No preview available
HomeMy WebLinkAboutC87-007A - remainder of Connecticut PolicyCONNECTICUT GENERAL LIFE INSURANCE COMPANY sr POLICYHOLDER: EAGLE COUNTY AMENDMENT POLICY NUMBER: 0488282-03 EFFECTIVE DATE OF THIS AMENDMENT: February 1, 1987 ISSUE DATE: March 27, 1987 As of the Effective Date of this Amendment, the Policy specified above is amended by the provisions shown below. The pages in List A are replaced in the policy by the pages in List B that are attached to this Amendment. List A List B 5C1 5C1 V-7 9C1 9C1 Spec. 7C2 7C2 7C4 7C4 The following pages attached to this Amendment are added to the policy: 7C1 7C3 V-6 CONNECTICUT GENERAL LIFE INSURANCE COMPANY Elizabeth A. Robinson -Prince . . . . . . . . . . . . . . . . . . . Registrar enio Vice President ACCEPTED BY: COUNTY OF EAGLE, STATE OF COLORADO Policyholder•Representative GM5804 RICHprRD L.S S0� Chairman, .ard Commissioners Title May 1, 1987 . . . . . . . . . . . . . . . . Date V-3 14 C-1: C CONNECTICUT GENERAL LIFE INSURANCE COMPANY ELIGIBILITY FOR EMPLOYEE INSURANCE Each Employee in one of the Classes of Eligible Employees shown below will become eligible for Employee Insurance on the day he completes the Waiting Period, if any. An Employee who was previously insured and whose insurance ceased must satisfy the Waiting Period to become insured again. If the insurance on an Employee ceased because he was no longer employed in a Class of Eligible Employees, he is not required to satisfy any Waiting Period if he again becomes a member of a Class of Eligible Employees within one year after his insurance ceased. WAITING PERIOD For each full time Management Employee and each Elected Official - None For each part time Employee and each Other Employee - 30 days of Active Service AFFILIATED EMPLOYERS None CLASSES OF ELIGIBLE EMPLOYEES Each Employee rr, GM5812 Page Added Effective February 1, 1987 GM5800 5C1 Section 5 V-7 CONNECTICUT GENERAL LIFE INiSURANCE COMPANY r EFFECTIVE DATE OF EMPLOYEE INSURANCE Each Employee may elect to be insured for Employee Insurance only by signing a payroll deduction form approved by the Policyholder and the Insurance Company. The effective date of his insurance depends upon the date on which the Employee elects the insurance. (1) If he elects Employee Insurance on or before the date he becomes eligible, his insurance will become effective on the date he, becomes eligible. (2) If he elects Employee Insurance within 30 days after he becomes eligible, his insurance will become effective on the date of election. (3) If he elects Employee Insurance more than 30 days after he becomes eligible, his insurance will become effective on the date the Insurance Company agrees in writing to insure him. (4) If his Employee Insurance ceased because he cancelled his payroll deduction, and he again elects to be insured, his insurance will become effective on the date the Insurance Company agrees in writing to insure him. Under the circumstances described in items 3 and 4, the Insurance Company may require the Employee to submit evidence of good health acceptable to the Insurance Company at his own expense before it agrees to insure him. If an Employee is not in Active Service on the date his insurance would otherwise become effective, it will become effective on the date he returns to Active Service. The provisions set forth on this page will apply only to each part time Employee. GM5811 GM5812 Page Added Effective February 1, 1487 GM5800 7C1 Section 7 3 CONNECTICUT GENERAL LIFE INSURANCE COMPANY a EFFECTIVE DATE OF DEPENDENT INSURANCE Each Employee will become insured for Dependent Insurance on the date he becomes eligible for it if he is insured for Employee Insurance on that date. If he is not insured for Employee Insurance on that date, his Dependent Insurance will become effective on the date he becomes insured for Employee Insurance. Any reference to an insured Dependent means a Dependent for whom the Employee is insured. The provisions set forth on this page will apply only to each full time Employee. GM5811 GM5812 Page Added Effective February 1, 1987 GM5800 7C4 Section V-1 7 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DEFINITIONS EMPLOYER. The term Employer means the Policyholder and all Affiliated Employers shown in the "Eligibility for Insurance" section. EMPLOYEE. The term Employee means a full time employee of the Employer, and includes employees who are part time or temporary and who normally work between 30 and 39 hours a week for the Employer. ACTIVE SERVICE. An Employee will be considered in Active Service with the Employer on a day which is one of the Employer's scheduled work days if he is performing in the usual way all of the regular duties of his work for the Employer on a full time basis on that day, either at one of the Employer's places of business or at some location to which the Employer's business requires him to travel. An Employee will be deemed in Active Service on a day which is not one of the Employer's scheduled work days only if he was in Active Service on the preceding scheduled work day. GM5812 Page Added Effective February 1, 1987 GM5800 9C1 Section Spec. 9 CONNECTICUT GENERAL LIFE INSURANCE COMPANY 117 EFFECTIVE DATE OF DEPENDENT INSURANCE Each Employee may elect to be insured for Dependent Insurance only by signing a payroll deduction form approved by the Policyholder and the Insurance Company. The effective date of insurance for each Dependent depends upon the date on which the Employee elects Dependent Insurance. (1) If the Employee elects Dependent Insurance on or before the date he becomes eligible for it, the insurance for each Dependent will become effective on the date the Employee becomes eligible for it. (2) If the Employee elects Dependent Insurance within 30 days after he becomes eligible for it, the insurance for each Dependent will become effective on the date of election. (3) If the Employee elects Dependent Insurance more than 30 days after he becomes eligible for it, the insurance for each Dependent will become effective on the date the Insurance Company agrees in writing to insure the Dependent. (4) If the Employee's Dependent Insurance ceased because he cancelled his payroll deduction, and he again elects to be insured for it, the insurance for each Dependent will become effective on the date the Insurance Company agrees in writing to insure the Dependent. Under the circumstances described in items 3 and 4, the Insurance Company may require the Employee, at his own expense, to submit evidence of the Dependent's good health before it agrees to insure the Dependent. An Employee will be insured for Dependent Insurance only if he is insured for Employee Insurance. Any reference to an insured Dependent means a Dependent for whom the Employee is insured. The provisions set forth on this page will apply only to each part time Employee. GM5811 GM5812 Page Added Effective February 1, 1987 GM5800 7C3 Section V-1 7 t Ic p40 South Uvalda, Suite B Aurora, Colorado 80012 �k:' EXECUTIVES SERVICE, INC. INSURANCE CONSULTANTS AND BROKERS December 18, 1986 Mrs. Julie Reimer Eagle County P.O. Box 850 Eagle, CO 81631 RE: Connecticut General Account No. 0488282 (303) 310-2444 WATS LINE 1-800-332-1168 Dear Julie: As per our conversation yesterday, please find enclosed a copy of the master contract as underwritten by Connecticut General for those group benefits elected by Eagle County. Also enclosed are copies of any amendment changes made during the life of the contract. Should you have any questions, please feel free to contact our office. (Mrs.) J na Shalata ssocie JS/bl Encl. POLICYHOLDER: EAGLE COUNTY POLICY NUMBER: 0488282-03 C87-7-35 CONNECTICUT GENERAL LIFE INSURANCE COMPANY AMENDMENT EFFECTIVE DATE OF THIS AMENDMENT: May 1, 1986 As of the Effective Date of this Amendment, the Policy sp-'e"above is amended by the provisions shown below. The page in List A is replaced in the policy by the page in List B that is attached to this Amendment. List A 11CM1 V-10 Spec. List B 11CM1 V-36 Spec. CONNECTICUT GENERAL LIFE INSURANCE COMPANY Registrar Senior Vice President ACCEPTED BY: .................... Policyholder Repre entative GM5804 Pie€ Qdpipip trat iye. Off } cgr, . Title Date l� L CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents COMPREHENSIVE MEDICAL BENEFITS If an Employee or a Dependent, while insured for these benefits, incurs Covered Expenses, the Insurance Company will pay an amount determined as follows, subject to the Maximum Benefit Provision and to the Mental Illness, Alcohol Abuse and Special Care Facility Maximums: 100% of the Covered Expenses