HomeMy Public PortalAboutExhibit MSD 18F4 MetLife - LifeExhibit MSD 18F4
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Metropolitan Life Insurance Company
200 Park Avenue, New York, New York 10166
APPLICATION FOR GROUP INSURANCE
The applicant named below is applying for a Group Policy to provide insurance for the persons specified below.
APPLICANT DATA
1. Full legal name of Applicant: Metropolitan St. Louis Sewer District (the "Policyholder")
2. Address: 2350 Market Street City St: Louis
POLICY EFFECTIVE DATE
State MO Zip 63103
The Group Policy's effective date will be February 1. 2011 , subject to MetLife's acceptance of
this application and the Applicant's payment of the Premium due on or before such date.
POLICY SITUS
The Group Policy will be issued for delivery in and governed by the laws of Missouri
COVERAGE DATA
Employees I Members Employees / Members
Only and Dependents
Life Insurance 0
Accidental Death and Dismemberment Insurance
PREMIUM DATA
Premiums will be paid: i%I monthly 0 quarterly ❑ annually ❑ other:
Attached is an advance payment of: $11,000.00
AGREEMENT
The Applicant signing below agrees to accept the terms and provisions of the Group Policy, including its Exhibits,
amendments and endorsements, if any.
Fraud Warning. Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or a statement of claim containing any materially false Information or conceals for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a
crime and subjects such person to criminal and civil penalties.
(Signature of Applicant's Authorized Representative)
Signature or Witness,
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(Signature of licensid`fv etl_ifd�Agent or Resident
Agent es requiredby law)
d Title of uthorized Representative)
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(Print Name
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(Print Name of Witnoss)
(State)
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(Agent's State License No.) (Print Name of Agent)
APP•GP99
NWIF
YOUR BENEFIT PLAN
Metropolitan St. Louis Sewer District
All Full -Time Employees
Basic Life Insurance
Supplemental Life Insurance
Dependent Life Insurance
Accidental Death and Dismemberment Insurance
Voluntary Accidental Death and Dismemberment Insurance
Certificate Date: February 1, 2011
Metropolitan St. Louis Sewer District
2350 Market Street
St. Louis, MO 63103
TO OUR EMPLOYEES:
All of us appreciate the protection and security insurance provides.
This certificate describes the benefits that are available to you. We urge you to read it carefully.
Metropolitan St. Louis Sewer District
Metropolitan Life Insurance Company
200 Park Avenue, New York, New York 10166
CERTIFICATE OF INSURANCE
Metropolitan Life Insurance Company ("MetLife"), a stock company, certifies that You and Your Dependents
are insured for the benefits described in this certificate, subject to the provisions of this certificate. This
certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group
Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY.
This certificate is part of the Group Policy. The Group Policy is a contract between MetLife and the
Policyholder and may be changed or ended without Your consent or notice to You.
Policyholder:
Group Policy Number:
Type of Insurance:
Metropolitan St. Louis Sewer District
146611-1-G
Term Life & Accidental Death and Dismemberment
Insurance
MetLife Toll Free Number(s):
For Claim Information FOR LIFE CLAIMS: 1-800-638-6420
THIS CERTIFICATE ONLY DESCRIBES TERM LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT
INSURANCE.
THE BENEFITS OF THE POLICY PROVIDING YOU COVERAGE ARE GOVERNED PRIMARILY BY THE
LAWS OF A STATE OTHER THAN FLORIDA.
THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED
IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS
REQUIRED BY MARYLAND LAW.
For Residents of North Dakota: If You are not satisfied with Your Certificate, You may return it to Us within
20 days after You receive it, unless a claim has previously been received by Us under Your Certificate. We
will refund within 30 days of Our receipt of the returned Certificate any Premium that has been paid and the
Certificate will then be considered to have never been issued. You should be aware that, if You elect to
return the Certificate for a refund of premiums, losses which otherwise would have been covered under Your
Certificate will not be covered.
WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE
AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S)
CAREFULLY.
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For Texas Residents:
IMPORTANT NOTICE
To obtain information or make a complaint:
You may call MetLife's toll free telephone number
for information or to make a complaint at
1-800-638-6420
You may contact the Texas Department of
Insurance to obtain information on companies,
coverages, rights or complaints at
1-800-252-3439
You may write the Texas Department of Insurance
P.O. Box 149104
Austin, TX 78714-9104
Fax # (512) 475-1771
Web: http://www.tdi.state.tx.us
Email: ConsumerProtection@tdi.state.tx.us
PREMIUM OR CLAIM DISPUTES: Should You
have a dispute concerning Your premium or about
a claim, You should contact MetLife first. If the
dispute is not resolved, You may contact the Texas
Department of Insurance.
ATTACH THIS NOTICE TO YOUR CERTIFICATE:
This notice is for information only and does not
become a part or condition of the attached
document.
Para Residentes de Texas:
AVISO IMPORTANTE
Para obtener informacion o para someter una queja:
Usted puede Ilamar al numero de telefono gratis de
MetLife para informacion o para someter una queja al
1-800-638-6420
Puede comunicarse con el Departamento de Seguros
de Texas para obtener informacion acerca de
companies, coberturas, derechos o quejas al
1-800-252-3439
Puede escribir al Departamento de Seguros de Texas
P.O. Box 149104
Austin, TX 78714-9104
Fax # (512) 475-1771
Web: http://www,tdi.state.tx.us
Email: ConsumerProtection@tdi.state.tx.us
DISPUTAS SOBRE PRIMAS 0 RECLAMOS: Si
tiene una disputa concerniente a su prima o a un
reclamo, debe comunicarse con MetLife primero. Si
no se resuelve la disputa, puede entonces
comunicarse con el departamento (TDI).
UNA ESTE AVISO A SU CERTIFICADO:
Este aviso es solo para proposito de informacion y no
se convierte en parte o condicion del documento
adjunto.
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NOTICE FOR RESIDENTS OF ALL STATES
LIFE INSURANCE BENEFITS WILL BE REDUCED IF AN ACCELERATED BENEFIT IS
PAID
DISCLOSURE: The Life Insurance accelerated benefit offered under this certificate is intended to qualify for
favorable tax treatment under the Internal Revenue Code 6f 1986. If this benefit qualifies for such favorable
tax treatment, the benefit will be excludable from Your income and not subject to federal taxation. Tax laws
relating to accelerated benefits are complex. You are advised to consult with a qualified tax advisor about
circumstances under which You could receive an accelerated benefit excludable from income under federal
law.
DISCLOSURE: Receipt of an accelerated benefit may affect Your, Your Spouse's or Your family's eligibility
for public assistance programs such as Medical Assistance (Medicaid), Aid to Families with Dependent
Children (AFDC), Supplementary Social Security Income (SSI), and drug assistance programs. You are
advised to consult with a qualified tax advisor and with social service agencies concerning how receipt of
such payment will affect Your, Your Spouse's and Your family's eligibility for public assistance.
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NOTICE FOR RESIDENTS OF LOUISIANA, MINNESOTA, MONTANA, NEW MEXICO,
TEXAS, AND UTAH
Definition of Child
For Louisiana Residents (Accidental Death and Dismemberment Insurance):
The term also includes Your grandchildren residing with You. The limiting age for children and grandchildren will
not be less than 26 regardless of marital status, student status or full-time employment status. Marital status will
not prevent or cease the continuation of insurance for a mentally or physically handicapped child or grandchild
past the limiting age.
For Minnesota Residents (Accidental Death and Dismemberment Insurance):
The term also includes Your grandchildren who are financially dependent upon You and reside with You
continuously from birth. The limiting age for children and grandchildren will not be less than 25 regardless of
student status or full-time employment status.
For Montana Residents (Accidental Death and Dismemberment Insurance):
The term also includes newborn infants of any person insured under this certificate. The limiting age for children
will not be less than 25 regardless of student status or full-time employment status.
For New Mexico Residents (Accidental Death and Dismemberment Insurance):
The limiting age for children will not be less than 25 regardless of student status or full-time employment status.
Your natural child, adopted child and step -child will not be denied accidental death and dismemberment insurance
coverage under this certificate because:
1. that child was born out of wedlock;
2. that child is not claimed as Your dependent on Your federal income tax return; or
3. that child does not reside with You.
For Texas Residents (Life Insurance):
The term also includes Your grandchildren. The limiting age for children and grandchildren will not be less than
25 regardless of student status or military service status. Grandchildren must be able to be claimed by You as a
dependent for Federal Income Tax purposes at the time You applied for Insurance.
For Texas Residents (Accidental Death and Dismemberment Insurance):
The term also includes Your grandchildren. The limiting age for children and grandchildren will not be less than
25 regardless of student status or military service status. Grandchildren must be able to be claimed by You as a
dependent for Federal Income Tax purposes at the time You applied for Insurance.
For Utah Residents (Accidental Death and Dismemberment Insurance):
The limiting age for children will not be less than 26 regardless of student status or full-time employment status.
Your natural child, adopted child and step -child will not be denied accidental death and dismemberment insurance
coverage solely because that child does not reside with You or solely because that child is solely dependent on
Your former spouse rather than on You.
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NOTICE FOR RESIDENTS OF ARKANSAS
If You have a question concerning Your coverage or a claim, first contact the Policyholder or group account
administrator. If, after doing so, You still have a concern, You may call the toll free telephone number shown
on the Certificate Face Page.
If You are still concerned after contacting both the Policyholder and MetLife, You should feel free to contact:
Arkansas Insurance Department
Consumer Services Division
1200 West Third Street
Little Rock, Arkansas 72201
(501) 371-2640 or (800) 852-5494
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NOTICE FOR RESIDENTS OF CALIFORNIA
IMPORTANT NOTICE
TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE
POLICYHOLDER OR THE METLIFE CLAIM OFFICE SHOWN ON THE EXPLANATION OF BENEFITS
YOU RECEIVE AFTER FILING A CLAIM.
IF, AFTER CONTACTING THE POLICYHOLDER AND/OR METLIFE, YOU FEEL THAT A SATISFACTORY
SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA
INSURANCE DEPARTMENT AT:
DEPARTMENT OF INSURANCE
300 SOUTH SPRING STREET
LOS ANGELES, CA 90013
1 (800) 927-4357
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NOTICE FOR RESIDENTS OF GEORGIA
IMPORTANT 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 violence.
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NOTICE FOR RESIDENTS OF IDAHO
If You have a question concerning Your coverage or a claim, first contact the Policyholder. If, after doing so,
You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.
If You are still concerned after contacting both the Policyholder and MetLife, You should feel free to contact:
Idaho Department of Insurance
Consumer Affairs
700 West State Street, 3rd Floor
PO Box 83720
Boise, Idaho 83720-0043
1-800-721-3272 or www.DOI.ldaho.gov
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NOTICE FOR RESIDENTS OF ILLINOIS
IMPORTANT NOTICE
To make a complaint to MetLife, You may write to:
MetLife
200 Park Avenue
New York, New York 10166
The address of the Illinois Department of Insurance is:
Illinois Department of Insurance
Public Services Division
Springfield, Illinois 62767
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NOTICE FOR MASSACHUSETTS RESIDENTS
CONTINUATION OF ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE
1. If Your AD&D Insurance ends due to a Plant Closing or Covered Partial Closing, such insurance will be
continued for 90 days after the date it ends.
2. If Your AD&D Insurance ends because:
® You cease to be in an Eligible Class; or
® Your employment terminates;
for any reason other than a Plant Closing or Covered Partial Closing, such insurance will continue for 31 days
after the date it ends.
Continuation of Your AD&D Insurance under the CONTINUATION WITH PREMIUM PAYMENT subsection
will end before the end of continuation periods shown above if You become covered for similar benefits under
another plan.
Plant Closing and Covered Partial Closing have the meaning set forth in Massachusetts Annotated Laws,
Chapter 151A, Section 71A.
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NOTICE FOR RESIDENTS OF MINNESOTA
This is a life insurance policy which pays accelerated death benefits at your option under conditions specified
in the policy. This policy is not a long-term care policy meeting the requirements of sections M.S.62A.46 to
62A.56 or chapter 62S.
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NOTICE FOR RESIDENTS OF MINNESOTA
CONTINUATION OF BASIC OR DEPENDENT LIFE INSURANCE WITH PREMIUM
PAYMENT
If Your Life Insurance ends due to termination of Your employment for any reason other than gross
misconduct, You may continue such insurance for You and for Your Dependents.
If You are eligible for continuation of Life insurance, Your employer will notify You of:
• Your right to elect to continue Life Insurance for You and for Your Dependents;
• the amount You must pay each month to Your employer to keep such insurance in force;
• instructions for payment; and
• the time that payments are due.
The amount of the premium You will be required to pay for continuation of Life Insurance will not exceed 102
percent of the amount of premium required to be paid for active employees in Your class for such insurance
(this includes any premium amountS' paid by the employer as well as the employee).
You will have 60 days within which to elect to continue Life Insurance under this section. The 60 day period
begins to run on the date Life Insurance would otherwise end or on the date upon which notice of the right to
continue Life Insurance is received, whichever is later. If You or a Dependent die during the 60 day election
period, we will consider You to have elected to continue Life Insurance under this section.
If Your employer fails to notify You of Your right to continue insurance under this section, or fails to forward a
required premium to Us that You have paid, causing insurance for You or Your Dependents to end, then Your
employer will become liable for these benefits to the same extent as, and in place of, us.
If You continue Life Insurance under this section, any reductions in Life Insurance that would have applied if
You were Actively at Work apply to the continued insurance.
Continuation of Life Insurance under this section will end on the earliest of:
• the date the group policy ends for all employees or for the class of employees to which you belonged
when Your Active Work ceased;
• the date you fail to make a required premium payment when due;
• the date you become covered for life insurance under this or any other group term life insurance plan;
• with respect to Your Spouse, the date Your marriage ends in divorce or annulment;
• with respect to a Child, the date the Child no longer qualifies as a Child for purposes of Life Insurance;
• with respect to You or Your Spouse, the date You or Your Spouse reach any applicable age limits; or
• the end of 18 months following the date Your Active Work ended.
When a continuation under this section ends, You and Your Dependents may buy an individual policy of life
insurance from Us. The details of this option are described in the section entitled LIFE INSURANCE:
CONVERSION OPTION FOR YOU and LIFE INSURANCE: CONVERSION OPTION FOR YOUR
DEPENDENTS. For the purpose of that section, the end of this continuation will be considered the end of
your employment.
Effect of Previous Conversion
If You or a Dependent converted Life Insurance to an individual policy, We will only pay Life Insurance under
this section if such individual policy is returned to Us. If it is returned to Us, We will refund to Your or Your
Dependent's estate the premiums paid for such policy without interest, less any debt incurred under such
policy.
