terminate the group policy, the group policy, together with all optional riders, will terminate on the day specified in such notice; or

4. if you fail to comply with any of the terms of the group policy, or fail to fulfill any obligations under or pertaining to this insurance, or fail to comply with or cooperate with us in satisfying the requirements of any applicable law or regulation pertaining to this insurance, the group policy, together with all optional riders, will terminate on the 32nd day after we have given you notice of our intent to terminate; or

5. if the number of employees/members who become insured under the group policy during any 12 month period does not meet the minimum participation requirement shown in the policy insurance schedule, we have the right to terminate the group policy, together with all optional riders on the 32nd day after we have given you written notice of our intent to terminate.

POLICYHOLDER PROVISIONS

Group Policyholder Application. You must submit to us an executed group policyholder application form electing to participate in the Flexible Premium Adjustable Group Life Insurance Policy.

Duties. Your duties include, but are not limited to, the following:

1. As required, provide us any and all information we determine is necessary for the enrollment and determination of eligibility of your employees/members. You must provide us with all information necessary to underwrite the coverage, to calculate premiums and to maintain necessary administrative records.

2. Maintain records pertaining to the insurance of your employees/members, which we may reasonably require information on while this group policy is in force and for 2 years after this group policy terminates. You must also allow us to examine these records at any reasonable time during normal business hours.

3. Cooperate fully with us in preparing and/or delivering any required notices regarding this insurance to your employees/members.

Inspection of the Group Policy. You must make this group policy available for inspection by your employees/members at all reasonable times during normal business hours.

Continuation of the Certificate or Conversion. If the insured loses eligibility for the coverage provided under the group policy for any reason other than non-payment of premiums, the certificateholder will have the option to continue the certificate or convert the amount of insurance that terminates under the policy to an individual life insurance policy.

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POLICYHOLDER PROVISIONS (continued)

Under the Continuation of the Certificate feature, the certificateholder will have the option to continue the certificate, including any riders, by paying the premiums directly to us at our Home Office. We will bill the certificateholder for these premiums. If the certificateholder stops paying premiums under this option, the certificate may enter its grace period.

Alternatively, the certificateholder has the right to continue the amount of insurance lost due to termination of the coverage under the policy to an individual life insurance policy. The individual policy will be available without presenting evidence of insurability in an amount up to and including the amount of coverage that ceased. The certificateholder may select from any non-term life policy that is available for sale by us. The premiums charged will be those applicable to the premium class and age at last birthday prior to the date of the selected individual policy.

This right to convert to an individual policy may only be exercised within 31 days of the termination of coverage under the policy.

These options are mutually exclusive. The certificateholder may not elect both the Continuation of the Certificate and Conversion.

GENERAL PROVISIONS

Entire Group Policy. The entire group policy consists of:

1. the group policy; and

2. any riders or endorsements; and

3. any schedules; and

4. the group policyholder's application form; and

5. the enrollment form for each insured.

The group policyholder is an agent of the insured. For all purposes related to the insurance issued under this group policy, you act as an agent of the insured. You do not, therefore, act as our agent for any purposes related to insurance provided under this group policy.

Incontestability. We rely on the statements made on the group policyholder application for this group policy. We will not use any statement you make to void this group policy after it has been in force for 2 years from the date of issue.

Clerical Errors. Any clerical error on the part of us, the group policyholder, insured or certificateholder will not void the group policy or an insured’s certificate validly in force. Nor will it continue the group policy or an insured’s certificate otherwise validly terminated.

Money Payable. All monies payable by or to us will be paid in the lawful currency of the United States of America.

Time Periods. All periods affecting the group policy begin and end at 12:01 a.m., standard time, at the group policyholder's address of record.

All periods affecting an insured’s certificate begin and end at 12:01 a.m., standard time, at the insured’s address of record.

CERTIFICATE PROVISIONS MADE PART OF THIS GROUP POLICY

The remainder of this group policy consists of the provisions that will appear in the certificate, including any optional riders or endorsements or amendments. The certificate describes the insurance made available under this group policy to your employees/members and their dependents, if applicable.

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AMERICAN HERITAGE LIFE INSURANCE COMPANY

A Stock Company

FLEXIBLE PREMIUM ADJUSTABLE GROUP LIFE INSURANCE

FLEXIBLE PREMIUMS PAYABLE DURING THE LIFE OF THE INSURED UNTIL MATURITY DATE

NET SURRENDER VALUE, IF ANY, PAID TO THE CERTIFICATE HOLDER ON THE MATURITY DATE IF THE

INSURED IS LIVING ON THAT DATE

DEATH BENEFIT PAYABLE AT DEATH OF INSURED PRIOR TO MATURITY DATE

NON-PARTICIPATING – NO DIVIDENDS

cert