first incurred for that Employee or Dependent due to an Injury during the 90 day period following the date of the accident, but not more than $500; 100% of the Covered Expenses incurred for that Employee or Dependent due to Injury (other than those described above) or Sickness, for: charges made by a Free -Standing Surgical Facility or the Outpatient Department of a Hospital for or in connection with outpatient surgery; charges made by a Physician for or in connection with outpatient surgery; charges for all outpatient diagnostic laboratory and X-ray examinations, up to $500 for all Injuries received in any one accident, and up to $500 in any calendar year for Sickness; charges made by a Physician for consultation and charges for laboratory and X-ray examinations in connection with obtaining a second opinion prior to the performance of an Elective Surgical - Procedure; and with respect to all otTer'Covered Expenses, 50% of the Covered Expenses incurred for or in connection with mental illness, alcohol or drug abuse while not Confined in a Hospital; 80% of the Covered Expenses incurred for or in connection with mental illness, alcohol or drug abuse while Confined in a Hospital; and 80% of the remaining Covered Expenses incurred; provided that the applicable Comprehensive Medical Deductible shown in The Schedule will first be deducted from such other Covered Expenses incurred for that person in each calendar year. GM5812 page Added Effective May 1, 1986 GM5800 llCM1 Section V-36 11 Spec. S CONNECTICUT GENERAL LIFE INSURANCE COMPANY RIDER POLICYHOLDER: EAGLE COUNTY POLICY NUMBER: 0488282-03 EFFECTIVE DATE OF RIDER: April 1, 1985 ISSUE DATE OF RIDER: June 19, 1985 The Rider is subject to all terms of the policy except those specifically changed by this Rider. 1. The following definitions apply to the policy and this Rider: a. "Plan" means the plan established by the Policyholder for a certain Class of Employees. , b. "Plan Benefits" means the Benefits in the Plan that are listed below for each Class of Employees. Rate Per Employee For Employee For Dependent Class of Employees Benefit Insurance Insurance Each Employee Medical $46.10 $76.77 c. "Policy Month" means the period starting on a monthly Premium Due Date and ending on the day before the next monthly Premium Due Date; except that the first Policy Month starts on the Effective Date of this Rider and the last Policy Month ends on the day the Rider terminates. d. "Monthly Amount" for each Class of Employees for each Benefit means the amount for any Policy Month that equals the number of Employees in that class multiplied by its Rate per Employee for that Policy Month for that Benefit. e. "Policy Year" means the period starting on a policy Anniversary Date and ending on the day before the next policy Anniversary Date; except that the first Policy Year starts on the Effective Date of the Rider and the last Policy Year ends on the day the Rider terminates. f. "Maximum Monthly Payment" for each Policy Month means the sum, for that Policy Month, of the Monthly Amount for each Class of Employees for each Benefit listed in item 1. b. GM5810 -1- CONNECTICUT GENERAL LIFE INSURANCE COMPANY g. "Maximum Yearly Payment" for each Policy Year means the sum of the Maximum Monthly Payments for each Policy Month in that Policy Year. h. "Benefit Payment Account" means the bank account of the Policyholder from which Plan Benefit payments for which he is liable are made. 2. The Policyholder is liable each Policy Month for payment of all Plan Benefits up to the sum of: a. the greater of: (i) the Maximum Monthly Payment for that month, or (ii) 95% of the Maximum Monthly Payment for the preceding Policy Month; and b. any excess of: (i) the sum of the Maximum Monthly Payments for each preceding Policy Month of the current Policy Year; over (ii) the sum of the Plan Benefits paid by the Policyholder in such Policy Months. 3. The Insurance Company, acting for the Policyholder will: a. determine the amount of any Plan Benefits that an Employee may be entitled to under item (2) above, b. pay all Plan Benefits so determined; and C. defend any action brought in connection with any claim for Plan Benefits so determined and make such settlement as it deems appropriate. 4. The Insurance Company will perform its duties as agent for the Policyholder with reasonable care and diligence and will be liable for any action not taken in good faith. The Policyholder will not sustain any loss with respect to the Rider because of the dishonest, fraudulent or criminal acts of any employee of the Insurance Company. 5. During any Policy Month the Insurance Company is obligated to pay all Plan Benefits that exceed the Plan Benefits the Policyholder has to pay during that Policy Month. GM5810 -2- CONNECTICUT GENERAL LIFE INSURANCE COMPANY 6. The Insurance Company will determine the amount of any Plan Benefits which an Employee may be entitled to under item (5) above. It will defend any action brought in connection with any claim for Plan Benefits so determined and make such settlement as it deems appropriate. 7. The Policyholder will carry out his obligation to pay Plan Benefits as described in item (2) above by providing sufficient funds in the Benefit Payment Account to pay from it all benefits payable by him under the Plan in a timely manner. 8. An Employee making a claim for Plan Benefits shall submit such claim to the Insurance Company, subject to the policy requirements relating to Notice of Claim and Proofs of Loss. 9. When any claim for Plan Benefits has been approved, the Insurance Company will determine if such claim or any part of it is an obligation of the Policyholder or of the Insurance Company. Payment of such claim will be made in accordance with this determination which, where made in good faith, will be binding on the Insurance Company and the Policyholder. 10. If any payment is approved in relation to a contested claim, the Insurance Company will determine, based on the date payment is actually made, if such payment or any part of it is an obligation of the Policyholder or of the Insurance Company. Benefit payments made in accordance with the terms of any judgement or settlement will be deemed benefits paid to Employees under the Plan for the month in which such judgement or settlement is satisfied. 11. The obligations of the Insurance Company and the Policyholder under the Rider will be mutually exclusive and neither party will be liable for the obligations of the other. GM5810 -3- V-3 (1) �A d CONNECTICUT GENERAL LIFE INSURANCE COMPANY 12. The Monthly Premium Rate in the policy will not apply to any Class of Employees and Benefits affected by the Rider. Instead, the following will be used: Rate Per Employee For Employee For Dependent Class of Employees Benefit Insurance Insurance Each Employee Medical $5.69 $9.42 13. In addition to the premium determined in accordance with item (12) above, a Supplemental Premium will be due on each Monthly Premium Due Date. Payment of such Supplemental Premium will be waived contemporaneously with a subsequent Monthly Supplemental Premium becoming due. The Supplemental Premium outstanding at termination of this rider will be payable on the date of such termination. The amount of the Supplemental Premium will be determined by use of a formula agreed upon by the Insurance Company and the Policyholder. In no event will the Supplemental Premium be greater than the amount which the Insurance Company would have accrued in accordance with its normal underwriting practices but for this Rider for both reserves and for premium =' taxes and expenses associated with claim payments issued after the Rider terminates. GM5810 -3a- V-3 (2) L� S CONNECTICUT GENERAL LIFE INSURANCE COMPANY 14. The Insurance Company has the right to change the Monthly Premium Rate, the Supplemental Premium, the Monthly Amount, and the Maximum Monthly Payment as of: (a) any policy Anniversary Date; (b) the date of any change in the Plan; (c) except for the Supplemental Premium, the date the Rider terminates; and (d) at such other times as are provided for in the policy. 15. The Rider will automatically terminate on the earliest date below: a. the date the Plan ends; b. the close of the third consecutive business day during which the Policyholder has failed to provide sufficient funds in the Benefit Payment Account to pay Plan Benefits as they arise. (For the purposes of this item, the close of business on any day will occur at any time when deposits made to the Benefit Payment Account on that day will be credited to it as of the next business day by the bank in which the Benefit Payment Account is maintained.); c. the date the policy terminates. In any case the Rider may be terminated by: (a) the Policyholder, on any Premium Due Date, if he gives written notice in advance of that date to the Insurance Company; and (b) the Insurance Company, at any time, if it gives the Policyholder 31 days' advance notice. 