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NOTICE FOR RESIDENTS OF MINNESOTA
CONTINUATION OF BASIC OR DEPENDENT LIFE INSURANCE WITH PREMIUM
PAYMENT (Continued)
If such individual policy is not returned to Us, We will pay the life insurance in effect under the individual
policy.
We will not pay insurance under both the Group Policy and the individual policy.
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NOTICE FOR RESIDENTS OF NEW MEXICO
If a Child is insured for Accidental Death and Dismemberment Insurance under this certificate and You are
not the custodial parent, notify Us that such is the case and provide Us with the name and address of the
custodial parent. After receipt of such notice We will:
(1) provide such information to the custodial parent as may be necessary for the Child to obtain benefits
through that insurance;
(2) permit the custodial parent or the provider, with the custodial parent's approval, to submit claims for
covered services without the approval of the non -custodial parent; and
(3) make payments on claims submitted in accordance with Paragraph (2) of this subsection directly to the
custodial parent, the provider or the state Medicaid agency.
If You are required by a court or administrative order to provide Accidental Death and Dismemberment
Insurance for a Child, and You are eligible to provide such insurance for that child, We will:
(1) permit You to enroll a Child who is otherwise eligible for such insurance without regard to any enrollment
season restrictions;
(2) if You are enrolled but fail to make application to obtain insurance for such Child, We will enroll the Child
for insurance upon application of the Child's other parent, the state agency administering the Medicaid
program or the state agency administering 42 U.S.C. Sections 651 through 669, the child support
enforcement program; and
(3)
We will not disenroll or eliminate insurance for such Child unless the insurer is provided satisfactory
written evidence that:
(a) the court or administrative order is no longer in effect; or
(b) the Child is or will be enrolled in comparable health insurance through another insurer that will take
effect not later than the effective date of disenrollment.
We will not impose requirements on a state agency that has been assigned the rights of an
individual eligible for medical assistance under the Medicaid program and insured for Accidental Death and
Dismemberment Insurance with Us that are different from requirements applicable to an agent or assignee of
any other individual so insured.
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NOTICE FOR RESIDENTS OF NORTH CAROLINA
Read your Certificate Carefully.
IMPORTANT CANCELLATION INFORMATION
Please Read The Provisions Entitled
DATE YOUR INSURANCE ENDS and DATE YOUR INSURANCE FOR
YOUR DEPENDENTS ENDS
Found on Pages e/ee and a/dep
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NOTICE FOR RESIDENTS OF NORTH CAROLINA
UNDER NORTH CAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON, EMPLOYER,
PRINCIPAL, AGENT, TRUSTEE, OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE FOR THE
PAYMENT OF GROUP HEALTH OR LIFE INSURANCE OR GROUP HEALTH PLAN PREMIUMS, SHALL:
(1) CAUSE THE CANCELLATION OR NONRENEWAL OF GROUP HEALTH OR LIFE 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 PERSONS 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 A WRITTEN NOTICE OF THE
PERSON'S INTENTION TO STOP PAYMENT OF PREMIUMS. THIS WRITTEN NOTICE MUST ALSO
CONTAIN A NOTICE TO ALL PERSONS COVERED BY THE GROUP POLICY OF THEIR RIGHTS TO
HEALTH INSURANCE CONVERSION POLICIES UNDER ARTICLE 53 OF CHAPTER 58 OF THE
GENERAL STATUTES AND THEIR RIGHTS TO PURCHASE INDIVIDUAL POLICIES UNDER THE
FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT AND UNDER ARTICLE
68 OF CHAPTER 58 OF THE GENERAL STATUTES.
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.
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NOTICE FOR RESIDENTS OF PENNSYLVANIA
Accidental Death and Dismemberment Insurance for a Dependent Child may be continued past the age limit if
that Child is a full-time student and insurance ends due to the Child being ordered to active duty (other than
active duty for training) for 30 or more consecutive days as a member of the Pennsylvania National Guard or
a Reserve Component of the Armed Forces of the United States.
Insurance will continue if such Child:
• re -enrolls as a full-time student at an accredited school, college or university that is licensed in the
jurisdiction where it is located;
• re -enrolls for the first term or semester, beginning 60 or more days from the child's release from active
duty;
• continues to qualify as a Child, except for the age limit; and
• submits the required Proof of the child's active duty in the National Guard or a Reserve Component of the
United States Armed Forces.
Subject to the Date Insurance For Your Dependents Ends subsection of the section entitled ELIGIBILITY
PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, this continuation will continue until the earliest of
the date:
• the insurance has been continued for a period of time equal to the duration of the child's service on active
duty; or
• the child is no longer a full-time student.
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NOTICE FOR RESIDENTS OF UTAH
Notice of Protection Provided by
Utah Life and Health Insurance Guaranty Association
This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association ("the
Association") and the protection it provides for policyholders. This safety net was created under Utah law,
which determines who and what is covered and the amounts of coverage.
The Association was established to provide protection in the unlikely event that your life, health, or annuity
insurance company becomes financially unable to meet its obligations and is taken over by its insurance
regulatory agency. If this should happen, the Association will typically arrange to continue coverage and pay
claims, in accordance with Utah law, with funding from assessments paid by other insurance companies.
The basic protections provided by the Association are:
• Life Insurance
o $500,000 in death benefits
o $200,000 in cash surrender or withdrawal values
• Health Insurance
o $500,000 in hospital, medical and surgical insurance benefits
o $500,000 in long-term care insurance benefits
o $500,000 in disability income insurance benefits
o $500,000 in other types of health insurance benefits
• Annuities
o $250,000 in withdrawal and cash values
The maximum amount of protection for each individual, regardless of the number of policies or contracts, is
$500,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits.
Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does
not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain
investment additions to the account value of a variable life insurance policy or a variable annuity contract.
Coverage is conditioned on residency in this state and there are substantial limitations and exclusions. For a
complete description of coverage, consult Utah Code, Title 3 IA, Chapter 28.
Insurance companies and agents are prohibited by Utah law to use the existence of the Association
or its coverage to encourage you to purchase insurance. When selecting an insurance company, you
should not rely on Association coverage. If there is any inconsistency between Utah law and this
notice, Utah law will control.
To learn more about the above protections, as well as protections relating to group contracts or retirement
plans, please visit the Association's website at www.utlifega.org or contact:
Utah Life and Health Insurance Guaranty Assoc.
60 East South Temple, Suite 500
Salt Lake City UT 84111
(801) 320-9955
Utah Insurance Department
3110 State Office Building
Salt Lake City UT 84114-6901
(801) 538-3800
A written complaint about misuse of this Notice or the improper use of the existence of the Association may
be filed with the Utah Insurance Department at the above address.
GTY-NOTICE-UT-0710 18
NOTICE FOR RESIDENTS OF VIRGINIA
IMPORTANT INFORMATION REGARDING YOUR INSURANCE
In the event You need to contact someone about this insurance for any reason please contact Your agent. If no
agent was involved in the sale of this insurance, or if You have additional questions You may contact the
insurance company issuing this insurance at the following address and telephone number:
MetLife
200 Park Avenue
New York, New York 10166
Attn: Corporate Consumer Relations Department
To phone in a claim related question, You may call Claims Customer Service at:
1-800-275-4638
If You have been unable to contact or obtain satisfaction from the company or the agent, You may contact the
Virginia State Corporation Commission's Bureau of Insurance at:
The Office of the Managed Care Ombudsman
Bureau of Insurance
P.O. Box 1157
Richmond, VA 23218
1-877-310-6560 - toll -free
1-804-371-9691 - locally
www.scc.virginia.gov - web address
ombudsman(cr�scc.virginia.gov - email
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NOTICE FOR RESIDENTS OF THE STATE OF WASHINGTON
Washington law provides that the following apply to Your certificate:
Wherever the term "Spouse" appears in this certificate it shall, unless otherwise specified, be read to include
Your Domestic Partner.
Domestic Partner means each of two people, one of whom is an Employee of the Policyholder, who have
registered as each other's domestic partner, civil union partner or reciprocal beneficiary with a government
agency where such registration is available.
Wherever the term "step -child" appears in this certificate it shall be read to include the children of Your
Domestic Partner.
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NOTICE FOR RESIDENTS OF WEST VIRGINIA
FREE LOOK PERIOD:
If You are not satisfied with Your certificate, You may return it to Us within 10 days after You receive it, unless
a claim has previously been received by Us under Your certificate. We will refund within 10 days of our receipt
of the returned certificate any Premium that has been paid and the certificate will then be considered to have
never been issued. You should be aware that, if You elect to return the certificate for a refund of premiums,
losses which otherwise would have been covered under Your certificate will not be covered.
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NOTICE FOR RESIDENTS OF WISCONSIN
KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS
PROBLEMS WITH YOUR INSURANCE? - If You are having problems with Your insurance company or
agent, do not hesitate to contact the insurance company or agent to resolve Your problem.
MetLife
Attn: Corporate Consumer Relations Department
200 Park Avenue
New York, NY 10166-0188
1-800-638-5433
You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which
enforces Wisconsin's insurance laws, and file a complaint. You can contact the OFFICE OF THE
COMMISSIONER OF INSURANCE by contacting:
Office of the Commissioner of Insurance
Complaints Department
P.O. Box 7873
Madison, WI 53707-7873
1-800-236-8517 outside of Madison or 608-266-0103 in Madison.
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TABLE OF CONTENTS
Section Page
CERTIFICATE FACE PAGE 1
NOTICES 2
SCHEDULE OF BENEFITS 25
DEFINITIONS 37
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU 40
Eligible Classes 40
Date You Are Eligible for Insurance 40
Enrollment Process 40
Date Your Insurance Takes Effect 40
Date Your Insurance Ends 44
ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS 45
Eligible Classes For Dependent Insurance 45
Date You Are Eligible For Dependent Insurance 45
Enrollment Process 45
Date Insurance Takes Effect For Your Dependents 45
Date Your Insurance For Your Dependents Ends 48
CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT 49
For Mentally or Physically Handicapped Children 49
For Family And Medical Leave 49
At Your Option: Portability 49
At Your Option: When You Cease Active Work Due To Total Disability 52
At The Policyholder's Option 53
EVIDENCE OF INSURABILITY 54
LIFE INSURANCE: FOR YOU 55
LIFE INSURANCE: FOR YOUR DEPENDENTS 56
LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO) FOR YOU 57
LIFE INSURANCE: CONVERSION OPTION FOR YOU 59
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TABLE OF CONTENTS (continued)
Section Page
LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS 61
ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED63
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 66
ADDITIONAL BENEFIT: SEAT BELT USE 68
ADDITIONAL BENEFIT: AIR BAG USE 69
ADDITIONAL BENEFIT: CHILD CARE 70
ADDITIONAL BENEFIT: CHILD EDUCATION 71
ADDITIONAL BENEFIT: SPOUSE EDUCATION 72
ADDITIONAL BENEFIT: HOSPITAL CONFINEMENT 73
ADDITIONAL BENEFIT: COMMON CARRIER 74
ADDITIONAL BENEFIT: REPATRIATION EXPENSE 75
FILING A CLAIM 76
GENERAL PROVISIONS 77
Assignment 77
Beneficiary 77
Entire Contract 77
Incontestability: Statements Made by You 78
Misstatement of Age 78
Conformity with Law 78
Physical Exams 78
Autopsy 78
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SCHEDULE OF BENEFITS
This schedule shows the benefits that are available under the Group Policy. You and Your
Dependents will only be insured for the benefits:
® for which You and Your Dependents become and remain eligible;
® which You elect, if subject to election; and
® which are in effect.
The amount of Insurance that We will pay will be decreased by the amount of any
contributions due and unpaid to Us for that insurance.
BENEFIT
Life Insurance For You
Basic Life Insurance
Basic Life Insurance is NOT Portability Eligible Insurance
For Active Employees
Maximum Basic Life Benefit
Accelerated Benefit Option
Supplemental Life Insurance
Supplemental Life Insurance is Portability Eligible Insurance
For Active Employees who elect:
Option 1
Option 2
BENEFIT AMOUNTS AND HIGHLIGHTS
An amount equal to 1 times Your
Basic Annual Earnings, rounded to
the next higher $1,000
$200,000
Up to 80% of Your Basic Life
amount not to exceed $160,000
An amount equal to 1 times Your
Basic Annual Earnings, rounded to
the next higher $1,000
An amount equal to 2 times Your
Basic Annual Earnings, rounded to
the next higher $1,000
Option 3 An amount equal to 3 times Your
Basic Annual Earnings, rounded to
the next higher $1,000
Option 4
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An amount equal to 4 times Your
Basic Annual Earnings, rounded to
the next higher $1,000
SCHEDULE OF BENEFITS (continued)
Option 5
Maximum Supplemental Life Benefit $400,000
Non -Medical Issue Amount
Accelerated Benefit Option
ESTATE RESOLUTION SERVICES
An amount equal to 5 times Your
Basic Annual Earnings, rounded to
the next higher $1,000
The lesser of 2 times Your Basic
Annual Earnings or $250,000
Up to 80% of Your Supplemental
Life amount not to exceed
$320,000
The following Estate Resolution Services are provided at no additional cost to individuals insured
for Group Supplemental Life Insurance coverage as described below. If You are eligible to
receive these Estate Resolution Services and You or Your Spouse (for the Will Preparation
Service) or You or a Beneficiary (for the Probate Service) would like to speak with a
representative from Hyatt Legal Services or get the name of a Plan Attorney that you can speak
with about these Services, please call (800) 821-6400.
THE FOLLOWING APPLIES TO RESIDENTS OF ALL STATES OTHER THAN TEXAS
Will Preparation Service
If You elect Group Supplemental Life Insurance coverage, a Will Preparation Service (the
"Service") will be made available to You, through a MetLife affiliate (the "Affiliate"), while Your
Group Supplemental Life Insurance coverage is in effect. This Service will be made available at
no cost to You. It enables You to have a will prepared for You and Your Spouse free of charge
by attorneys designated by the Affiliate. If You have a will prepared by an attorney not
designated by the Affiliate, You must pay for the attorney's services directly. Upon Proof of such
payment, You will be reimbursed for the attorney's services in an amount equal to the lesser of
the amount You paid for the attorney's services and the amount customarily reimbursed for such
services by the Affiliate.
Probate Service
If You become insured for Group Supplemental Life Insurance coverage and die while such
Group Supplemental Life Insurance coverage is in effect, a probate benefit (the "Benefit") will be
made available to Your estate, through a MetLife affiliate ("Affiliate").
The Benefit provides for certain probate services to be made available upon Your death, free of
charge by attorneys designated by the Affiliate. If probate services are provided by an attorney
not designated by the Affiliate, Your estate must pay for those attorney's services directly. Upon
Proof of such payment, Your estate will be reimbursed for the attorney's services in an amount
equal to the lesser of the amount Your estate paid for the attorney's services and the amount
customarily reimbursed for such services by the Affiliate.
This Benefit will be provided at no cost to You and will end on the date Your Group Supplemental
Life Insurance coverage ends.
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SCHEDULE OF BENEFITS (continued)
THE FOLLOWING APPLIES TO RESIDENTS OF TEXAS ONLY
Will Preparation Service
If You elect Group Supplemental Life Insurance coverage, a Will Preparation Service (the
"Service") will be made available to You through a MetLife affiliate (the "Affiliate"), as agreed to by
the Policyholder and MetLife, while Your Group Supplemental Life Insurance coverage is in effect
under this Policy.
Will Preparation Service means a service covering the preparation of wills and codicils for You
and Your Spouse. The creation of any testamentary trust is covered. The Will Preparation Service
does not include tax planning.
This Service will be made available at no cost to You. It enables You to have a will prepared for
You and Your Spouse free of charge by attorneys designated by the Affiliate. If You have a will
prepared by an attorney not designated by the Affiliate, You must pay for the attorney's services
directly. Upon Proof of such payment, You will be reimbursed for the attorney's services in an
amount equal to the lesser of the amount You paid for the attorney's services and the amount
customarily reimbursed for such services by the Affiliate.
Probate Service
If You become insured for Group Supplemental Life Insurance coverage and die while such
Group Supplemental Life Insurance coverage is in effect, a probate benefit (the "Benefit") will be
made available to Your estate, through a MetLife affiliate ("Affiliate").
The Benefit includes attorney representation and payment of legal fees for the executor or
administrator of insured employee's estate including representation for the preparation of all
documents and all of the court proceedings needed to transfer probate assets from the estate to
insured employee's heirs; and the completion of correspondence necessary to transfer non -
probate assets such as proceeds from insurance policies, joint bank accounts, stock accounts or
a house; and associated tax filings.
The Benefit provides for such services to be made available upon Your death, free of charge by
attorneys designated by the Affiliate. If probate services are provided by an attorney not
designated by the Affiliate, Your estate must pay for those attorney's services directly. Upon
Proof of such payment, Your estate will be reimbursed for the attorney's services in an amount
equal to the lesser of the amount Your estate paid for the attorney's services and the amount
customarily reimbursed for such services by the Affiliate.
This Benefit will be provided at no cost to You and will end on the date Your Group Supplemental
Life Insurance coverage ends.
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SCHEDULE OF BENEFITS (continued)
Accidental Death and Dismemberment Insurance (AD&D) for You
Full Amount for Basic AD&D
Accidental Death and Dismemberment Insurance for You is NOT Portability Eligible
Insurance
For Active Employees An amount equal to Your Basic Life
Insurance
Maximum Accidental Death and Dismemberment
Full Amount $200,000
Additional Benefits:
Seat Belt Benefit Yes
Air Bag Use Benefit Yes
Child Care Benefit NONE
Child Education Benefit NONE
Spouse Education Benefit NONE
Hospital Confinement Benefit NONE
Common Carrier Benefit Yes
Repatriation Expense Benefit Yes
Schedule of Covered Losses for Accidental Death and Dismemberment Insurance
All amounts listed are stated as percentages of the Full Amount.
Covered Losses
Loss of life 100%
Loss of a hand permanently severed at or above the wrist but
below the elbow 50%
Loss of a foot permanently severed at or above the ankle but
below the knee 50%
Loss of an arm permanently severed at or above the elbow 75%
Loss of a leg permanently severed at or above the knee 75%
Loss of sight in one eye 50%
Loss of sight means permanent and uncorrectable loss of sight in the eye.
Visual acuity must be 20/200 or worse in the eye or the field of vision must be
less than 20 degrees.
Loss of any combination of hand, foot, or sight of one eye, as
defined above 100%
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SCHEDULE OF BENEFITS (continued)
Loss of the thumb and index finger of same hand 25%
Loss of thumb and index finger of same hand means that the thumb and
index finger are permanently severed through or above the third joint from the tip
of the index finger and the second joint from the tip of the thumb.
Loss of speech and loss of hearing 100%
Loss of speech or loss of hearing 50%
Loss of speech means the entire and irrecoverable loss of speech that
continues for 6 consecutive months following the accidental injury.
Loss of hearing means the entire and irrecoverable loss of hearing in both ears
that continues for 6 consecutive months following the accidental injury.
Paralysis of both arms and both legs 100%
Paralysis of both legs 50%
Paralysis of the arm and leg on either side of the body 50%
Paralysis of one arm or leg 25%
Paralysis means loss of use of a limb, without severance. A Physician must
determine the paralysis to be permanent, complete and irreversible.
Brain Damage 100%
Brain Damage means permanent and irreversible physical damage to the brain
causing the complete inability to perform all the substantial and material functions
and activities normal to everyday life. Such damage must manifest itself within
30 days of the accidental injury, require a hospitalization of at least 5 days and
persists for 12 consecutive months after the date of the accidental injury.
Coma 1% monthly
beginning on the
7th day of the
Coma for the
duration of the
Coma to a
maximum of 60
months
Coma means a state of deep and total unconsciousness from which the
comatose person cannot be aroused. Such state must begin within 30 days of
the accidental injury and continue for 7 consecutive days.
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SCHEDULE OF BENEFITS (continued)
Full Amount for Voluntary AD&D
Voluntary Accidental Death and Dismemberment Insurance is Portability Eligible
Insurance
For Active Employees An amount, elected by You, which
is a multiple of $10,000
Minimum Voluntary Accidental Death and
Dismemberment Full Amount $10,000
Maximum Voluntary Accidental Death and
Dismemberment Full Amount $500,000
Additional Benefits:
Seat Belt Benefit Yes
Air Bag Use Benefit Yes
Child Care Benefit Yes
Child Education Benefit Yes
Spouse Education Benefit Yes
Hospital Confinement Benefit Yes
Common Carrier Benefit Yes
Repatriation Expense Benefit NONE
Schedule of Covered Losses for Voluntary Accidental Death and
Dismemberment Insurance
All amounts listed are stated as percentages of the Full Amount.
Covered Losses
Loss of life 100%
Loss of a hand permanently severed at or above the wrist but
below the elbow 50%
Loss of a foot permanently severed at or above the ankle but
below the knee 50%
Loss of an arm permanently severed at or above the elbow 75%
Loss of a leg permanently severed at or above the knee 75%
Loss of sight in one eye 50%
Loss of sight means permanent and uncorrectable loss of sight in the eye.
Visual acuity must be 20/200 or worse in the eye or the field of vision must be
less than 20 degrees.
Loss of any combination of hand, foot, or sight of one eye, as
defined above 100%
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SCHEDULE OF BENEFITS (continued)
Loss of the thumb and index finger of same hand 25%
Loss of thumb and index finger of same hand means that the thumb and
index finger are permanently severed through or above the third joint from the tip
of the index finger and the second joint from the tip of the thumb.
Loss of speech and loss of hearing 100%
Loss of speech or loss of hearing 50%
Loss of speech means the entire and irrecoverable loss of speech that
continues for 6 consecutive months following the accidental injury.
Loss of hearing means the entire and irrecoverable loss of hearing in both ears
that continues for 6 consecutive months following the accidental injury.
Paralysis of both arms and both legs 100%
Paralysis of both legs 50%
Paralysis of the arm and leg on either side of the body 50%
Paralysis of one arm or leg 25%
Paralysis means loss of use of a limb, without severance. A Physician must
determine the paralysis to be permanent, complete and irreversible.
Brain Damage 100%
Brain Damage means permanent and irreversible physical damage to the brain
causing the complete inability to perform all the substantial and material functions
and activities normal to everyday life. Such damage must manifest itself within
30 days of the accidental injury, require a hospitalization of at least 5 days and
persists for 12 consecutive months after the date of the accidental injury.
Coma 1% monthly
beginning on the 7th
day of the Coma for
the duration of the
Coma to a maximum
of 60 months
Coma means a state of deep and total unconsciousness from which the
comatose person cannot be aroused. Such state must begin within 30 days of
the accidental injury and continue for 7 consecutive days.
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SCHEDULE OF BENEFITS (continued)
If You Are Age 70 Or Older
If You are age 70 or older on Your effective date of insurance, the appropriate percentage from the
following table will be applied to the amount of Your Basic Life and Accidental Death and
Dismemberment Insurance on Your effective date of insurance.
If You are under age 70 on Your effective date of insurance, the amounts of Your Basic Life and
Accidental Death and Dismemberment Insurance on and after age 70 will be determined by applying
the appropriate percentage from the following table to the amount of Your insurance in effect on the
day before Your 70th birthday:
Age of Employee
70
75
Percentage
65%
50%
Life Insurance For Your Dependents
Life Insurance for Your Dependents is NOT Portability Eligible Insurance
For Your Spouse $10,000
For each of Your Children $5,000
Accidental Death and Dismemberment Insurance (AD&D) For Your Dependents
Full Amount for Voluntary AD&D
Voluntary Accidental Death and Dismemberment Insurance is Portability Eligible Insurance
Spouse and Child(ren)
Spouse Only
For each of Your Children
An amount equal to: (a) 50% for
Your Spouse Only; and (b) 10%
for each Child; of Your Voluntary
Accidental Death and
Dismemberment Insurance
An amount equal to 50% of Your
Voluntary Accidental Death and
Dismemberment Insurance
Child(ren) Only An amount equal to 10% of Your
Voluntary Accidental Death and
Dismemberment Insurance for
each Child
Minimum Spouse Voluntary Accidental Death and
Dismemberment Full Amount $5,000
Minimum Child Voluntary Accidental Death and
Dismemberment Full Amount $1,000
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SCHEDULE OF BENEFITS (continued)
Maximum Spouse Voluntary Accidental Death and
Dismemberment Full Amount $250,000
Maximum Child Voluntary Accidental Death and
Dismemberment Full Amount $50,000
Additional Benefits:
Seat Belt Benefit Yes
Air Bag Use Benefit Yes
Child Care Benefit Yes
Child Education Benefit Yes
Hospital Confinement Benefit Yes
Common Carrier Benefit Yes
Repatriation Expense Benefit NONE
Schedule of Covered Losses for Voluntary Accidental Death and Dismemberment
Insurance
All amounts listed are stated as percentages of the Full Amount.
Covered Losses
Loss of life 100%
Loss of a hand permanently severed at or above the wrist but
below the elbow 50%
Loss of a foot permanently severed at or above the ankle but
below the knee 50%
Loss of an arm permanently severed at or above the elbow 75%
Loss of a leg permanently severed at or above the knee 75%
Loss of sight in one eye 50%
Loss of sight means permanent and uncorrectable loss of sight in the eye. Visual acuity
must be 20/200 or worse in the eye or the field of vision must be less than 20 degrees.
Loss of any combination of hand, foot, or sight of one eye, as
defined above 100%
Loss of the thumb and index finger of same hand 25%
Loss of thumb and index finger of same hand means that the thumb and index finger
are permanently severed through or above the third joint from the tip of the index finger
and the second joint from the tip of the thumb.
Loss of speech and loss of hearing 100%
Loss of speech or loss of hearing 50%
Loss of speech means the entire and irrecoverable loss of speech that continues for 6
consecutive months following the accidental injury.
Loss of hearing means the entire and irrecoverable loss of hearing in both ears that
continues for 6 consecutive months following the accidental injury.
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SCHEDULE OF BENEFITS (continued)
Paralysis of both arms and both legs 100%
Paralysis of both legs 50%
Paralysis of the arm and leg on either side of the body 50%
Paralysis of one arm or leg 25%
Paralysis means loss of use of a limb, without severance. A Physician must determine
the paralysis to be permanent, complete and irreversible.
Brain Damage 100%
Brain Damage means permanent and irreversible physical damage to the brain causing
the complete inability to perform all the substantial and material functions and activities
normal to everyday life. Such damage must manifest itself within 30 days of the
accidental injury, require a hospitalization of at least 5 days and persists for 12
consecutive months after the date of the accidental injury.
Coma 1% monthly beginning on
the 7th day of the Coma for
the duration of the Coma to
a maximum of 60 months.
Coma means a state of deep and total unconsciousness from which the comatose
person cannot be aroused. Such state must begin within 30 days of the accidental injury
and continue for 7 consecutive days.
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SCHEDULE OF BENEFITS (continued)
Portability Eligible Life and AD&D Insurance
Life and AD&D Insurance For You:
Portability Eligible Life Insurance For You:
Minimum Portability Eligible Life Insurance Amount
Maximum Portability Eligible Life Insurance Amount
$10,000
The lesser of Your total Life
Insurance in effect on the
date You elect to Port or
$2,000,000.
Portability Eligible Accidental Death and Dismemberment Insurance For You:
Minimum Portability Eligible AD&D Insurance Amount
Maximum Portability Eligible AD&D Insurance Amount
$10,000
The lesser of Your total AD&D
Insurance in effect on the
date You elect to Port or
$1,000,000.
If Your Portability Eligible Insurance ends due to the end of the Group Policy or the amendment of the Group
Policy to end the Portability Eligible Insurance for an eligible class of which You are a member, the
maximum amount of insurance that You may Port is the lesser of:
• the amount of Your Portability Eligible Insurance that ends under the Group Policy less the amount of
life insurance for which You become eligible under any group policy issued to replace this Group Policy;
or
• $10,000.
AD&D Insurance For Your Spouse
Portability Eligible Dependent Spouse Accidental Death and Dismemberment Insurance:
Minimum Portability Eligible
Dependent Spouse AD&D Insurance Amount $2,500
Maximum Portability Eligible
Dependent Spouse AD&D Insurance Amount
The lesser of Your total
Dependent Spouse AD&D
Insurance in effect on the
date You elect to Port or
$250,000.
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SCHEDULE OF BENEFITS (continued)
If Your Portability Eligible Insurance or Your Portability Eligible Dependent Insurance ends due to the end of
the Group Policy or the amendment of the Group Policy to end the Portability Eligible Insurance or Your
Portability Eligible Dependent Insurance for an eligible class of which You are a member, the maximum
amount of insurance that You may Port is the lesser of:
• the amount of Your Portability Eligible Insurance or Portability Eligible Dependent Insurance that ends
under the Group Policy less the amount of life insurance for which You become eligible under any group
policy issued to replace this Group Policy; or
• $10,000.
AD&D Insurance For Your Children
Portability Eligible Dependent Child Accidental Death and Dismemberment Insurance:
Minimum Portability Eligible Dependent Child AD&D
Insurance Amount $1,000
Maximum Portability Eligible Dependent Child AD&D
Insurance Amount
The lesser of Your total
Dependent Child Accidental
Death and Dismemberment
Insurance in effect on the
date You elect to Port or
$25,000.