16. When the Rider terminates, the sum of (a), (b) and (c) below will be due and payable without delay by the Policyholder to the Insurance Company; a. all unpaid monthly premiums; b. the Supplemental Premium; and c. any excess of: (i) the sum of the Maximum Monthly Payments for each of the Policy Months in the last Policy Year, over (ii) the sum of: (a) all Plan Benefits the Policyholder has paid for such Policy Year; and (b) all Plan Benefits not yet paid at the time of such termination which the Policyholder must pay under the terms of this Rider for such Policy Year. GM5810 -4- V-1 tC � CONNECTICUT GENERAL LIFE INSURANCE COMPANY 17. When the Rider terminates, the Policyholder will be responsible for the payment of all Plan Benefits for which checks were issued on the Benefit Payment Account before the Rider terminated, but not for payment of any other Plan Benefits under the Rider after its termination. G/i Registrar•• Accepted B .................... ............ Policyholder Representative .. .September 18, 1985...•,,.,...• Date t� GM5810 CONNECTICUT GENERAL LIFE INSURANCE COMPANY -5- Senior Vice President .Chairman, Board of County Commissioners . , . Title CONNECTICUT GENERAL LIFE INSURANCE COMPANY RIDER POLICYHOLDER: EAGLE COUNTY POLICY NUMBER: 0488282-04 EFFECTIVE DATE OF RIDER: April 1, 1985 ISSUE DATE OF RIDER: June 19, 1985 The Rider is subject to all terms of the policy except those specifically changed by this Rider. 1. The following definitions apply to the policy and this Rider: a. "Plan" means the plan established by the Policyholder for a certain Class of Employees. b. "Plan Benefits" means the Benefits in the Plan that are listed below for each Class of Employees. f �-` Rate Per Employee For Employee For Dependent Class of Employees Benefit Insurance Insurance Each Employee Dental $8.65 $18.39 c. "Policy Month" means the period starting on a monthly Premium Due Date and ending on the day before the next monthly Premium Due Date; except that the first Policy Month starts on the Effective Date of this Rider and the last Policy Month ends on the day the Rider terminates. d. "Monthly Amount" for'each Class of Employees for each Benefit means the amount for any Policy Month that equals the number of Employees in that class multiplied by its Rate per Employee for that Policy Month for that Benefit. e. "Policy Year" means the period starting on a policy Anniversary Date and ending on the day before the next policy Anniversary Date; except that the first Policy Year starts on the Effective Date of the Rider and the last Policy Year ends on the day the Rider terminates. f. "Maximum Monthly Payment" for each Policy Month means the sum, for that Policy Month, of the Monthly Amount for each Class of Employees for each Benefit listed in item 1. b. GM5810 -1- C_ �y CONNECTICUT GENERAL LIFE INSURANCE COMPANY g. "Maximum Yearly Payment" for each Policy Year means the sum of the Maximum Monthly Payments for each Policy Month in that Policy Year. h. "Benefit Payment Account" means the bank account of the Policyholder from which Plan Benefit payments for which he is liable are made. 2. The Policyholder is liable each Policy Month for payment of all Plan Benefits up to the sum of: a. the greater of: (i) the Maximum Monthly Payment for that month, or (ii) 95% of the Maximum Monthly Payment for the preceding Policy Month; and b. any excess of: (i) the sum of the Maximum Monthly Payments for each preceding Policy Month of the current Policy Year; over (ii) the sum of the Plan Benefits paid by the Policyholder in such Policy Months. 3. The Insurance Company, acting for the Policyholder will: a. determine the amount of any Plan Benefits that an Employee may be entitled to under item (2) above, b. pay all Plan Benefits so determined; and c. defend any action brought in connection with any claim for Plan Benefits so determined and make such settlement as it deems appropriate. 4. The Insurance Company will perform its duties as agent for the Policyholder with reasonable care and diligence and will be liable for any action not taken in good faith. The Policyholder will not sustain any loss with respect to the Rider because of the dishonest, fraudulent or criminal acts of any employee of the Insurance Company. 5. During any Policy Month the Insurance Company is obligated to pay all Plan Benefits that exceed the Plan Benefits the Policyholder has to pay during that Policy Month. GM5810 -2- N CONNECTICUT GENERAL LIFE INSURANCE COMPANY 6. The Insurance Company will determine the amount of any Plan Benefits which an Employee may be entitled to under item (5) above. It will defend any action brought in connection with any claim for Plan Benefits so determined and make such settlement as it deems appropriate. 7. The Policyholder will carry out his obligation to pay Plan Benefits as described in item (2) above by providing sufficient funds in the Benefit Payment Account to pay from it all benefits payable by him under the Plan in a timely manner. 8. An Employee making a claim for Plan Benefits shall submit such claim to the Insurance Company, subject to the policy requirements relating to Notice of Claim and Proofs of Loss. 9. When any claim for Plan Benefits has been approved, the Insurance Company will determine if such claim or any part of it is an obligation of the Policyholder or of the Insurance Company. Payment of such claim will be made in accordance with this determination which, where made in good faith, will be binding on the Insurance Company and the Policyholder. 10. If any payment is approved in relation to a contested claim, the Insurance Company will determine, based on the date payment is actually made, if such payment or any part of it is an obligation of the Policyholder or of the Insurance Company. Benefit payments made in accordance with the terms of any judgement or settlement will be deemed benefits paid to Employees under the Plan for the month in which such judgement or settlement is satisfied. 11. The obligations of the Insurance Company and the Policyholder under the Rider will be mutually exclusive and neither party will be liable for the obligations of the other. CM5810 -3- V-3 (1) C y CONNECTICUT GENERAL LIFE INSURANCE COMPANY 4. 12. The Monthly Premium Rate in the policy will not apply to any Class of Employees and Benefits affected by the Rider. Instead, the following will be used: Rate Per Employee For Employee For Dependent Class of Employees Benefit Insurance Insurance Each Employee Dental $1.14 $2.40 13. In addition to the premium determined in accordance with item (12) above, a Supplemental Premium will be due on each Monthly Premium Due Date. Payment of such Supplemental Premium will be waived contemporaneously with a subsequent Monthly Supplemental Premium becoming due. The Supplemental Premium outstanding at termination of this rider will be payable on the date of such termination. The amount of the Supplemental Premium will be determined by use of a formula agreed upon by the Insurance Company and the Policyholder. In no event will the Supplemental Premium be greater than the amount which the Insurance Company would have accrued in accordance with its normal underwriting practices but for this Rider for both reserves and for premium taxes and expenses associated with claim payments issued after the Rider terminates. CM5810 -3a- V-3 (2) r CONNECTICUT GENERAL LIFE INSURANCE COMPANY 14. The Insurance Company has the right to change the Monthly Premium Rate, the Supplemental Premium, the Monthly Amount, and the Maximum Monthly Payment as of: (a) any policy Anniversary Date; (b) the date of any change in the Plan; (c) except for the Supplemental Premium, the date the Rider terminates; and (d) at such other times as are provided for in the policy. 15. The Rider will automatically terminate on the earliest date below: a. the date the Plan ends; b. the close of the third consecutive business day during which the Policyholder has failed to provide sufficient funds in the Benefit Payment Account to pay Plan Benefits as they arise. (For the purposes of this item, the close of business on any day will occur at any time when deposits made to the Benefit Payment Account on that day will be credited to it as of the next business day by the bank in which the Benefit Payment Account is maintained.); c. the date the policy terminates. In any case the Rider may be terminated by: (a) the Policyholder, on any Premium Due Date, if he gives written notice in advance of that date to the Insurance Company; and (b) the Insurance Company, at any time, if it gives the Policyholder 31 days' advance notice. 