If Your Portability Eligible Insurance or Your Portability Eligible Dependent Insurance ends due to the end of
the Group Policy or the amendment of the Group Policy to end the Portability Eligible Insurance or Your
Portability Eligible Dependent Insurance for an eligible class of which You are a member, the maximum
amount of insurance that You may Port is the lesser of:
® the amount of Your Portability Eligible Insurance or Portability Eligible Dependent Insurance that ends
under the Group Policy less the amount of life insurance for which You become eligible under any group
policy issued to replace this Group Policy; or
® $10,000.
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DEFINITIONS
As used in this certificate, the terms listed below will have the meanings set forth below. When defined terms
are used in this certificate, they will appear with initial capitalization. The plural use of a term defined in the
singular will share the same meaning.
Actively at Work or Active Work means that You are performing all of the usual and customary duties of
Your job on a Full -Time basis. This must be done at:
• the Policyholder's place of business;
• an alternate place approved by the Policyholder; or
• a place to which the Policyholder's business requires You to travel.
You will be deemed to be Actively at Work during weekends or Policyholder approved vacations, holidays or
business closures if You were Actively at Work on the last scheduled work day preceding such time off.
Basic Annual Earnings means Your gross annual rate of pay as determined by Your Policyholder, excluding
overtime and other extra pay. "Basic Annual Earnings" for You if You are a salesman includes commissions
and/or bonuses which shall be averaged for the most recent 12 month period.
Beneficiary means the person(s) to whom We will pay insurance as determined in accordance with the
GENERAL PROVISIONS section.
Child means the following (See Notice for Louisiana, Minnesota, Montana, New Mexico, Texas, and Utah
Residents):
for Life Insurance, Your natural child, adopted child (including a child from the date of placement with the
adopting parents until the legal adoption) or stepchild and who, in each case, is at least 15 days old, under
age 25, unmarried and supported by You.
The term does not include any person who:
• is in service in the armed forces of any country or international authority. However, service in reserve
forces does not constitute service in the armed forces, unless in connection with such reserve service an
individual is on active military duty as determined by the applicable military authority other than weekend
or summer training. For purposes of this provision reserve forces are defined as reserve forces of any
branch of the military of the United States or of any other country or international authority, including but
not limited to the National Guard of the United States or the national guard of any other country; or
• is insured under the Group Policy as an employee.
for Voluntary Accidental Death and Dismemberment Insurance, Your natural child, adopted child
(including a child from the date of placement with adopting parents until the legal adoption) or stepchild and
who, in each case, is under age 25, unmarried and supported by You.
The term does not include any person who:
• is in service in the armed forces of any country or international authority. However, service in reserve
forces does not constitute service in the armed forces, unless in connection with such reserve service an
individual is on active military duty as determined by the applicable military authority other than weekend
or summer training. For purposes of this provision reserve forces are defined as reserve forces of any
branch of the military of the United States or of any other country or international authority, including but
not limited to the National Guard of the United States or the national guard of any other country; or
• is insured under the Group Policy as an employee.
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DEFINITIONS (continued)
Common Carrier means a government regulated entity that is in the business of transporting fare paying
passengers.
The term does not include:
• chartered or other privately arranged transportation;
• taxis; or
• limousines.
Contributory Insurance means insurance for which the Policyholder requires You to pay any part of the
premium.
Contributory Insurance includes: Supplemental Life Insurance, Voluntary Accidental Death and
Dismemberment Insurance and Dependent Life Insurance.
Dependent(s) means Your Spouse and/or Child.
Full -Time means:
• for all employees except laborers, Active Work of at least 37.5 hours per week on the Policyholder's
regular work schedule for the eligible class of employees to which You belong;
• for all laborers, Active Work of at least 40 hours per week on the Policyholder's regular work schedule for
the eligible class of employees to which You belong.
Hospital means a facility which is licensed as such in the jurisdiction in which it is located and:
• provides a broad range of medical and surgical services on a 24 hour a day basis for injured and sick
persons by or under the supervision of a staff of Physicians; and
• provides a broad range of nursing care on a 24 hour a day basis by or under the direction of a registered
professional nurse.
Hospitalized means:
• admission for inpatient care in a Hospital;
• receipt of care in the following:
• a hospice facility;
• an intermediate care facility; or
• a long term care facility; or
• receipt of the following treatment, wherever performed:
• chemotherapy;
• radiation therapy; or
• dialysis.
Noncontributory Insurance means insurance for which the Policyholder does not require You to pay any
part of the premium.
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DEFINITIONS (continued)
Physician means:
• a person licensed to practice medicine in the jurisdiction where such services are performed; or
• any other person whose services, according to applicable law, must be treated as Physician's services for
purposes of the Group Policy. Each such person must be licensed in the jurisdiction where he performs
the service and must act within the scope of that license. He must also be certified and/or registered if
required by such jurisdiction.
The term does not include:
• You;
• Your Spouse; or
• any member of Your immediate family including Your and/or Your Spouse's:
• parents;
• children (natural, step or adopted);
• siblings;
• grandparents; or
• grandchildren.
Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements
for any benefit described in this certificate. When a claim is made for any benefit described in this certificate,
Proof must establish:
• the nature and extent of the loss or condition;
• Our obligation to pay the claim; and
• the claimant's right to receive payment.
Proof must be provided at the claimant's expense.
Signed means any symbol or method executed or adopted by a person with the present intention to
authenticate a record, which is on or transmitted by paper or electronic media which is acceptable to Us and
consistent with applicable law.
Spouse means Your lawful spouse.
The term does not include any person who:
• is in service in the armed forces of any country or international authority. However, service in reserve
forces does not constitute service in the armed forces, unless in connection with such reserve service an
individual is on active military duty as determined by the applicable military authority other than weekend
or summer training. For purposes of this provision reserve forces are defined as reserve forces of any
branch of the military of the United States or of any other country or international authority, including but
not limited to the National Guard of the United States or the national guard of any other country; or
• is insured under the Group Policy as an employee.
We, Us and Our mean MetLife.
Written or Writing means a record which is on or transmitted by paper or electronic media which is
acceptable to Us and consistent with applicable law.
You and Your mean an employee who is insured under the Group Policy for the insurance described in this
certificate.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU
ELIGIBLE CLASS(ES)
All Full -Time employees of the Policyholder.
DATE YOU ARE ELIGIBLE FOR INSURANCE
You may only become eligible for the insurance available for Your eligible class as shown in the SCHEDULE
OF BENEFITS.
You will be eligible for insurance described in this certificate on the later of:
1. February 1, 2011; and
2. the date You complete the Waiting Period of 30 days.
Waiting Period means the period of continuous membership in an eligible class that You must wait before You
become eligible for insurance. This period begins on the date You enter an eligible class and ends on the date
You complete the period(s) specified.
Previous Employment With The Policyholder
If You were employed by the Policyholder and insured by Us under a policy of group life insurance when Your
employment ended, You will not be eligible for life insurance under this Group Policy if You are re -hired by the
Policyholder within 2 years after such employment ended, unless You surrender:
• any individual policy of life insurance to which You converted when Your employment ended; and
• any certificate of insurance continued as ported insurance when such employment ended.
The cash value, if any, of such surrendered insurance will be paid to You.
ENROLLMENT PROCESS
If You are eligible for insurance, You may enroll for such insurance by completing the required form. In
addition, You must give evidence of Your Insurability satisfactory to Us at Your expense if You are required to
do so under the section entitled EVIDENCE OF INSURABILITY. If You enroll for Contributory Insurance, You
must also give the Policyholder Written permission to deduct premiums from Your pay for such insurance.
You will be notified by the Policyholder how much You will be required to contribute.
DATE YOUR INSURANCE TAKES EFFECT
Rules for Noncontributory Insurance
When You complete the enrollment process for Noncontributory Insurance, such insurance will take effect on
the date You become eligible, provided You are Actively at Work on that date.
If You are not Actively at Work on the date the Noncontributory Insurance would otherwise take effect,
insurance will take effect on the day You resume Active Work.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued)
Rules for Contributory Insurance
If You request Contributory Insurance before the date You become eligible for insurance, such insurance will
take effect as follows:
if You are not required to give evidence of Your insurability, such insurance will take effect on the date
You become eligible for such insurance if You are Actively at Work on that date.
if You are required to give evidence of Your insurability and We determine that You are insurable, the
benefit will take effect on the date We state in Writing, provided You are Actively at Work on that date.
If You request Contributory Insurance within 31 days of the date You become eligible for insurance, such
insurance will take effect as follows:
® if You are not required to give evidence of Your insurability, such insurance will take effect on the date
You become eligible for such insurance if You are Actively at Work on that date.
® if You are required to give evidence of Your insurability and We determine that You are insurable, the
benefit will take effect on the date We state in Writing, provided You are Actively at Work on that date.
If You request Contributory Insurance more than 31 days after the date You become eligible, You must give
evidence of Your insurability satisfactory to us. You must give such evidence at Your expense. If We
determine that You are insurable, such insurance will take effect on the date We state in Writing, if You are
Actively at Work on that date.
If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on
the day You resume Active Work. In addition to having been Actively at Work on the date Your Contributory
Life Insurance benefit is to take effect, You must also have been Actively at Work for at least 20 hours during
the 7 calendar days preceding that date.
Enrollment During An Annual Enrollment Period
During any annual enrollment period as determined by the Policyholder, You may enroll for insurance for
which You are eligible or choose a different option than the one for which You are currently enrolled. The
insurance enrolled for or changes to Your insurance made during an annual enrollment period will take effect
as follows:
® for any amount for which You are not required to give evidence of Your insurability, such insurance will
take effect on the first day of the month following the annual enrollment period, if You are Actively at Work
on that date. You are not required to give evidence of Your insurability for Voluntary Accidental Death
and Dismemberment Insurance.
® for any amount for which You are required to give evidence of Your insurability and We determine that
You are insurable, such insurance will take effect on the date We state in Writing, if You are Actively at
Work on that date. You are not required to give evidence of Your insurability for Voluntary Accidental
Death and Dismemberment Insurance and such insurance will take effect even if Your Life Insurance
does not take effect.
If You are not Actively at Work on the date an amount of insurance would otherwise take effect, that amount
of insurance will take effect on the day You resume Active Work. For a Contributory Life Insurance Benefit to
take effect, in addition to having been Actively at Work on the date the insurance benefit is to take effect, You
must also have been Actively at Work for at least 20 hours during the 7 calendar days preceding that date.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued)
Enrollment Due to a Qualifying Event
You may enroll for insurance for which You are eligible or change the amount of Your insurance if You have a
Qualifying Event.
If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on
the day You resume Active Work.
Qualifying Event includes:
• marriage;
• the birth, adoption or placement for adoption of a dependent child;
• divorce, legal separation or annulment; or
• a change in Your or Your dependent's employment status, such as beginning or ending employment,
strike, lockout, taking or ending a leave of absence, changes in worksite or work schedule, if it causes
You or Your dependent to gain or lose eligibility for group coverage.
If You have a Qualifying Event, You will have 31 days from the date of that change to make a request. This
request must be consistent with the nature of the Qualifying Event. The insurance enrolled for, or changes to
Your insurance, made as a result of a Qualifying Event will take effect as follows:
• for any amount for which You are not required to give evidence of Your insurability, such insurance will
take effect on the date of the Qualifying Event, if You are Actively at Work on that date. You are not
required to give evidence of Your insurability for Voluntary Accidental Death and Dismemberment
Insurance.
• for any amount for which You are required to give evidence of Your insurability and We determine that
You are insurable, such insurance will take effect on the date We state in Writing, if You are Actively at
Work on that date. You are not required to give evidence of Your insurability for Voluntary Accidental
Death and Dismemberment Insurance and such insurance will take effect even if Your Life Insurance
does not take effect.
If You are not Actively at Work on the date an amount of insurance would otherwise take effect, that amount
of insurance will take effect on the day You resume Active Work. For a Contributory Life Insurance Benefit to
take effect, in addition to having been Actively at Work on the date the insurance benefit is to take effect, You
must also have been Actively at Work for at least 20 hours during the 7 calendar days preceding that date.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued)
Increase in Insurance
An increase in insurance due to an increase in Your earnings or a requested increase in insurance will take
effect as follows:
if You are required to give evidence of insurability for the entire increase in insurance and We approve
Your evidence of insurability, the increase will take effect on the date We state in Writing. If We do not
approve Your evidence of insurability, or You do not submit evidence of insurability, the increase in
insurance will not take effect.
® if You are required to give evidence of insurability for a portion of the increase in insurance:
• the portion of the increase in insurance that is not subject to evidence of insurability will take effect on
the date of Your request or the date of the increase in Your earnings.
® if We approve Your evidence of insurability, the portion of the increase in insurance that is subject to
evidence of insurability will take effect on the date We state in writing. If We do not approve Your
evidence of insurability or You do not submit evidence of insurability, the increase in insurance will
not take effect.
if You are not required to give evidence of insurability, the increase will take effect on the dateof Your
request or the date of the increase in Your earnings.
If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on
the day You resume Active Work. For a Contributory Life Insurance Benefit to take effect, in addition to having
been Actively at Work on the date the insurance benefit is to take effect, You must also have been Actively at
Work for at least 20 hours during the 7 calendar days preceding that date.
Decrease in Insurance
A decrease in insurance due to a decrease in Your earnings will take effect on the date of change.
If You make a Written request to decrease Your insurance, that decrease will take effect as of the date of Your
Written request.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued)
DATE YOUR INSURANCE ENDS
Your insurance will end on the earliest of:
for all coverages
1. the date the Group Policy ends; or
2. the date insurance ends for Your class; or
3. the end of the period for which the last premium has been paid for You; or
for Basic Life Insurance
4. the date Your employment ends; Your employment will end if You cease to be Actively at Work in any
eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM
PAYMENT; or
5. the date You retire in accordance with the Policyholder's retirement plan; or
for Supplemental Life Insurance
6. the date Your employment ends; Your employment will end if You cease to be Actively at Work in any
eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM
PAYMENT; or
7. the date You retire in accordance with the Policyholder's retirement plan; or
for Accidental Death and Dismemberment Insurance
8. the date Your employment ends; Your employment will end if You cease to be Actively at Work in any
eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM
PAYMENT; or
9. the date You retire in accordance with the Policyholder's retirement plan; or
for Voluntary Accidental Death and Dismemberment Insurance
10. the date Your employment ends; Your employment will end if You cease to be Actively at Work in any
eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM
PAYMENT; or
11. the date You retire in accordance with the Policyholder's retirement plan.
Please refer to the section entitled ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE
YOU ARE TOTALLY DISABLED for information concerning continuation of Your Life Insurance if insurance
ends while You are Totally Disabled. Please refer to the section entitled LIFE INSURANCE: CONVERSION
OPTION FOR YOU for information concerning the option to convert to an individual policy of life insurance if
Your Life Insurance ends.
In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF
INSURANCE WITH PREMIUM PAYMENT.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS
ELIGIBLE CLASS(ES) FOR DEPENDENT INSURANCE
All Full -Time employees of the Policyholder.