16. When the Rider terminates, the sum of (a), (b) and (c) below will be due and payable without delay by the Policyholder to the Insurance Company; a. all unpaid monthly premiums; b. the Supplemental Premium; and c. any excess of: (i) the sum of the Maximum Monthly Payments for each of the Policy Months in the last Policy Year, over (ii) the sum of: (a) all Plan Benefits the Policyholder has paid for such Policy Year; and (b) all Plan Benefits not yet paid at the time of such termination which the Policyholder must pay under the terms of this Rider for such Policy Year. GM5810 -4- V-1 y CONNECTICUT GENERAL LIFE INSURANCE COMPANY 17. When the Rider terminates, the Policyholder will be responsible for the payment of all Plan Benefits for which checks were issued on the Benefit Payment Account before the Rider terminated, but not for payment of any other Plan Benefits under the Rider after its termination. Registrar Accepted B : Policyholder Representative September 18, 1985 . C. Date GM5810 CONNECTICUT GENERAL LIFE INSURANCE COMPANY -5- Senior Vice President Chairman: Board of County Commissioners • ••.•• ••. Title •f. J.. CONNECTICUT GENERAL LIFE INSURANCE COMPANY (called CG) CERTIFICATE RIDER Policyholder: EAGLE COUNTY Effective Date: April 1, 1985 if you are in Active Service on that day; otherwise, on the date you return to Active Service. if you are not insured for the benefits described in your certificate on that date, the effective date of this certificate rider will be the date you become insured. Policy No. or Nos. 0488282-01, 02, 03, 04 This certificate rider forms a part of the certificate issued to you by CG describing the benefits provided under the poi- icy(ies) specified above. The section entitled "Waiting Period" on the EL2 page enti- tled "Who is Eligible" in your certificate is changed to read as follows: A period of time as determined by your Employer. Senior Vice President GM6000 R 7 Ml s a?s 1' trj a C. N CONNECTICUT GENERAL LIFE INSURANCE COMPANY AMENDMENT POLICYHOLDER: EAGLE COUNTY POLICY NUMBER: 0488282-01 EFFECTIVE DATE OF THIS AMENDMENT: April 1, 1985 ISSUE DATE: June 3, 1985 As of the Effective Date of this Amendment, the Policy specified above is amended by the provisions shown below. For each Management Employee and each Elected Official who became employed by the Employer before the Effective Date of This Amendment but who were not eligible for Employee Insurance before that date, the Waiting Period is deemed to be completed on the Effective Date of This Amendment. For each Management Employee and each Elected Official who become employed by the Employer on or after the Effective Date of This Amendment, there is no Waiting Period. The Waiting Period for each Employee other than each Management Employee and each Elected Official whose employment with the Employer starts on or after the Effective Date of This Amendment is 90 days of Active Service with the Employer. r9istrar ACCEPTED : Policyholder Representative GM5804 CONNECTICUT GENERAL LIFE INSURANCE COMPANY 00 Senior Vice President Chairman, Board of County Commissioners . . . . . . . . . . . . . . Title geDtember 18t 1985. Date V-3 D CONNECTICUT GENERAL LIFE INSURANCE COMPANY ELIGIBILITY FOR EMPLOYEE INSURANCE Each Employee in one of the Classes of Eligible Employees shown below will become eligible for Employee Insurance on the day he completes the Waiting Period, if any. An Employee who was previously insured and whose insurance ceased must satisfy the Waiting Period to become insured again. If the insurance on an Employee ceased because he was no longer employed in a Class of Eligible Employees, he is not required to satisfy any Waiting Period if he again becomes a member of a Class of'Eligible Employees within one year. after his insurance ceased. WAITING PERIOD Each Management Employee and each Elected Official - None Each Other Employee - 90 days of Active Service AFFILIATED EMPLOYERS ' None CLASSES OF ELIGIBLE EMPLOYEES Each Employee GM5812 Page Added Effective April 1, 1985 GM5800 5C1 Section 5 V-7 C CONNECTICUT GENERAL LIFE INSURANCE COMPANY AMENDMENT POLICYHOLDER: EAGLE COUNTY POLICY NUMBER: 0488282-03 EFFECTIVE DATE OF THIS AMENDMENT: January 1, 1984 As of the Effective Date of this Amendment, the Policy specified above is amended by the provisions shown below. The page in List A is replaced in the policy by the page in List B that is attached to this Amendment. List A 3CM1 11CM2 V-8 Spec. List B -3CM1 11CM2 V-8 Spec. CONNECTICUT GENERAL LIFE INSURANCE COMPANY Registrar Senior Vice President ACCEPTED BY: /podlicythold Representative CM5804 Title �/ 2 Date _ V � �Q 12 L� ��,U• a CONNECTICUT GENERAL LIFT INSURANCE COMPANY THE SCHEDULE COMPREHENSIVE MEDICAL BENEFITS Maximum Benefit - Alcohol Abuse Maximum (Out -of -Hospital) - Mental Illness Maximum (Out -of -Hospital) - Special Care Facility Maximum - Covered Expense Daily Limit for: Bed and Board - Comprehensive Medical Deductible - Unlimited $ 500 $ 1,000 $ 1,000 The Hospital's most common daily rate for a semi -private room $ 200 CREDIT FOR COMPREHENSIVE MEDICAL DEDUCTIBLE. The Comprehensive Medical Deductible for any person will be reduced to the extent that the Comprehensive Medical Deductible for the prior calendar year was deducted from Covered Expenses incurred for that person during October, November and December of such prior year. FAMILY DEDUCTIBLE. After Comprehensive Medical Deductibles totaling $600 have been applied in a calendar year for either (a) an Employee and his Dependents or (b) an Employee's Dependents, any Comprehensive Medical Deductible will be waived for that family for the rest of that year. Such $600 will be reduced in any calendar year to the extent that Comprehensive Medical Deductibles were applied for that family during October, November and December of such prior year. CM5800 3CM1 0 CM5812 Page Added Effective January 1, 1984 Section 3 11 CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees and Dependents COMPREHENSIVE MEDICAL BENEFITS (Continued) FULL PAYMENT AREA. When an Employee or Dependent has incurred $700 of Covered Expenses in a calendar year for which no payment is provided because of the Deductible and the coinsurance factor, benefits for that person for Covered Expenses incurred during the rest of that calendar year will be payable at the rate of 100%. However, the rate of payment for benefits payable for or in connection with mental illness, alcohol or drug abuse will riot change. MAXIMUM BENEFIT PROVISION. The total amount of Comprehensive Medical Benefits payable for all expenses incurred for an Employee or Dependent in his lifetime will not exceed the Maximum Benefit shown in The Schedule. MENTAL ILLNESS MAXIMUM. The total amount of Comprehensive Medical Benefits payable for all expenses incurred for an Employee or Dependent in a calendar year for or in connection with mental illness while he is not Confined in a Hospital will not exceed the Mental Illness Maximum shown in The Schedule. ALCOHOL AND DRUG ABUSE MAXIMUM. The total amount of Comprehensive Medical Benefits payable for all expenses incurred for an Employee or a Dependent in a calendar year for or 'in connection with alcohol and drug abuse while he is not Confined in a Hospital will not exceed the Alcohol and Drug Abuse Maximum shown in The Schedule. SPECIAL CARE FACILITY MAXIMUM. The total amount of Comprehensive Medical Benefits payable for all expenses incurred for an Employee or a Dependent in a calendar year for charges made by a Special Care Facility will not exceed the Special Care Facility Maximum shown in The Schedule. GM5812 Page Added Effective January 1, 1984 GM5800 11CM2 Section V_8 11 Spec. SCHEDULE OF BENEFITS 1 The following is the Schedule of Benefits applying to your Croup Insur- ance Plan. It is important to note that an employee may be insured only for the appropriate amounts indicated in the following schedule: ACCIDENTAL DEATH AND CLASSIFICATION LIFE INSURANCE DISMEMBERMENT INSURANCE Each Employee $5,000 $5,000 Medical Care and Dental Care Expense Benefits— All employees and their eligible dependents. Life and Accidental Death & Dismemberment insurance reduce to 65% at age 65, further reduce to 50% at age 70, and cancel at retirement. The term basic earnings means the employee's rate of pay excluding overtime, bonus or additional compensation based on a normal workweek. Medical Care insurance may be continued'at retirement. Revised Effective January 1, 1983 S1 t (-CQN7MATION OF INSURANCE When an employee's full-time service with the Company ceases for any reasons noted below. the insurance may be continued as follows: *Waiver of Premium — When an employee who is less than 60 years of age becomes disabled and unable to work, a waiver of premium may be obtained. See the Waiver of Premium page in this section. A waiver of premium is not available to an employee age 60 or over who becomes disabled and unable to work. Continuation of insurance for such an employee may only be done with Connecticut General's approval and payment of the required premium. See the Waiver of Premium page in this section. X Revised Effective January 1, 1983 C2 SICKNESS LEAVE PENSIONED OR TEMPORARY OF OR INJURY LAYOFF ABSENCE RETIRED Life* As long as For up to For up to May not be your Company 60 days 60 days continued wishes* Medical Care As long as For up to For up to May be Expense your Company 60 days 60 days continued Benefits wishes Accidental As long as For up to For up to May not be Death and your Company 60 days 60 days continued Dismemberment wishes Dental As long as For up too For up to May not be Expense your Company 60 days 60 days continued Benefits wishes *Waiver of Premium — When an employee who is less than 60 years of age becomes disabled and unable to work, a waiver of premium may be obtained. See the Waiver of Premium page in this section. A waiver of premium is not available to an employee age 60 or over who becomes disabled and unable to work. Continuation of insurance for such an employee may only be done with Connecticut General's approval and payment of the required premium. See the Waiver of Premium page in this section. X Revised Effective January 1, 1983 C2 w 3. CONNECTICUT it7qERAL LIFE INSU ANCE COMPANY Hartford, Connecticut EAGLE COUNTY nubs APPLICATION FOR GROUP INSURANCE ress P. 0. Box 850, Eagle, CO 81631 175 59 116 Have any of the classes of individuals eligible been covered under a group insurance policy or any other form of group plan within the past five years? --- yeS.............. If so, please specify the benefits, the underwriting company or organization, and the dates these benefits were terminated Life, health and dental with Mutual of New York terminated December 31, 1982 7. GROUP INSURANCE APPLIED FOR (please check) INDIVIDUAL DEPENDENT R ❑ Life Insurance Q ❑ Accidental Death and Dismemberment Insurance ❑ — Disability Income Insurance ❑ — Long Term Disability Income Insurance ❑ ❑ Hospital Expense Benefits ❑ ❑ Surgical Expense Benefits ❑ ❑ Doctor's Attendance Benefits ❑ ❑ X -Ray and Laboratory Expense Benefits ❑ ❑ Major Medical Expense Benefits [� CR Comprehensive Medical Expense Benefits C� Q Dental Expense Benefits ❑ ❑............................................................................... 8. EFFECTIVE DATE REQUESTED:......._................1ARVArY... s 19.63 .................................................................................... Group Insurance at the Insurance Company's rates and under the terms and conditions of the policy or policies applied for will take effect as of the Effective Date Requested provided that this Application is accepted at the Home Office of the Insurance Company and provided that if certain individuals eligible are to contribute to the cost of any of the Group Insurance, such Group Insurance will become effective on the date the required number have enrolled or on the Effective Date Requested, whichever is the later date. If this Application is not accepted, no insurance will become effective and any premium payment advanced by the Applicant will be refunded upon surrender of the Conditional Receipt. 9. THE APPLICANT DECLARES that he has read the statements and the answers to the above questions and that to the best of his knowledge and belief they are complete and true. The Applicant understands and agrees that this Application is offered as an inducement for the issuance of the insurance applied for, that it will form a part of any policy issued, that no information given to, or acquired by, any representative of the Insurance Company will bind the Insurance Company unless it appears in writing on this Application and that no waiver or modification will bind the Insurance Company unless in writing and signed by an Executive Officer of the Insurance Company. The Applicant further under- stands that no coverage will be provided for any individual unless the individual is eligible under the terms of the policy or policies issued. Dated-------•................_...on.__.--------------------------------------. �L Name of ADDlicanL.........FAGLE Witness: Soliciting Agent ---------------------------------------- if other than Witness...__-__.._. .......... ............. ........................... ZHEREBY ment to be signed by ApplicirM�pon payment of the premium or any part thereof. DECLARE that 1 have paid to .................................................... ......_....Agent Dollars for which I hold his receipt. Date....... _....... ....... _.._...... -- ...... _... Applicant: ...........------------------...................-----..........-----_._.... GM19M rT° 4030 Rev. K. Mailing A Harford, Connecticut 06152 Home Office. Blooy0eld, Connecticut CONNECTICUT GENERAL LIFE INSURANCE COMPANY POLICYHOLDERS EAGLE COUNTY ADDRESS: Eagle, Colorado POLICY NUMBER: 0488282-01 EFFECTIVE DATES January 1, 1983 t ANNIVERSARY DATEs January 1 GROUP TERM LIFE INSURANCE POLICY This policy contains the terms under which the insurance Company sprees to Insure certain Employees and pay benefits. The Insurance Company and the Policyholder have agreed to all of the terms of this policy. CONNECTICUT GW4EnAL LIFE INSURANCE COMPANY COMMNTS I. BENEFITS SECTION Conversion Privilege for Life Insurance 26 Insuring Provisions - Employees 11 Extension of Life Insurance During Total Disability 24 Payment of Benefits 20 The Schedule 3 II. PREMIUMS Average Monthly Premium Rates 34 Calculation of Premiums 34 Changes in Premium Bates 34 Due Date 34 Grace Period 36 Misstatement of Age 38 Payment of Premiums 34 Tables for Calculating Premium Rates 28 III. OTHER PROVISIONS Beneficiary, Designation and Change of 18 Cancellation of Policy 36 Certificate 38 Definitions 9 Effective Date of Insurance 7 Eligibility for Insurance 5 Incontestability 38 Termination of Insurances 21 This policy includes the following pages on date of issuer 1C1, 2LI1, XII, 5C1, 7C2, 9C1, 11LI1, 18C1, 20LI1, 21LI1 V-1, 24LI1, 24LI3, 26LI16 2BLI19 28LI20 34C1, 34LI1, 341,I2, 36C1 V-10 38LI1, 38LI2 GM5800 2LI1 Section 2 r� � r CONNECTICUT GENERAL LIFE INSURANCE COMPANY THE SCHEDULE Each Employee age 70 or older Amount of Life Insurance $2,500 Each Employee age 65 or older but under age 70 $3,250 Each Employee under age 65 $50000 INITIAL AMOUNT OF LIFE INSURANCE. The amount of Life Insurance on an Employee on the day he becomes insured is based on his age on that day. CHANGES IN AMOUNT OF LIFE INSURANCE. Any decrease in the amount of Life Insurance on an Employee due to age will take place on his birthday. CM5800 3LI1 Section 3 N CONNECTICUT GENERAL LIFE INSURANCE COMPANY ELIGIBILITY FOR EMPLOYEE INSURANCE Each Employee in one of the Classes of Eligible Employees shown below will become eligible for Employee Insurance on the day he completes the Waiting Period, if any. An Employee who was previously insured and whose insurance ceased must satisfy the New Employee Group Waiting Period to become insured again. If the insurance on an Employee ceased because he was no longer employed in a Class of Eligible Employees, he is not required to satisfy any Waiting Period if he again becomes a member of a Class of Eligible Employees within one year after his insurance ceased. INITIAL EMPLOYEE GROUP. The Initial Employee Group is made up of Employees: (1) in the employ of an Employer on the Effective Date of the policy; or (2) in the employ of an Employer on the date that Employer becomes an Affiliated Employer. NEW EMPLOYEE GROUP. The New Employee Group is made up of Employees not in the Initial Employee Group... WAITING PERIOD Initial Employee Group: 30 days of Active Service New Employee Group: 30 days of Active Service AFFILIATED EMPLOYERS None CLASSES OF ELIGIBLE EMPLOYEES Each Employee GN5800 5C1 Section 5 c CONNECTICUT GENERAL LIFE INSURANCE COMPANY EFFECTIVE DATE OF EMPLOYEE INSURANCE Each Employee will become insured for Employee