DATE YOU ARE ELIGIBLE FOR DEPENDENT INSURANCE
You may only become eligible for the Dependent insurance available for Your eligible class as shown in
the SCHEDULE OF BENEFITS.
You will be eligible for Dependent insurance described in this certificate on the latest of:
1. February 1, 2011;
2. the date You enter a class eligible for insurance;
3. the date You obtain a Dependent; and
4. the date You complete the Waiting Period of 30 days.
Waiting Period means the period of continuous membership in an eligible class that You must wait before
You become eligible for insurance. This period begins on the date You enter an eligible class and ends on
the date You complete the period(s) specified.
No person may be insured as a Dependent of more than one employee.
ENROLLMENT PROCESS
In order to enroll for Life Insurance for Your Dependents, You must either (a) already be enrolled for
Supplemental Life Insurance for You or (b) enroll at the same time for Supplemental Life Insurance for
You.
If You are eligible for Dependent insurance, You may enroll for such insurance by completing an
enrollment form for each Dependent to be insured. In addition, each of Your Dependents must give
evidence of insurability satisfactory to Us at Your expense if required to do so under the section entitled
EVIDENCE OF INSURABILITY. If You enroll for Contributory Insurance, You must also give the
Policyholder written permission to deduct premiums from Your pay for such insurance. You will be
notified by the Policyholder how much You will be required to contribute.
DATE INSURANCE TAKES EFFECT FOR YOUR DEPENDENTS
Enrollment When First Eligible
If You complete the enrollment process for Dependent insurance within before the date You become
eligible for insurance, such insurance will take effect for each enrolled Dependent as follows:
• if the Dependent is not required to give evidence of insurability, such insurance will take effect on the
date You become eligible for such insurance if You are Actively at Work on that date and the
Dependent satisfies the Additional Requirement stated below.
• if the Dependent is required to give evidence of insurability and We determine that the Dependent is
insurable, such insurance will take effect on the date We state in Writing, if You are Actively at Work
on that date and the Dependent satisfies the Additional Requirement stated below.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued)
If You complete the enrollment process for Dependent insurance within 31 days of becoming eligible for
insurance, such insurance will take effect for each enrolled Dependent as follows:
• if the Dependent is not required to give evidence of insurability, such insurance will take effect on the
date You become eligible for such insurance if You are Actively at Work on that date and the
Dependent satisfies the Additional Requirement stated below.
• if the Dependent is required to give evidence of insurability and We determine that the Dependent is
insurable, such insurance will take effect on the date We state in Writing, if You are Actively at Work
on that date and the Dependent satisfies the Additional Requirement stated below.
If You complete the enrollment process for Dependent Insurance more than 31 days after the date You
become eligible for such insurance, each Dependent must give evidence of his insurability satisfactory to
us. You must give such evidence at Your expense. If We determine that the Dependent is insurable,
such insurance will take effect on the date We state in Writing, if You are Actively at Work on that date
and then Dependent satisfies the Additional Requirement stated below.
If You are not Actively at Work on the date Dependent insurance would otherwise take effect, insurance
will take effect on the day You resume Active Work.
Enrollment During An Annual Enrollment Period
During any annual enrollment period, You may enroll for Dependent insurance for which You are eligible
or change the amount of Your Dependent insurance. The insurance enrolled for or changes to Your
insurance made during the annual enrollment period will take effect for each enrolled Dependent as
follows:
• if the Dependent is not required to give evidence of insurability, such insurance will take effect on the
first day of the month following the annual enrollment period, if You are Actively at Work on that date
and the Dependent satisfies the Additional Requirement stated below. The Dependent is not required
to give evidence of insurability for Dependent Voluntary Accidental Death and Dismemberment
Insurance.
if the Dependent is required to give evidence of insurability and We determine that the Dependent is
insurable, such insurance will take effect on the date We state in Writing, if You are Actively at Work
on that date and the Dependent satisfies the Additional Requirement stated below. The Dependent is
not required to give evidence of insurability for Dependent Voluntary Accidental Death and
Dismemberment Insurance and such insurance will take effect even if Your Dependent Life Insurance
does not take effect.
If You are not Actively at Work on the date Dependent insurance would otherwise take effect, insurance
will take effect on the day You resume Active Work.
Enrollment Due to a Qualifying Event
You may enroll for Dependent insurance for which You are eligible or change the amount of Your
Dependent insurance if You have a Qualifying Event.
Qualifying Event includes:
• marriage;
• the birth, adoption or placement for adoption of a dependent child;
• divorce, legal separation or annulment; or
• a change in Your or Your dependent's employment status, such as beginning or ending employment,
strike, lockout, taking or ending a leave of absence, changes in worksite or work schedule, if it causes
You or Your dependent to gain or lose eligibility for group coverage.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued)
If You have a Qualifying Event, You will have 31 days from the date of that change to make a request.
This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for or
changes to Your insurance made as a result of a Qualifying Event will take effect for each enrolled
Dependent as follows:
• if the Dependent is not required to give evidence of insurability, such insurance will take effect on the
date of the Qualifying Event, if You are Actively at Work on that date and the Dependent satisfies the
Additional Requirement stated below. The Dependent is not required to give evidence of insurability
for Dependent Voluntary Accidental Death and Dismemberment Insurance.
• if the Dependent is required to give evidence of insurability and We determine that the Dependent is
insurable, such insurance will take effect on the date We state in Writing, if You are Actively at Work
on that date and the Dependent satisfies the Additional Requirement stated below. The Dependent is
not required to give evidence of insurability for Dependent Voluntary Accidental Death and
Dismemberment Insurance and such insurance will take effect even if Your Dependent Life Insurance
does not take effect.
If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take
effect on the day You resume Active Work.
Additional Requirement
On the date Dependent insurance is scheduled to take effect, the Dependent must not be:
• confined at home under a Physician's care;
• receiving or applying to receive disability benefits from any source; or
• Hospitalized.
If the Dependent does not meet this requirement on such date, insurance for the Dependent will take
effect on the date that Dependent is no longer:
• confined;
• receiving or applying to receive disability benefits from any source; or
• Hospitalized.
Increase in Insurance
An increase in insurance due to a requested increase in insurance will take effect as follows:
• if You are required to give evidence of insurability for the entire increase in insurance and We
approve Your evidence of insurability, the increase will take effect on the date We state in Writing. If
We do not approve Your evidence of insurability, or You do not submit evidence of insurability, the
increase in insurance will not take effect.
• if You are required to give evidence of insurability for a portion of the increase in insurance:
• the portion of the increase in insurance that is not subject to evidence of insurability will take
effect on the date of Your request or the date of the increase in Your earnings.
• if We approve Your evidence of insurability, the portion of the increase in insurance that is subject
to evidence of insurability will take effect on the date We state in writing. If We do not approve
Your evidence of insurability or You do not submit evidence of insurability, the increase in
insurance will not take effect.
• if You are not required to give evidence of insurability, the increase will take effect on the date of Your
request or the date of the increase in Your earnings.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued)
If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take
effect on the day You resume Active Work. For a Contributory Life Insurance Benefit to take effect, in
addition to having been Actively at Work on the date the insurance benefit is to take effect, You must also
have been Actively at Work for at least 20 hours during the 7 calendar days preceding that date.
Decrease in Insurance
If You make a Written request to decrease Your insurance, that decrease will take effect as of the date of
Your Written request.
DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS
A Dependent's insurance will end on the earliest of:
1. for Dependent Life Insurance, the date all of the Life Insurance under the Group Policy ends; or
2. for Dependent Voluntary Accidental Death and Dismemberment Insurance, the date all of Your
Accidental Death and Dismemberment Insurance under the Group Policy ends; or
3. the date You die; or
4. the date the Group Policy ends; or
5. the date Your Employee Life Insurance under the Group Policy ends; or
6. the date Insurance for Your Dependents ends under the Group Policy; or
7. the date Insurance for Your Dependents ends for Your class; or
8. the date the person ceases to be a Dependent; or
9. the date Your employment ends; Your employment will end if You cease to be Actively at Work in any
eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH
PREMIUM PAYMENT; or
10. for Utah residents, with respect to Voluntary Accidental Death and Dismemberment Insurance, the
last day of the calendar month the person ceases to be a dependent; or
11. for Utah residents, with respect to Voluntary Accidental Death and Dismemberment Insurance, the
last day of the calendar month the Dependent Child reaches the limiting age; or
12. for Dependent Life Insurance and Voluntary Accidental Death and Dismemberment Insurance, the
date You retire in accordance with the Policyholder's retirement plan; or
13. the end of the period for which the last premium has been paid for the Dependent.
Please refer to the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOUR
DEPENDENTS for information concerning the option to convert to an individual policy of life insurance if
Life Insurance for a Dependent ends.
In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF
INSURANCE WITH PREMIUM PAYMENT.
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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT
FOR MENTALLY OR PHYSICALLY HANDICAPPED CHILDREN
Insurance for a Dependent Child may be continued past the age limit if the child is incapable of self-
sustaining employment because of a mental or physical handicap as defined by applicable law. Proof of
such handicap must be sent to Us within 31 days after the date the Child attains the age limit and at
reasonable intervals after such date.
Subject to the DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section
entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, insurance will continue
while such Child:
• remains incapable of self-sustaining employment because of a mental or physical handicap; and
• continues to qualify as a Child, except for the age limit.
FOR FAMILY AND MEDICAL LEAVE
Certain leaves of absence may qualify for continuation of insurance under the Family and Medical Leave
Act of 1993 (FMLA), or other legally mandated leave of absence or similar laws. Please contact the
Policyholder for information regarding such legally mandated leave of absence laws.
AT YOUR OPTION: PORTABILITY
For Life and Accidental Death and Dismemberment Insurance
If Your Portability Eligible Insurance ends for any of the reasons stated below, You have the option to
continue that insurance under another group policy in accordance with the conditions and requirements of
this section. This is referred to as Porting. Evidence of Your insurability will not be required.
For purposes of this subsection the term "Portability Eligible Insurance" refers to Your Life Insurance and
Accidental Death and Dismemberment Insurance benefits for which the Portability Eligible Insurance is
shown as available in the SCHEDULE OF BENEFITS.
If Insurance for Your Dependents is in effect, the term "Portability Eligible Dependent Insurance" refers to
Your Accidental Death and Dismemberment Insurance for Your Dependents for which the Portability
Eligible Dependent Insurance is shown as available in the SCHEDULE OF BENEFITS.
When Porting is an Option
Porting may only be exercised by a request in Writing during the Request Period specified below.
If You choose not to Port, Life Insurance benefits may be converted in accordance with the section
entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU.
1. You may choose to Port if Portability Eligible Insurance ends because:
• You become retired from active service with the Employer; or
• Your employment ends, due to a reason other than retirement; or
• You cease to be in a class that is eligible for such insurance; or
• The Policy is amended to end the Portability Eligible Insurance, unless such insurance is
replaced by similar insurance under another group insurance policy issued to the Policyholder or
its successor; or
• This Policy has ended, unless such insurance is replaced by similar insurance under another
group insurance policy issued to the Policyholder or its successor.
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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (continued)
2. You may choose to Port the reduced amount of insurance if Your Portability Eligible Insurance is
reduced due to:
o Your age; or
• An amendment to the Plan which affects the amount of insurance for Your class.
3. Your former Dependent Spouse may choose to Port if their Portability Eligible Dependent Insurance
on his or her own life ends because:
• You die; or
• Your marriage ends in divorce or annulment
provided that former Dependent Spouse satisfies the Additional Requirement subsection of the
ELIGIBILITY PROVISIONS; INSURANCE FOR YOUR DEPENDENTS.
4. Your former Dependent Spouse may also Port Portability Eligible Dependent Insurance on Your
Dependent Child if Your former Dependent Spouse Ports insurance on his or her own life. If Your
former Dependent Spouse Ports that insurance on that Dependent Child, that Porting will have no
effect on the insurance You may have on that Dependent Child.
5 Your former Dependent Child may request to Port Portability Eligible Dependent Insurance on his or
her own life if that insurance ends because Your former Dependent Child no longer meets the
definition of Child.
If a request is made under this subsection, We will issue a new certificate of insurance which will explain
the new insurance benefits. The insurance benefits under the new certificate may not be the same as
those that ended under this Policy.
A request under this subsection may be made, if on the date the Portability Eligible Insurance ended, the
following requirements are met:
• the Group Policy is in effect;
• With respect to any amount of Portability Eligible Life Insurance that is to be Ported, no application
has been made to convert that amount of insurance to an individual policy of life insurance as
provided in the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU; and
• the person making the request resides in a jurisdiction that permits this Portability feature.
Request Period
For You or a former Dependent to Port, We must receive a completed request form within the Request
Period as described below.
If written notice of the option to Port is given within 15 days before or after the date such insurance ends,
the Request Period:
• begins on the date the insurance ends, and
• expires 31 days after the date.
If written notice of the option to Port is given more than 15 days after but within 91 days of the date such
insurance ends, the Request Period:
• begins on the date the insurance ends, and
• expires 45 days after the date of the notice.
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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (continued)
If written notice of the option to Port is not given within 91 days of the date such insurance ends, the
Request Period:
® begins on the date the insurance ends, and
® expires at the end of such 91 day period.
Amount of the New Certificate
The amount of Ported Insurance for You that may be continued is shown in the SCHEDULE OF
BENEFITS. However, at the time of Porting You may change the amount of Portability Eligible Insurance
in the following circumstances:
Your Increase in Amount
For Portability Eligible Life Insurance
At the time of Porting, You may increase the amount of Your Portability Eligible Life Insurance.
This may be done in increments of $25,000, up to a maximum increase of $250,000. To be
eligible for this increased amount, You must provide evidence of Your insurability satisfactory to
us, at Your expense. If We approve the increase, it will take effect on the date We state in
Writing.
For Portability Eligible Accidental Death and Dismemberment Insurance
At the time of Porting, You may increase the amount of Your Portability Eligible Accidental Death
and Dismemberment Insurance. This may be done in increments of $25,000, up to a maximum
increase of $250,000. This increase will take effect on the date We state in Writing.
Dependent Spouse Increase in Amount
For Portability Eligible Dependent Accidental Death and Dismemberment Insurance
At the time of Porting, the amount of Your Spouse's (or Your former Dependent Spouse's)
Portability Eligible Dependent Accidental Death and Dismemberment Insurance may be
increased. This may be done in increments of $25,000; up to a maximum increase of $250,000.
This increase will take effect on the date We state in Writing.
Dependent Child Increase in Amount
Portability Eligible Dependent Accidental Death and Dismemberment Insurance
At the time of Porting, the amount of Your former Dependent Child's Portability Eligible
Dependent Accidental Death and Dismemberment Insurance may be increased. This may be
done in increments of $25,000; up to a maximum increase of $250,000. This increase will take
effect on the date We state in Writing.