Insurance on the date he becomes eligible for it. If an Employee is not in Active Service on the date his Insurance would otherwise become effective, it will become effective on the date he returns to Active Service. GH5800 7C2 Section 7 i CONNECTICUT GENERAL LIFE INSURANCE COMPANY DEFINITIONS EMPLOYER. The term Employer means the Policyholder and all Affiliated Employers shown in the "Eligibility for Insurance" section. EMPLOYEE. The -term Employee means a full time employee of the Employer, but does not include employees who are part time or temporary or who normally work less than 30 hours a week for the Employer. ACTIVE SERVICE. An Employee will be considered in Active Service with the Employer on a day which is one of the Employer's scheduled work days if he is performing in the usual way all of the regular duties of his work for the Employer on a full time basis on that day, either at one of the Employer's places of business or at some location to which the Employer's business requires his to travel. An Employee will be deemed in Active Service on a day which is not one of the Employer's scheduled work days only if he was in Active Service on the preceding scheduled work days. GM5800 9C1 Section 9 CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS ~ Cy For Employees LIFE INSURANCE The Insurance Company will pay the amount of Life Insurance in force on an Employee when it receives due proof that the Employee died while insured for this Life Insurance. The amount payable is determined from The Schedule and the other terms of the policy. 1 Gi5800 111,I1 Section 11 i CONNECTICUT GENERAL LIFE INSURANCE COMPANY BENEFICIARY DESIGNATION For Employees BENEFICIARY. Each Employee will designate a Beneficiary. This designation will be filed with the Insurance Company or, if agreed to in advance by the Insurance Company, with the Policyholder. CHANGE OF BENEFICIARY. An Employee maychange his Beneficiary at any time. The change must be made on a form satisfactory to the Insurance Company and signed by the Employee. No change of Beneficiary will take effect until this fore is received by the Insurance Company or by the Policyholder, if it has been agreed that Beneficiary designations be filed with the Policyholder. When this fors is received, the change will take effect as of the date on the form. If the Employee dies before the fora is received, the Insurance Company will not be liable for any payment that was made before receipt of the form. CONSENT OF BENEFICIARY. Consent of the Beneficiary will not be required to change the Beneficiary or to effect any other changes. GM5800 18C1 Section 28 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PAYMENT OF BENEFITS Benefits for loss of life of the Employee will be paid to his designated Beneficiary. Any amount of the Employee's loss of life benefit for which there is no designated or surviving Beneficiary will be paid, at the option of the Insurance Company, to any of the following living relatives of the Employees spouse, mother, father, child or children; or to the executors or administrators of the Employee's estate. The Insurance Company will also have the right to make payment in such manner if it is not able, within what it considers a reasonable period of time, to locate the Beneficiary. If the Beneficiary is a minor or, in the opinion of the Insurance Company, is not able to give valid receipt for any payment due him, such payment will be made to his legal guardian. However, if no request for payment has been made by his legal guardian, the Insurance Company may at its option, make payment to the person or institution appearing to have assumed his custody and support. Payment in this event will be made in monthly instalments of not more than $500 each. Payment in the manner described above will release the Insurance Company from all liability to the extent of any payment made. OPTIONAL METHODS OF SETTLEMENT. At the Employee's written request, his amount of Life Insurance will be paid in instalments after his death rather than in one sum, based on the Insurance Company's instalment plans then available. If the Employee does not make this request, the Beneficiary may do so, in writing, after the Employee's death. Instalment plans are not available if the amount of the Employee's Life Insurance is less than $2500. If a Beneficiary dies while receiving instalment payments, the remaining Instalments, unless otherwise disposed of, will be commuted at the rate of 3% compound interest per year. Payment will then be made in one sum to the executors or administrators of the Beneficiary's estate. CM5800 20LI1 Section 20 t t CONNECTICUT GENERAL LIFE INSURANCE COMPANY TERMINATION OF INSURANCE For Employees The insurance on an Employee will cease on the earliest date below except as otherwise provided in the "Extension of Life Insurance During Total Disability" sections (1) the date the Employee ceases to be in a Class of Eligible Employees or ceases to qualify as an Employee; (2) the last day for which the Employee has made any required contribution for the insurance; (3) the date the policy is cancelled; (k) the date the Employee's Active Service ends, except as net forth below. TEMPORARY LAYOFF OR LEAVE OF ABSENCE. If an Employee's Active Service ends due to temporary layoff or leave of absence, the insurance will be continued until the date the Policyholders (a) stops paying premium for the Employee; or (b) otherwise cancels, the insurance. However, the insurance will not be continued for more than 60 days past the date the Employee's Active Service ends. INJURY OR SICKNESS. If an Employee's Active Service ends due to an injury or a sickness, the insurance will be continued while the Employee remains totally and continuously disabled as a result of the injury y or sickness. However, the insurance will not be continued past the earlier of: (a) one year from the date the Employee's Active Service ends unless the Policyholder obtains the Insurance Company's consent in writing to a longer period; or (b) the date the Policyholder stops paying premium for. the Employee or otherwise cancels the insurance. // Any continuation of insurance must be based on a plan which Individual selection. GM5800 21LI1 Section V-1 21 CONNECTICUT GENERAL LIFE INSURANCE COMPANY EXTENSION OF LIFE INSURANCE DURING TOTAL DISABILITY For Employees If an insured Employee terminates Active Service before age 60 because of Total Disability (as defined below) and if the Policyholder stops paying premium for him, his Term Life Insurance will be extended while he remains continuously Totally Disabled, but for no more than one year from the date his Active Service ends. If the Employee dies while his insurance is being extended, no death claim will be paid unless the Insurance Company receives, within one year after the Employee's death, proof that the Employee's Total Disability was continuous from the date his Active Service ended until he died. If the Employee submits due proof to the Insurance Company that he became Totally Disabled prior to his 60th birthday and has remained continuously Totally Disabled for 9 months or more, his Term Life Insurance will be extended, without further payment of premiums for him, for a period of one year from the date that proof is received by the Insurance Company. Such proof must be submitted no later than one year from the date his Active Service ends because of Total Disability. After that, his insurance will be extended without payment of premiums for him, for further periods of one year if; (1) he remains continuously Totally Disabled; and (2) he submits to the Insurance Company, during the three months before the end of each such one year period, proof of the continuation of Total Disability. TOTAL DISABILITY OR TOTALLY DISABLED. An Employee will be considered Totally Disabled when he is completely unable to engage in any occupation for wage or profit because of injury or sickness. If an Employee dies while his insurance is being extended, the amount payable will be determined from The Schedule which was in effect on his last day of Active Service, taking into account any age or retirement reductions shown in that Schedule. Any retirement reductions will apply as of the Employee's normal retirement date. No death claim will be paid unless written notice of the Employee's death is received by the Insurance Company within one year from the date of death. GH5800 24LI1 Section 24 i Cy CONNECTICUT GENERAL LIFE INSURANCE COMPANY EXTENSION OF LIFE INSURANCE DURING TOTAL DISABILITY (Continued) For Employees At any time while the insurance is extended, the Insurance Company will have the right to require proof of the continuing Total Disability and, at its own expense, to have a physician of its choice examine the Employee. If an Employee has been issued a Converted Life Policy, his insurance will not be extended unless the Converted Life Policy to returned to the Insurance Company without claim except for the return of any premium paid. The insurance which is being extended on an Employee will automatically cease: (a) when the Employee is no longer Totally Disabled, except that if he returns to Active Service in a Class of Eligible Employees, his insurance will be continued if the Policyholder pays premium for his; (b) if the Employee does not submit to any physical examination required by the Insurance Company; (c) If the Employee fails to give proof of continuous Total Disability; or (d) if the insurance under the policy is not continued at retirement, on the Employee's normal retirement date. If the Employee's insurance under this section ceases he will be Entitled to Convert under the terms of the "Conversion Privilege for Life Insurance" section. GM5800 24LI3 Section 24 CONNECTICUT GENERAL LIFE INSURANCE COMPANY \ CONVERSION PRIVILEGE FOR LIFE INSURANCE For Employees When an Employee's Life Insurance ceases, he may apply to the Insurance Company for an individual life policy (called the Converted Life Policy). A Converted Life Policy will be issued to an Employee who is Entitled to Convert if he applies in writing and pays the first premium for the Converted Life Policy to the Insurance Company within 31 days after the date his Life Insurance ceases. Evidence of good health is not needed. EMPLOYEES ENTITLED TO CONVERT. An Employee is Entitled to Convert bis Life Insurance only if: 1. His insurance ceases because he is no longer in Active Service or no longer eligible for Life Insurance. 2. His insurance ceases or is reduced because of retirement or age. 3. The policy is cancelled for the class of Employees to which he then belongs and he has been insured under the policy for at least five years before it is cancelled. CONVERTED LIFE POLICY. The amount that an Employee may convert when he loses all or a part of his Life Insurance will not be more than the amount of his Life Insurance which terminates at that time. If all insurance under the policy is cancelled on the class of Employees to which the Employee belongs, the amount of insurance under the Converted Life Policy will not be more than the smaller oft (a) the amount of the Employee's insurance which ceases less any amount of group life insurance for which he becomes eligible within 31 days after the Insurance ceases; or (b) $2,000. The Converted Life Policy will be one of the Insurance Company's current offerings based on its rules for Converted Life Policies. It will be issued at the Employee's attained age for the premium that applies to the class of risk to which he then belongs and will take affect on the 32nd day after the date his Life Insurance ceases. Neither tern insurance nor disability benefits are offered under the Converted Life Policy. PAYMENT DURING THE 31—DAY CONVERSION PERIOD. If an Employee dies during the 31 days in which he may convert his Life Insurance, the Insurance Company will pay to the Beneficiary designated under the group policy the amount of insurance which the Employee could have converted. In this case, no payment will be made under a Converted Life Policy. GM5800 26LI1 Section 26 CONNECTICUT GENERAL LIFE INSURANCE COMPANY , TABLES FOR CALCULATING AVERAGE MONTHLY PREMIUM SATE For Employees TABLE I MONTHLY PREMIUM RATES Calendar Premium Calendar Premium Calendar Premium Calendar Premium Age Per $1.000 Age Per $1,000 Age Per $1,000 Age Per $1.000 15 .19 35 $ .32 55 1.65 75 $ 8.56 16 .20 36 .34 56 1.80 76 9.24 17 .21 37 .36 57 1.97 77 10.00 18 .22 38 .38 58 2.14 78 10.86 19 .23 39 .41 59 2.32 79 11.81 20 .23 40 .45 60 2.51 80 12.83 21 .24 41 .49 61 2.72 81 13.93 22 .24 42 .53 62 2.96 82 15.07 23 .25 43 .58 63 3.21 83 16.26 24 .25 44 .63 64 3.48 84 17.50 25 .25 45 .68 65 3.78 85 18.80 26 .25 46 .74 66 4.11 86 20.16 27 .26 47 .81 67 4.48 87 21.60 28 .26 48 .89 68 4.89 88 23.13 29 .26 49 .97 69 5.34 89 24.79 30 .27 50 1.06 70 5.81 90 26.62 31 .27 51 1.16 71 6.32 91 28.68 32 .28 52 1.26 72 6.84 92 31.03 33 .29 53 1.38 73. 7.38 93 33.75 34 .30 54 1.51 74 7.95 94 36.95 95 40.98 GM 5800 28LI1 Section 28 CONNECTICUT GENERAL LIFE INSURANCE COMPANY TABLES FOR CALCULATING AVERAGE MONTHLY PREMIUM RATE (Continued) For Employees TABLE II FACTORS TO CONVERT FROM CALENDAR AGE TO INSURANCE AGE Date as of which Average Monthly Premium Rate is Calculated Factor January 1 through January 15 .965 January 16 through February 14 .971 February 15 through March 15 .977 March 16 through April 15 .983 April 16 through May 15 .988 May 16 through June 15 .994 June 16 through July 15 1.000 July 16 through August 15 1.006 August 16 through September 15 1.013 September 16 through October 15 1.019 October 16 through November 15 1.025 November 16 through December 15 1.032 December 16 through December 31 1.038 TABLE III EXPENSE ADJUSTMENT FACTORS Gross Monthly Cost Factor Gross Monthly Cost Factor GM 5800 28LI2 Section 28 Less than $ 200 1.00 # 10700 but less than $ 2,000 .82 # 200 but lass than 225 .99 20000 but less than 2,500 .81 225 but less than 250 .98 21500 but less than 30000 .80 250 but less than 300 .97 3,000 but less than 3,500 .79 300 but less than 350 .96 3,500 but less than 4,000 .78 350 but less than 400 .95 40000 but less than 5,000 .77 400 but less than 450 .94 50000 but less than 6,000 .76 450 but less than 500 .93 60000 but less than 7,500 .75 500 but less than 550 .92 7,500 but less than 9,500 .74 550 but less than 600 .91 99500 but less than 120000 .73 600 but less than 650 .90 12,000 but less than 159000 .72 650 but less than 700 .89 150000 but lass than 20,000 .71 700 but less than 800 .88 200000 but lase than 270000 .70 800 but less than 900 .87 278000 but less than 350000 .69 900 but less than 1,000 .86 35,000 but less than 45,000 .68 1,000 but less than 1,200 .85 45,000 but less than 600000 .67 1,200 but less than 1,400 .84 60,000 but less than 801000 .66 10400 but less than 1,700 .83 800000 and over .65 GM 5800 28LI2 Section 28 f CONNECTICUT GENERAL LIFE INSURANCE COMPANY PREMIUMS PREMIUM PAYMENT. The first premium will be due on the Effective Date. After that, premium will be due monthly unless the Policyholder and the Insurance Company agree on some other method of premium payment. The Policyholder and, the Insurance Company may agree to change the method of premium payment from time to time. Premiums are payable at the Rome Office of the Insurance Company or to an authorized agent of the Insurance Company. PREMIUM DUE DATE. After the Effective Date, the Premium Due Date will be the day of the month with the same number as the Anniversary Date or the last day of a month In which there is no day with the same number as the Anniversary Date. If the Policyholder and the Insurance Company agree that premiums will be paid on a quarterly, semiannual or annual basis, the Premium Due Date will be at the appropriate regular interval, quarterly, semiannually or annually. MONTHLY STATEMENT DATE. If premiums are to be paid monthly, the Monthly Statement Date will be the same as the Premium Due Date. If premiums are to be paid on a quarterly, semiannual or annual basis, the Monthly Statement Date will be the day in each month with the same number as the Premium Due Date. MONTHLY PREMIUM STATEMENT. If premiums are due monthly, a Monthly Premium Statement will be prepared as of the Premium Due Date. This Monthly Premium Statement will show the premium due. If premiums are due quarterly, semiannually or annually, a Monthly Premium Statement will be prepared as of the Monthly Statement Date for the time from the Monthly Statement Date to the next Premium Due Date. This Monthly Statement will reflect any pro rata premium charges and credits due to changes in the number of insured persons and changes in insurance amounts that took place in the preceding month. SIMPLIFIED ACCOUNTING. To simplify the accounting process, premium adjustments will be made on the Monthly Statement Date that is the same as or next follows the date that (1), (2) or (3) below takes place. (1) A person becomes insured. (2) The amount of insurance on a person changes, but not due to a revision of The Schedule. (3) A person ceases to be insured. GM5800 34C1 Section 34 r! Ah CONNECTICUT GENERAL LIFE INSURANCE COMPANY PREMIUMS (Continued) AVERAGE MONTHLY PREMIUM BATE. The first