You and/or Your Dependent(s) Decrease in Amount
If We receive a request to decrease an amount of insurance, any such decrease will take place
on the date We state in Writing.
Premiums for the New Certificate
All premium payments must be made directly to Us. When We issue the new certificate, We will also
provide a schedule of premiums and payment instructions.
You are not required to provide evidence of insurability to Port Your existing amount of Portability Eligible
Life Insurance. However, to qualify for a lower premium rate, You may give us, at Your expense, evidence
of Your insurability satisfactory to Us. If We determine that the evidence satisfies Us, We will notify You
that the lower premium rates will apply to You.
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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (continued)
Right to Convert Life Insurance Amounts Not Ported
Any amount of Life Insurance not Ported under this subsection may be converted under the section
entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU.
If You Die Within 31 Days of the Date Portability Eligible Life Insurance Ends
If You die within 31 days of the date Portability Eligible Life Insurance ends and an application to Port is
not received by Us during such period, We will determine whether Your life insurance qualifies for
payment. This determination will be made in accordance with the section entitled LIFE INSURANCE:
CONVERSION OPTION FOR YOU.
If You are Totally Disabled on the Date Your Employment Ends
If You are Totally Disabled on the date Your employment ends and You elect to Port as provided in this
subsection, You may at a later date become approved for the continuation of insurance under the section
entitled LIFE INSURANCE: ELIGIBILITY FOR CONTINUATION IF LIFE INSURANCE ENDS WHILE
YOU ARE TOTALLY DISABLED. If You are so approved, all Ported insurance continued under this
Portability subsection will end, including Life Insurance.
AT YOUR OPTION: WHEN YOU CEASE ACTIVE WORK DUE TO TOTAL DISABILITY
If You cease Active Work because You are Totally Disabled, You may continue Life Insurance for You
and Your Dependents for up to 6 months by continuing to pay any premiums you were required to pay for
such insurance. This continuation of Life Insurance will end if you cease to be Totally Disabled or the
Group Policy ends.
Total Disability or Totally Disabled means, for purposes of this section, that due to an injury or
sickness:
• You are unable to perform the material duties of Your regular job; and
• You are unable to perform any other job for which You are fit by education, training or experience.
Proof Requirements
You should contact Us as soon as reasonably possible to advise Us that You were disabled on the date
You ceased Active Work. You must send Us Proof that You were Totally Disabled. As part of such Proof,
We may choose a Physician to examine You to verify that You are eligible to continue Life Insurance with
premium payment. If We do so, We will pay for such exam.
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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (continued)
AT THE POLICYHOLDER'S OPTION
The Policyholder has elected to continue insurance by paying premiums for employees who cease Active
Work in an eligible class for any of the reasons specified below;
1. for the period You cease Active Work in an eligible class due to injury or sickness, up to 12 months;
2. for the period You cease Active Work in an eligible class due to any other Policyholder approved
leave of absence, up to 1 month.
At the end of any of the continuation periods listed above, Your insurance will be affected as follows:
• if You resume Active Work in an eligible class at this time, You will continue to be insured under the
Group Policy;
• if You do not resume Active Work in an eligible class at this time, Your employment will be considered
to end and Your insurance will end in accordance with the DATE YOUR INSURANCE ENDS
subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOU.
If Your insurance ends, Your Dependents' insurance will also end in accordance with the DATE YOUR
INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY
PROVISIONS: INSURANCE FOR YOUR DEPENDENTS.
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EVIDENCE OF INSURABILITY
We require evidence of insurability satisfactory to Us as follows:
1. in order to receive an increase in the amount of Your Supplemental Life Insurance over the Non -
Medical Issue Amount as shown in the SCHEDULE OF BENEFITS due to an increase in Your Basic
Annual Earnings.
If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, the increase in Your Life Insurance will be limited to the Non -Medical Issue Amount.
2. in order to become covered for an amount of Supplemental Life Insurance greater than the Non -Medical
Issue Amount as shown in the SCHEDULE OF BENEFITS.
If You do not give Us evidence of Your insurability, or if such evidence of insurability is not accepted by
Us as satisfactory, the amount of Your Supplemental Life Insurance will be limited to the Non -Medical
Issue Amount.
3. if You make a request during an annual enrollment period to increase the amount of Your
Supplemental Life Insurance to an option which is more than one level above Your current amount of
Supplemental Life Insurance.
If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, the amount of Your Supplemental Life Insurance will not be increased by more than one
level, up to the Non -Medical Issue Amount as shown in the SCHEDULE OF BENEFITS.
4. if You make a request during an annual enrollment period to increase the amount of Your
Supplemental Life Insurance which is below the Non -Medical Issue Amount to an option one level
higher which is above the Non -Medical Issue Amount.
If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, the amount of Your Supplemental Life Insurance will not be increased.
5. if You make a request within 31 days of a Qualifying Event to increase the amount of Your
Supplemental Life Insurance to an option which is more than one level above Your current amount of
Supplemental Life Insurance.
If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, the amount of Your Supplemental Life Insurance will not be increased by more than one
level, up to the Non -Medical Issue Amount as shown in the SCHEDULE OF BENEFITS.
6. if You make a request within 31 days of a Qualifying Event to increase the amount of Your
Supplemental Life Insurance which is below the Non -Medical Issue Amount to an option one level
higher which is above the Non -Medical Issue Amount.
If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, the amount of Your Supplemental Life Insurance will not be increased.
The Non -Medical Issue Limit is shown in the SCHEDULE OF BENEFITS.
7. if You make a request that is not during an annual enrollment period or is not within 31 days of a
Qualifying Event to increase the amount of Your Supplemental Life Insurance.
If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, the amount of Your Supplemental Life Insurance will not be increased.
The Non -Medical Issue Limit is shown in the SCHEDULE OF BENEFITS.
8. if You make a late request for Supplemental Life Insurance. A late request is one made more than 31
days after You become eligible.
If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, You will not be covered for Supplemental Life Insurance.
9. if You make a late request for Life Insurance for Your Dependents. A late request is one made more
than 31 days after Your Dependent becomes eligible.
If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, Your Dependents will not be covered for Life Insurance.
The evidence of insurability is to be given at Your expense.
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LIFE INSURANCE: FOR YOU
If You die, Proof of Your death must be sent to Us. When We receive such Proof with the claim, We will
review the claim and, if We approve it, will pay the Beneficiary the Life Insurance in effect on the date of
Your death.
PAYMENT OPTIONS
We will pay the Life Insurance in one sum. Other modes of payment may be available upon request. For
details, call Our toll free number shown on the Certificate Face Page.
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LIFE INSURANCE: FOR YOUR DEPENDENTS
If a Dependent dies, Proof of the Dependent's death must be sent to Us. When We receive such Proof
with the claim, We will review the claim and, if We approve it, will pay the Beneficiary the Life Insurance in
effect on the life of such Dependent on the date of death.
PAYMENT OPTIONS
We will pay the Life Insurance in one sum. Other modes of payment may be available upon request. For
details, call Our toll free number shown on the Certificate Face Page.
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LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO) FOR YOU
For purposes of this section, the term "ABO Eligible Life Insurance" refers to each of Your Life Insurance
benefits for which the Accelerated Benefit Option is shown as available in the SCHEDULE OF
BENEFITS.
If You become Terminally I I I , You or Your legal representative have the option to request Us to pay ABO
Eligible Life Insurance before Your death. This is called an accelerated benefit. The request must be
made while ABO Eligible Life Insurance is in effect.
Terminally III or Terminal Illness means that due to injury or sickness, You are expected to die within 12
months.
Requirements For Payment of an Accelerated Benefit
Subject to the conditions and requirements of this section, We will pay an accelerated benefit to You or
Your legal representative if:
• the amount of each ABO Eligible Life Insurance benefit to be accelerated equals or exceeds $20,000;
and
• the ABO Eligible Life Insurance to be accelerated has not been assigned; and
• We have received Proof that You are Terminally III.
We will only pay an accelerated benefit for each ABO Eligible Life Insurance benefit once.
Proof of Your Terminal Illness
We will require the following Proof of Your Terminal Illness:
a completed accelerated benefit claim form;
• a signed Physician's certification that You are Terminally III; and
• an examination by a Physician of Our choice, at Our expense, if We request it.
You or Your legal representative should contact the Policyholder to obtain a claim form and information
regarding the accelerated benefit.
Upon Our receipt of Your request to accelerate benefits, We will send You a letter with information about
the accelerated benefit payment You requested. Our letter will describe the amount of the accelerated
benefits We will pay and the amount of Life Insurance remaining after the accelerated benefit is paid.
Accelerated Benefit Amount
We will pay an accelerated benefit up to the percentage shown in the SCHEDULE OF BENEFITS for
each ABO Eligible Life Insurance benefit in effect for You, subject to the following:
Maximum Accelerated Benefit Amount. The maximum amount We will pay for each ABO Eligible
Life Insurance benefit is shown in the SCHEDULE OF BENEFITS.
Scheduled Reduction of an ABO Eligible Life Insurance Benefit. If an ABO Eligible Life
Insurance benefit is scheduled to reduce within the 12 month period after the date You or Your legal
representative request an accelerated benefit, We will calculate the accelerated benefit using the
amount of such ABO Eligible Life Insurance that will be in effect immediately after the reduction(s)
scheduled for such period.
Scheduled End of an ABO Eligible Life Insurance Benefit. If an ABO Eligible Life Insurance
benefit is scheduled to end within 12 months after the date You or Your legal representative request
an accelerated benefit, We will not pay an accelerated benefit for such ABO Eligible Life Insurance
benefit.
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LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO) FOR YOU (continued)
Previous Conversion of an ABO Eligible Life Insurance Benefit. We will not pay an accelerated
benefit for any amount of ABO Eligible Life Insurance which You previously converted under the
section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU.
We will pay the accelerated benefit in one sum unless You or Your legal representative select another
payment mode.
Effect of Payment of an Accelerated Benefit
On premium for Your Life Insurance. After We pay the accelerated benefit, any premium You are
required to pay will be based upon the amount of Your Life Insurance remaining after the accelerated
benefit is paid.
On Your Life Insurance at Your death. The amount of Life Insurance that We will pay at Your death
will be decreased by the amount of the accelerated benefit paid by Us.
On Your Life Insurance at conversion. The amount to which You are entitled to convert under the
section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU will be decreased by the
amount of the accelerated benefit paid by Us.
On Your Accidental Death and Dismemberment Insurance. Payment of an accelerated benefit
will not affect Your Accidental Death and Dismemberment Insurance.
Date Your Option to Accelerate Benefits Ends
The accelerated benefit option will end on the earliest of:
® the date the ABO Eligible Life Insurance ends;
the date You or Your legal representative assign all ABO Eligible Life Insurance; or
• the date You or Your legal representative have accelerated all ABO Eligible Life Insurance benefits.
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LIFE INSURANCE: CONVERSION OPTION FOR YOU
If Your life insurance ends or is reduced for any of the reasons stated below, You have the option to buy
an individual policy of life insurance ("new policy") from Us during the Application Period in accordance
with the conditions and requirements of this section. This is referred to as the "option to convert".
Evidence of Your insurability will not be required.
When You Will Have the Option to Convert
You will have the option to convert when:
A. Your life insurance ends because:
• You cease to be in an eligible class;
® Your employment ends;
® this Group Policy ends, provided You have been insured for life insurance for at least 5
continuous years; or
• this Group Policy is amended to end all life insurance for an eligible class of which You are a
member, provided You have been insured for at least 5 continuous years; or
B. Your life insurance is reduced:
® on or after the date You attain age 60;
® because You change from one eligible class to another; or
® due to an amendment of this Group Policy.
If You opt not to convert a reduction in the amount of Your life insurance as described above, You will not
have the option to convert that amount at a later date.
A reduction in the amount of Your life insurance as a result of the payment of an accelerated benefit will
not give rise to a right to convert under this section.
Application Period
If You opt to convert Your life insurance for any of the reasons stated above, We must receive a
completed conversion application form from You within the Application Period described below.
If You are given Written notice of the option to convert within 15 days before or after the date Your life
insurance ends or is reduced, the Application Period begins on the date that such life insurance ends or is
reduced and expires 31 days after such date.
If You are given Written notice of the option to convert more than 15 days after the date Your life
insurance ends or is reduced, the Application Period begins on the date such life insurance ends or is
reduced and expires 15 days from the date of such notice. In no event will the Application Period exceed
91 days from the date Your life insurance ends or is reduced.
Option Conditions
The option to convert is subject to the following:
A. Our receipt within the Application Period of:
® Your Written application for the new policy; and
® the premium due for such new policy;
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LIFE INSURANCE: CONVERSION OPTION FOR YOU (continued)
B. the premium rates for the new policy will be based on:
• Our rates then in use;
• the form and amount of insurance for which you apply;
• Your class of risk; and
• Your age;
C. the new policy may be on any form then customarily offered by Us excluding term insurance;
D. the new policy will be issued without an accidental death and dismemberment benefit, an accelerated
benefit option, a waiver of premium benefit or any other rider or additional benefit; and
E. the new policy will take effect on the 32nd day after the date Your life insurance ends or is reduced;
this will be the case regardless of the duration of the Application Period.
Maximum Amount of the New Policy
If Your Life Insurance ends due to the end of this Group Policy or the amendment of this Group Policy to
end all life insurance for an eligible class of which You are a member, the maximum amount of insurance
that You may elect for the new policy is the lesser of:
• the amount of Your life insurance that ends under this Group Policy less the amount of life insurance
for which You become eligible under any group policy within 31 days after the date insurance ends
under this Group Policy; or
• $10,000.
If Your life insurance ends or is reduced due to the Policyholder's organizational restructuring, the
maximum amount of insurance that You may elect for the new policy is the amount of Your life insurance
that ends under this Group Policy less the amount of life insurance for which You become eligible under
any other group policy within 31 days after the date insurance ends under this Group Policy.
If Your life insurance ends or is reduced for any other reason, the maximum amount of insurance that You
may elect for the new policy is the amount of Your life insurance which ends under this Group Policy.
If You Die Within 31 Days After Your Life Insurance Ends Or Is Reduced,
If You die within 31 days after Your life insurance ends or is reduced by an amount You are entitled to
convert, Proof of Your death must be sent to Us. When We receive such Proof with the claim, We will
review the claim and if We approve it will pay the Beneficiary. The amount We will pay is the amount You
were entitled to convert.
The amount You were entitled to convert will not be paid as insurance under both a new individual
conversion policy and the Group Policy.
If You Become Eligible To Have Insurance Continued Due To Your Total Disability
If You obtain a new individual conversion policy because Your life insurance ends or is reduced and You
later become eligible to have insurance continued under the section entitled ELIGIBILITY FOR
CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED, We will only
continue Your life insurance under such section if the conversion policy is returned to Us.
If the conversion policy is returned to Us, We will refund to Your estate the premium paid for such policy
without interest, less any debt incurred under such policy.
We will not pay a benefit for insurance under both the Group Policy and the new individual conversion
policy.
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LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS
If life insurance for a Dependent ends or is reduced for any of the reasons stated below, You or that
Dependent will have the option to buy from Us an individual policy of life insurance on the life of the
Dependent ("new policy") during the Application Period in accordance with the conditions and
requirements of this section. This is referred to as "the option to convert". Evidence of the Dependent's
insurability will not be required.
When You or a Dependent Will Have the Option to Convert
You will have the option to convert life insurance for a Dependent when:
A. life insurance for the Dependent ends because:
• You cease to be in an eligible class;
• Your employment ends;
• this Group Policy ends, provided You have been insured for life insurance for the Dependent for
at least 5 continuous years; or
• this Group Policy is amended to end all life insurance for Dependents for an eligible class of
which You are a member, provided You have been insured for life insurance for the Dependent
for at least 5 continuous years; or
B. life insurance for the Dependent is reduced:
• on or after the date You attain age 60;
• because You change from one eligible class to another; or
• due to an amendment of this Group Policy.
A Dependent will have the option to convert when:
• life insurance for such Dependent ends because that Dependent ceases to qualify as a
Dependent as defined in this certificate, or
• You die.
If You opt not to convert a reduction in the amount of life insurance for a Dependent, You will not have the
option to convert that amount at a later date.
You must notify the Policyholder in the event that a Dependent ceases to qualify as a Dependent as
defined in this certificate.
Application Period
If You or a Dependent opt to convert as stated above, We must receive a completed conversion
application form within the Application Period described below.
If Written notice of the option to convert is given within 15 days before or after the date life insurance for a
Dependent ends or is reduced, the Application Period begins on the date that such life insurance ends or
is reduced and expires 31 days after such date.
If Written notice of the option to convert is given more than 15 days after the date life insurance for the
Dependent ends or is reduced, the Application Period begins on the date such life insurance ends or is
reduced and expires 15 days from the date of such notice. In no event will the Application Period exceed
91 days from the date Life Insurance for the Dependent ends or is reduced.
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LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS (continued)
Option Conditions
The option to convert is subject to the following:
A. Our receipt within the Application Period of:
• a Written application for the new policy for the Dependent; and
• the premium due for such new policy;
B. the premium rates for the new policy will be based on:
• Our rates then in use;
• the form and amount of insurance which is applied for;
• the Dependent's class of risk; and
• the Dependent's age;
C. the new policy may be on any form then customarily offered by Us excluding term insurance;
D. the new policy will be issued without an accidental death and dismemberment benefit, an
accelerated benefit option, waiver of premium benefit or any other rider or additional benefit; and
E. the new policy will take effect on the 32nd day after the date Life Insurance for the Dependent ends or
is reduced; this will be the case regardless of the duration of the Application Period.
Maximum Amount of the New Policy
If Life Insurance for a Dependent ends due to the end of this Group Policy or the amendment of this
Group Policy to end all life insurance for Dependents for an eligible class of which You are a member, the
maximum amount of insurance that may be elected for the new policy is the lesser of:
• the amount of Life Insurance for the Dependent that ends under this Group Policy less the amount of
life insurance for Dependents for which You become eligible under any group policy within 31 days
after the date insurance ends under this Group Policy; or
• $10,000.
If life insurance for a Dependent ends or is reduced due to the Policyholder's organizational restructuring,
the maximum amount of insurance that may be elected for the new policy is the amount of life insurance
for the Dependent that ends under this Group Policy less the amount of life insurance for dependents for
which You become eligible under any other group policy within 31 days after the date insurance ends
under this Group Policy.
If Your life insurance for a Dependent ends or is reduced for any other reason, the maximum amount of
insurance that You may elect for the new policy is the amount of Your life insurance for a Dependent that
ends under this Group Policy.
If a Dependent Dies Within the 31 Days After Life Insurance for a Dependent Ends Or Is Reduced
If a Dependent dies within 31 days after the date life insurance for the Dependent ends or is reduced by
an amount eligible for convert, Proof of the Dependent's death must be sent to Us. When we receive
such Proof with the claim, We will review the claim and if We approve it, will pay the Beneficiary. The
amount We will pay is the amount that could have been converted.
The amount that could have been converted will not be paid as insurance under both a new individual
conversion policy and the Group Policy.
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ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE
TOTALLY DISABLED
If You become Totally Disabled while You are insured for Continuation Eligible Insurance under this policy,
You may qualify to continue certain insurance under this section. If continued, premium payment will not be
required. We will determine if You qualify for this continuation after We receive Proof that You have satisfied
the conditions of this section.
Total Disability must start before You attain age 60 and while You are insured for Continuation Eligible
Insurance.
Your Total Disability must continue without interruption from the date You became Totally Disabled through
the end of the Continuation Waiting Period.
DEFINITIONS
For the purpose of this section, "Continuation Eligible Insurance" means
® Basic Life Insurance;
® Supplemental Life Insurance; and
® Accidental Death and Dismemberment Insurance if You continue Basic Life Insurance;
to the extent that such insurance was in effect for You on the date Your Total Disability began.
Continuation Eligible Insurance does not include Life Insurance amounts accelerated under the section
entitled LIFE INSURANCE: ACCELERATED BENEFIT OPTION FOR YOU.
Continuation Waiting Period means the period which starts on the date You become Totally Disabled and
ends 180 consecutive days later.
Total Disability or Totally Disabled means, for purposes of this section, that due to an injury or Sickness:
• You are unable to perform the material and substantial duties of Your regular job; and
® You are, after an initial benefit period of 12 months, unable to perform the material and substantial duties
of any other job for which You are fit by education, training or experience.
TOTAL DISABILITY AND PROOF REQUIREMENTS
If You become disabled You should contact Us as soon as reasonably possible. After the Continuation
Waiting Period ends, You must send Us Proof that You were Totally Disabled with no interruption throughout
the Continuation Waiting Period. You must do this within the time frame specified in the section entitled
FILING A CLAIM.
As part of such Proof, We may choose a Physician to examine You to verify that You are Totally Disabled.
We will pay for the exam.
After We receive and review Your Proof, We will determine if You qualify. We will notify You in writing of Our
decision.
To verify that You continue to be Totally Disabled without interruption, We may require from time to time that
You send Us Proof that You continue to be Totally Disabled. We will not ask for Proof more than once each
year.
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ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE
TOTALLY DISABLED (Continued)
IF YOU DIE OR SUSTAIN A LOSS COVERED BY THE CONTINUED INSURANCE DURING
CONTINUATION
If You die or sustain a loss for which You believe benefits may be payable during the continuation, Proof of
the death must be sent to Us. In addition to the Proof which is otherwise required for the insurance, the Proof
must show that Your Total Disability continued with no interruption from the date We informed You that the
continuation was approved until the date of the death or the date of loss.
When We receive such Proof with the claim, We will review the claim and if We approve it, will pay any
benefit payable under the insurance continued under this section.
EFFECT OF PREVIOUS CONVERSION
If You converted any portion of Your Continuation Eligible Life Insurance to an individual policy, We will only
pay the life insurance under this section if the individual policy is returned to Us. If it is returned to Us, We will
refund to Your estate the premiums paid for such policy without interest, less any debt incurred under such
policy.
If such individual policy is not returned to Us, We will pay the life insurance in effect under the individual
policy.
We will not pay insurance under both the Group Policy and the individual policy.
EFFECT OF PREVIOUS ELECTION TO PORT COVERAGE
If You ported any portion of Your Continuation Eligible Insurance to a certificate under another policy, We will
only pay insurance under this section if the other policy's certificate is surrendered to Us. If it is returned to
Us, We will refund to Your estate the premiums paid under such policy without interest.
If that certificate is not returned to Us, We will pay any insurance which applies under the other policy's
certificate.
We will not pay insurance under both this Group Policy and the other policy.
DATE CONTINUATION ENDS
The Continuation Eligible Insurance continued under this section may be continued in a reduced amount on
account of Your age or the payment of accelerated benefits and will end at the earliest of:
1. the date You die;
2. the date Your Total Disability ends;
3. the date You do not give Us Proof of Total Disability, as required;
4. the date You refuse to be examined by Our Physician, as required; or
5. the date You attain age 65.
Option To Convert Your Continuation Eligible Life Insurance
When a continuation under this section ends, You may buy an individual policy of life insurance from Us. The
details of this option are described in the section entitled LIFE INSURANCE: CONVERSION OPTION FOR
YOU. For the purpose of that section, the end of this continuation will be considered the end of Your
employment. You may not use the conversion option described in those sections if before the end of the
Application Period for conversion You return to Active Work in an eligible class and become insured under the
Group Policy. You will not be able to convert any of Your Continuation Eligible Life Insurance which You have
already converted to an individual policy.
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ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE
TOTALLY DISABLED (Continued)
Option To Port Your Continuation Eligible Insurance
When a continuation under this section ends, You may elect to port to a different policy the insurance which
has been continued under this section. The details of this option are described in the At Your Option:
Portability subsection of the CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT section. For the
purpose of that section, the end of this continuation will be considered the end of Your employment. You may
not use the portability option described in that section if before the end of the Portability Request Period, You
return to Active Work in an eligible class and become insured under the Group Policy. You will not be able to
port any of Your Continuation Eligible Insurance which You have already converted to an individual policy.
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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
If You or a Dependent sustain an accidental injury that is the Direct and Sole Cause of a Covered Loss
described in the SCHEDULE OF BENEFITS, Proof of the accidental injury and Covered Loss must be sent to
Us. When We receive such Proof We will review the claim. If We approve the claim We will pay the insurance
in effect on the date of the injury within 30 days of Our receipt of such Proof.
Direct and Sole Cause means that the Covered Loss occurs within 12 months of the date of the accidental
injury and was a direct result of the accidental injury, independent of other causes.
We will deem a loss to be the direct result of an accidental injury if it results from unavoidable exposure to the
elements and such exposure was a direct result of an accident.
PRESUMPTION OF DEATH
You and/or a Dependent will be presumed to have died as a result of an accidental injury if:
• the aircraft or other vehicle in which You and/or a Dependent were traveling disappears, sinks, or is
wrecked; and
• the body of the person who has disappeared is not found within 1 year of:
• the date the aircraft or other vehicle was scheduled to have arrived at its destination, if traveling in an
aircraft or other vehicle operated by a Common Carrier; or
• the date the person is reported missing to the authorities, if traveling in any other aircraft or other
vehicle.
EXCLUSIONS
We will not pay benefits under this section for any loss caused or contributed to by:
1. physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity;
2. infection, other than pyogenic infection that results from an accidental bodily injury, or bacterial infection
that results from the accidental ingestion of contaminated substances;
3. suicide or attempted suicide while sane;
4. intentionally self-inflicted injury while sane, or while insane if it is not attempted suicide;
5. service in the armed forces of any country or international authority. However, service in reserve forces
does not constitute service in the armed forces, unless in connection with such reserve service an
individual is on active military duty as determined by the applicable military authority other than weekend
or summer training. For purposes of this provision reserve forces are defined as reserve forces of any
branch of the military of the United States or of any other country or international authority, including but
not limited to the National Guard of the United States or the national guard of any other country;
6. any incident related to:
• travel in an aircraft as a pilot, crew member, flight student or while acting in any capacity other than
as a passenger;
• travel in an aircraft for the purpose of parachuting or otherwise exiting from such aircraft while it is in
flight;
• parachuting or otherwise exiting from an aircraft while such aircraft is in flight, except for self-
preservation;
• travel in an aircraft or device used:
• for testing or experimental purposes;
• by or for any military authority; or
• for travel or designed for travel beyond the earth's atmosphere;
7. committing or attempting to commit a felony;
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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued)
8. the voluntary intake or use by any means of:
• any drug, medication or sedative, unless it is:
• taken or used as prescribed by a Physician; or
• an "over the counter" drug, medication or sedative taken as directed;
• alcohol in combination with any drug, medication, or sedative; or
• poison, gas, or fumes; or
9. war, whether declared or undeclared; or act of war, insurrection, rebellion or riot.
Exclusion for Intoxication
We will not pay benefits under this section for any loss if the injured party is intoxicated at the time of the
incident and is the operator of a vehicle or other device involved in the incident.
Intoxicated means that the injured person's blood alcohol level met or exceeded the level that creates a legal
presumption of intoxication under the laws of the jurisdiction in which the incident occurred.
COMMON DISASTER
If You and Your Spouse are injured in the same accident and die within 365 days as a result of injuries in
such accident, the Full Amount that we will pay for Your Spouse's loss of life will be increased to equal the
Full Amount payable for Your loss of life.
BENEFIT PAYMENT
For loss of Your life, We will pay benefits to Your Beneficiary.
For any other loss sustained by You, or for any loss sustained by a Dependent, We will pay benefits to You.
If You or a Dependent sustain more than one Covered Loss due to an accidental injury, the amount We will
pay, on behalf of any such injured person, will not exceed the Full Amount.
We will pay benefits in one sum. Other modes of payment may be available upon request. For details call Our
toll free number shown on the Certificate Face Page.
If You and any Dependent die within a 24 hour period, We will pay the Dependent's Accidental Death and
Dismemberment Insurance to the Beneficiary receiving payment of Your Accidental Death and
Dismemberment Insurance including payment of any Additional Benefits, or We may pay Your estate. If a
Beneficiary is a minor or is incompetent to receive payment, We will pay that person's guardian.
APPLICABILITY OF PROVISIONS
The provisions set forth in this ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE section apply to
all Accidental Death and Dismemberment Insurance — Additional Benefit sections included in this certificate
except as may otherwise be provided in such Additional Benefit sections.
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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued)
ADDITIONAL BENEFIT: SEAT BELT USE
If You or a Dependent die as a result of an accidental injury, We will pay this additional Seat Belt Use benefit
if:
1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
section;
2. this benefit is in effect on the date of the injury; and
3. We receive Proof that the deceased person:
• was in an accident while driving or riding as a passenger in a Passenger Car;
• was wearing a Seat Belt which was properly fastened at the time of the accident; and
• died as a result of injuries sustained in the accident.
A police officer investigating the accident must certify that the Seat Belt was properly fastened. A copy of
such certification must be submitted to Us with the claim for benefits.
Passenger Car means any validly registered four-wheel private passenger car, four-wheel drive vehicle,
sports -utility vehicle, pick-up truck or mini -van. It does not include any commercially licensed car, any private
car being used for commercial purposes, or any vehicle used for recreational or professional racing.
Seat Belt means any restraint device that:
• meets published United States Government safety standards;
• is properly installed by the car manufacturer; and
® is not altered after the installation.
The term includes any child restraint device that meets the requirements of state law.
BENEFIT AMOUNT
The Seat Belt Use benefit is an additional benefit equal to 10% of the Full Amount shown in the SCHEDULE
OF BENEFITS. However, the amount We will pay for this benefit will not be less than $1,000 or more than
$25,000.
BENEFIT PAYMENT
For loss of Your life, We will pay benefits to Your Beneficiary.
For loss of a Dependent's life, We will pay benefits to You.
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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued)
ADDITIONAL BENEFIT: AIR BAG USE
If You or a Dependent die as a result of an accidental injury, We will pay this additional benefit if:
1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
section;
2. this benefit is in effect on the date of the injury; and
3. We receive Proof that the deceased person:
• was in an accident while driving or riding as a passenger in a Passenger Car equipped with an Air
Bag(s);
• was riding in a seat protected by an Air Bag;
• was wearing a Seat Belt which was properly fastened at the time of the accident; and
• died as a result of injuries sustained in the accident.
A police officer investigating the accident must certify that the Seat Belt was properly fastened and that the
Passenger Car in which the deceased was traveling was equipped with Air Bags. A copy of such certification
must be submitted to Us with the claim for benefits.
Passenger Car means any validly registered four-wheel private passenger car, four-wheel drive vehicle,
sports -utility vehicle, pick-up truck or mini -van. It does not include any commercially licensed car, any private
car being used for commercial purposes, or any vehicle used for recreational or professional racing.
Seat Belt means any restraint device that:
• meets published United States government safety standards;
• is properly installed by the car manufacturer; and
• is not altered after the installation.
The term includes any child restraint device that meets the requirements of state law.
Air Bag means an inflatable restraint device that:
• meets published United States government safety standards;
• is properly installed by the car manufacturer; and
• is not altered after the installation.
BENEFIT AMOUNT
The Air Bag Use Benefit is an additional benefit equal to 5% of the Full Amount shown in the SCHEDULE OF
BENEFITS. However, the amount We will pay for this benefit will not be less than $1,000 or more than
$10,000.
BENEFIT PAYMENT
For loss of Your life, We will pay benefits to Your Beneficiary. For a loss of a Dependent's life, We will pay
benefits to You.
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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued)
ADDITIONAL BENEFIT: CHILD CARE
If You or Your Spouse die as a result of an accidental injury, We will pay this additional Child Care benefit if:
1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
section;
2. this benefit is in effect on the date of the injury; and
3. We receive Proof that:
• on the date of Your death a Child was enrolled in a Child Care Center; or
• within 12 months after the date of Your death a Child was enrolled in a Child Care Center.
Child Care Center means a facility that:
• is operated and licensed according to the law of the jurisdiction where it is located; and
• provides care and supervision for children in a group setting on a regularly scheduled and daily basis.
BENEFIT AMOUNT
For each Child who qualifies for this benefit, We will pay an amount equal to the Child Care Center charges
incurred for a period of up to 4 consecutive years, not to exceed:
• an annual maximum of $5,000; and
• an overall maximum of 12% of the Full Amount shown in the SCHEDULE OF BENEFITS.
In the event that both You and Your Spouse die such that each death would cause a payment to be made for
a Child under this Additional Benefit, the following rules apply:
• the annual maximum will be 2 times the amount stated above;
• the overall maximum will be equal to the stated percentage applied to the sum of the Full Amounts
shown in the Schedule of Benefits for both You and Your Spouse; and
• in no event will the amount paid under all Child Care benefits exceed the amount of Child Care
charges incurred.
We will not pay for Child Care Center charges incurred after the date a Child attains age 12.
We may require Proof of the Child's continued enrollment in a Child Care Center during the period for which a
benefit is claimed.
BENEFIT PAYMENT
We will pay this benefit quarterly when We receive Proof that Child Care Center charges have been paid.
Payment will be made to the person who pays such charges on behalf of the Child.
If this benefit is in effect on the date You die and there is no Child who could qualify for it, We will pay $1,000
to Your Beneficiary in one sum.
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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued)
ADDITIONAL BENEFIT: CHILD EDUCATION
If You or Your Spouse die as a result of an accidental injury, We will pay this additional Child Education
benefit if:
1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
section;
2. this benefit is in effect on the date of the injury; and
3. We receive Proof that on the date of Your death a Child was:
enrolled as a full-time student in an accredited college, university or vocational school above the 12th
grade level; or
• at the 12th grade level and, within one year after the date of Your death, enrolls as a full-time student
in an accredited college, university or vocational school.
BENEFIT AMOUNT
For each Child who qualifies for this benefit, We will pay an amount equal to the tuition charges incurred for a
period of up to 4 consecutive academic years, not to exceed:
• an academic year maximum of $10,000; and
• an overall maximum of 20% of the Full Amount shown in the SCHEDULE OF BENEFITS.
In the event that both You and Your Spouse die such that each death would cause a payment to be made for
a Child under this Additional Benefit, the following rules apply:
• the academic year maximum will be 2 times the amount stated above;
• the overall maximum will be equal to the stated percentage applied to the sum of the Full Amounts
shown in the Schedule of Benefits for both You and Your Spouse; and
• in no event will the amount paid under all Child Education benefits exceed the amount of tuition
incurred.
We may require Proof of the Child's continued enrollment as a full-time student during the period for which a
benefit is claimed.
BENEFIT PAYMENT
We will pay this benefit semi-annually when We receive Proof that tuition charges have been paid. Payment
will be made to the person who pays such charges on behalf of the Child.
If this benefit is in effect on the date You die and there is no Child who could qualify for it, We will pay $1,000
to Your Beneficiary in one sum.
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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued)
ADDITIONAL BENEFIT: SPOUSE EDUCATION
If You die as a result of an accidental injury, We will pay this additional Spouse Education benefit if:
1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
section;
2. this benefit is in effect on the date of the injury; and
3. We receive Proof that:
• on the date of Your death, Your Spouse was enrolled as a full-time student in an accredited school; or
• within 12 months after the date of Your death, Your Spouse enrolls as a full-time student in an
accredited school.
BENEFIT AMOUNT
We will pay an amount equal to the tuition charges incurred for a period of up to 1 academic year, not to
exceed:
• an academic year maximum of $5,000; and
• an overall maximum of 3% of the Full Amount shown in the SCHEDULE OF BENEFITS.
We may require Proof of the Spouse's continued enrollment as a full-time student during the period for which
a benefit is claimed.
BENEFIT PAYMENT
We will pay this benefit semi-annually when We receive Proof that tuition charges have been paid. Payment
will be made to the Spouse.
If this benefit is in effect on the date You die and there is no Spouse who could qualify for it, We will pay
$1,000 to Your Beneficiary in one sum.
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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued)
ADDITIONAL BENEFIT: HOSPITAL CONFINEMENT
Subject to the provisions of the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE, We will pay
this additional benefit if:
1. We receive Proof that You or a Dependent are confined in a Hospital as a result of an accidental injury
which is the direct result of such -confinement independent of other causes; and
2. This benefit is in effect on the date of the injury.
BENEFIT AMOUNT
We will pay an amount for each full month of Hospital Confinement equal to the lesser of:
® 1% of the Full Amount shown in the SCHEDULE OF BENEFITS; and
• $2,500.
We will pay this benefit on a monthly basis beginning on the 5th day of confinement, for up to 12 months of
continuous confinement. This benefit will be paid on a pro -rata basis for any partial month of confinement.
We will only pay benefits for one period of continuous confinement for any accidental injury. That period will
be the first period of confinement that qualifies for payment.
BENEFIT PAYMENT
Benefit payments will be made monthly. Payment will be made to You.
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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued)
ADDITIONAL BENEFIT: COMMON CARRIER
If You or a Dependent die as a result of an accidental injury, We will pay this additional benefit if:
1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
section;
2. this benefit is in effect on the date of the injury; and
3. We receive Proof that the injury resulting in the deceased's death occurred while traveling in a Common
Carrier.
BENEFIT AMOUNT
The Common Carrier Benefit is an amount equal to the Full Amount shown in the SCHEDULE OF
BENEFITS.
BENEFIT PAYMENT
For loss of Your life, We will pay benefits to Your Beneficiary. For a loss of a Dependent's life, We will pay
benefits to You.
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ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued)
ADDITIONAL BENEFIT: REPATRIATION EXPENSE
If You die as a result of an accidental injury, We will pay this additional benefit if:
1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
section;
2. this benefit is in effect on the date of the injury; and
3. We receive Proof that Your death occurred at least 100 miles from Your principal place of residence.
BENEFIT AMOUNT
We will pay an additional benefit equal to the charges incurred for the preparation and transportation of the
deceased's body to the city of the deceased's principal residence; not to exceed $5,000.
BENEFIT PAYMENT
We will pay this benefit when We receive Proof that the charges described above have been paid. Payment
will be made to the person who paid such charges.
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FILING A CLAIM
The Policyholder should have a supply of claim forms. Obtain a claim form from the Policyholder and fill it out
carefully. Return the completed claim form with the required Proof to the Policyholder. The Policyholder will
certify Your insurance under the Group Policy and send the certified claim form and Proof to Us.
When We receive the claim form and Proof, We will review the claim and, if We approve it, We will pay
benefits subject to the terms and provisions of this certificate and the Group Policy.
CLAIMS FOR LIFE INSURANCE BENEFITS
When a claimant files a claim for Life Insurance benefits, Proof should be sent to Us as soon as is
reasonably possible after the death of an insured.
When a claimant files a claim to continue Life Insurance while being Totally Disabled, Proof should be
sent to Us as soon as reasonably possible, but in all events must be received by Us within 12 months of
the date the claimant became Totally Disabled, except in the case of legal incapacity of the claimant.
CLAIMS FOR OTHER INSURANCE BENEFITS
When a claimant files a claim for any other insurance benefits described in this certificate, both the
notice of claim and the required Proof should be sent to Us within 90 days of the date of a loss.
Notice of claim and Proof may also be given to Us by following the steps set forth below:
Step 1
A claimant may give Us notice by calling Us at the toll free number shown in the Certificate Face
Page within 20 days of the date of a loss.
Step 2
We will send a claim form to the claimant and explain how to complete it. The claimant should
receive the claim form within 15 days of giving Us notice of claim.
Step 3
When the claimant receives the claim form, the claimant should fill it out as instructed and return
it with the required Proof described in the claim form.
If the claimant does not receive a claim form within 15 days after giving Us notice of claim, Proof
may be sent using any form sufficient to provide Us with the required Proof.
Step 4
The claimant must give Us Proof not later than 90 days after the date of the loss.
If notice of claim or Proof is not given within the time limits described in this section, the delay will not
cause a claim to be denied or reduced if such notice and Proof are given as soon as is reasonably
possible.
Time Limit on Legal Actions. A legal action on a claim may only be brought against Us during a certain
period. This period begins 60 days after the date Proof is filed and ends 3 years after the date such Proof is
required.
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GENERAL PROVISIONS
Assignment
The rights and benefits under the Group Policy are not assignable prior to a claim for benefits, except as
required by law. We are not responsible for the validity of an assignment.
Beneficiary
You may designate a Beneficiary in Your application or enrollment form. You may change Your Beneficiary at
any time. To do so, You must send a Signed and dated, Written request to the Policyholder using a form
satisfactory to Us. Your Written request to change the Beneficiary must be sent to the Policyholder within 30
days of the date You Sign such request.
You do not need the Beneficiary's consent to make a change. When We receive the change, it will take effect
as of the date You Signed it. The change will not apply to any payment made in good faith by Us before the
change request was recorded.
If two or more Beneficiaries are designated and their shares are not specified, they will share the insurance
equally.
If there is no Beneficiary designated or no surviving designated Beneficiary at Your death, We may determine
the Beneficiary to be one or more of the following who survive You:
• Your Spouse;
• Your child(ren);
• Your parent(s); or
• Your sibling(s).
Instead of making payment to any of the above, We may pay Your estate. Any payment made in good faith
will discharge our liability to the extent of such payment. If a Beneficiary or a payee is a minor or incompetent
to receive payment, We will pay that person's guardian.
For Your Life Insurance for Your Dependents, We may pay You as the Beneficiary if alive. If you are not
alive, We may determine the Beneficiary to be one or more of the following who survive You:
• Your Spouse;
• Your child(ren);
• Your parent(s); or
• Your sibling(s).
Instead of making payment to any of the above, We may pay Your estate. Any payment made in good faith
will discharge our liability to the extent of such payment.
If You and any Dependent die within a 24 hour period, We will pay the Dependent's Life Insurance to the
Beneficiary receiving payment of your Life Insurance or We may pay Your estate. If a Beneficiary or a payee
is a minor or incompetent to receive payment, We will pay that person's guardian.
Entire Contract
Your insurance is provided under a contract of group insurance with the Policyholder. The entire contract with
the Policyholder is made up of the following:
1. the Group Policy and its Exhibits, which include the certificate(s);
2. the Policyholder's application; and
3. any amendments and/or endorsements to the Group Policy.
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GENERAL PROVISIONS (continued)
Incontestability: Statements Made by You
Any statement made by You will be considered a representation and not a warranty. We will not use such
statement to avoid Life Insurance, reduce benefits or defend a claim unless the following requirements are met:
1. the statement is in a Written application or enrollment form;
2. You have Signed the application or enrollment form; and
3. a copy of the application or enrollment form has been given to You or Your Beneficiary.
For Life Insurance
We will not use Your statements which relate to insurability to contest insurance after it has been in force for 2
years during Your life. In addition, We will not use such statements to contest an increase or benefit addition
to such insurance after the increase or benefit has been in force for 2 years during Your life, unless the
statement is fraudulent.
For Accidental Death and Dismemberment Insurance
We will not use Your statements which relate to insurability to contest Accidental Death and Dismemberment
Insurance after it has been in force for 2 years during Your life. In addition, We will not use such statements
to contest an increase or benefit addition to such insurance after the increase or benefit has been in force for
2 years during Your life.
Misstatement of Age
If Your or Your Dependent's age is misstated, the correct age will be used to determine if insurance is in
effect and, as appropriate, We will adjust the benefits and/or premiums.
Conformity with Law
If the terms and provisions of this certificate do not conform to any applicable law, this certificate shall be
interpreted to so conform.
Physical Exams
If a claim is submitted for insurance benefits other than life insurance benefits, We have the right to ask the
insured to be examined by a Physician(s) of Our choice as often as is reasonably necessary to process the
claim. We will pay the cost of such exam.
Autopsy
We have the right to make a reasonable request for an autopsy where permitted by law. Any such request
will set forth the reasons We are requesting the autopsy. We will pay the cost of such autopsy.
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For information about the Will Preparation Service and Estate
Resolution Service, you may contact the provider, Hyatt Legal
Plans, Inc. by phone.
Phone: 1-800-821-6400