Average Monthly Premium Rate will be calculated as of the Effective Date. The Insurance Company may recalculate the Average Monthly Premium Rate as of any Premium Due Date. The method of calculation will be as follows: (1) Determine the Calendar Age of each insured Employee by subtracting his year of birth from the year as of which the Average Monthly Premium Rate Is being calculated. (2) Multiply the amount of insurance in force for each insured male Employee by the premium per #1,000 in Table I for that Employee's Calendar Age. Add the results. (3) Multiply the amount of insurance in force for each insured female Employee by the premium per $1,000 in Table I for that Employee's Calendar Age. Add the results and multiply the sum by 0.60. (4) Multiply the total premium for male and female Employees by the appropriate factor shown in Table II. Round the result to the nearer cent. (5) Add to the result the lesser of (a) $.20 for each $1,000 of insurance in force under the policy or (b) $8.00. (6) Multiply the resulting Gross Monthly Cost by the appropriate factor shown In Table III. Round the result to the nearer cent. (7) Divide the result by the total number of $1,000 units of insurance then in force under the policy. Round the result to the nearer cent. MAXIMUM EMPLOYEE CONTRIBUTION. The most that an Employee may contribute to the cost of any insurance on his life under the policy is $.60 per month for each $1,000 of insurance. GH5800 34LI1 section 34 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PREMIUMS (Continued) CALCULATION OF PREMIUMS. The monthly premium will be calculated by multiplying the total number of $1000 units of insurance in force for Employees on the Premium Due Date by the Average Monthly Premium Rate in effect on that date. If premiums are to be paid other than monthly, the method of calculation is the same. However, the rate for each class is first changed to quarterly semiannual or annual rates by multiplying them by 2.9852, 5.9557 or 11.8221 respectively. All results are taken to the nearer cent. If the Policyholder and the Insurance Company agree to a change in the method of premium payment or to a change in the Anniversary Date, a pro rata adjustment will be made in the premium due. CHANGES IN PREMIUM RATES. The Tables of Monthly Premium Rates may be changed by the Insurance Company from time to time with at least 31 days advance written notice. No such change will be made until 12 months after the Effective Date. An increase will not be made more often than once in a 12 month period. If an increase in premium rates takes place on a date that is not a Premium Due Date, a pro rata premium will be due on the date of the increase. The pro rata premium will apply for the increase from the date of the increase to the next Premium Due Date. If. a decrease in premium rates taken place on a date that is not a Premium Due Date, a pro rata credit will be granted. The pro rata credit will apply for the decrease from the date of the decrease to the next Premium Due Date. As of any Anniversary Date after the policy has been in force for 12 months, the Insurance Company may grant a credit in such amount as it may determine, based on experience. The experience under this policy may be combined with the experience under other group insurance policies issued by the Insurance Company to the Policyholder. CM5800 34LI2 Section 34 CONNECTICUT GENERAL LIFE INSURANCE COMPANY CANCELLATION OF POLICY The Policyholder may cancel the policy as of any Premium Due Date by giving written notice to the Insurance Company before that date. The Insurance Company may cancel the policy as of any Premium Due Date if the number of insured Employees is less than 25 or less than 75% of those eligible. If a premium is not paid when due, the policy will automatically be cancelled as of the Premium Due Date, except as set forth below. GRACE PERIOD. If, before a Premium Due Date, the Policyholder has not given written notice to the Insurance Company that the policy is to be cancelled, a Grace Period of 31 days will be granted for the payment of each premium after the initial premium. The policy will stay in effect during that time. If any premium is not paid by the end of the Grace Period, the policy will automatically be cancelled at the end of the Grace Period; except that, if the Policyholder has given written notice in advance of an earlier date of cancellation, the policy will be cancelled as of the earlier date. The Policyholder will be liable to the Insurance Company for any unpaid premium for the time the policy was in force. GN5800 36C1 section V-1 36 CONNECTICUT GENERAL LIFE INSURANCE COMPANY MISCELLANEOUS PROVISIONS J EXECUTION OF POLICY. The policy is executed at the Home Office of the Insurance Company. The Post Office address of the Insurance Company is Hartford. Connecticut. CONSIDERATION. The policy is issued to the Policyholder in consideration of the application and payment of premiums. INSURANCE DATA. The Policyholder will give the Insurance Company all of the data that it needs to calculate the premium and all other data that it nay reasonably require. Failure of the Policyholder to give this data will not void or continue an Employee's insurance. The Insurance Company has the right to examine the Policyholder's records relative to these benefits at any reasonable time while the policy In in effect. It also has this right until all rights and obligations under the policy are finally determined. ASSIGNMENT. An Employee may assign all of his rights in and to this Life Insurance with the written approval of the Policyholder. An assignment will transfer the interest of the Employee and any Beneficiary to the assignee. Any such assignment will remain in force until , changed by the assignee. No assignment will be in effect until a copy is filed with the Insurance Company. However, the assignment may be filed with the Policyholder if the Insurance Company agrees in advance. The Insurance Company is not responsible for the validity or sufficiency of any assignment. �J MALE PRONOUN. The male pronoun as used herein will be deemed to Include the female. GM5800 38LI1 Section 38 CONNECTICUT GENERAL LIFE INSURANCE COMPANY MISCELLANEOUS PROVISIONS (Continued) MISSTATEMENT OF AGE. The misstatement of an Employee's age will not affect his amount of insurance. Premiums will be adjusted so that the Policyholder will pay the Insurance Company the premiums at the true age of the Employee. INCONTESTABILITY. The Insurance Company will not contest the validity of the policy after two years from the date of issue except for non-payment of premiums. No statement made by an Employee as to his insurability will be used to contest the validity of the insurance after it has been in force prior to the contest for a period of two years during the Employee's life. No statement made by an Employee will be used unless it is made in writing and signed by him. ENTIRE CONTRACT. The entire contract will be made up of the policy, the application of the Policyholder, a copy of which is attached to the policy, and the applications, if any, of the Employees. POLICY CHANGES. Changes may be made in the policy only by amendment signed by the Policyholder and by the Insurance Company acting through its President, Vice President, Secretary or Assistant Secretary. No agent may change or waive any terms of the policy. STATEMENTS NOT WARRANTIES. All statements made by the Policyholder or by an Insured Employee will, in the absence of fraud, be deemed representations and _ not warranties. No statement made by the Policyholder or by the Employee to obtain insurance will be used to avoid or reduce the insurance unless it is made in writing, and is signed by the Policyholder or the Employee and a ­'copy Is sent to the policyholder, the Employee or his Beneficiary. CERTIFICATES. The Insurance Company will issue to the Policyholder for delivery to each insured Employee an individual certificate. The policyholder will be responsible for distributing the certificates to its Employees. The certificate will show the benefits provided under the policy. It will set forth any changes in benefits due to age, to whom benefits will be paid and the terms of the Conversion Privilege. Nothing in the certificate will change or void the terms of the policy. GH5800 30LI2 Section 38 r Mailingrasa Hartford, Connecticut 06158 Home Office: Bloontfield, Connecticut CONNECTICUT GENERAL LIFE INSURANCE COMPANY POLICYHOLDER: EAGLE COUNTY ADDRESS: Eagle, Colorado POLICY NUMBER: 0488282-02 EFFECTIVE DATE: January 1, 1983 ANUIVEBSARY DATE: January 1 GROUP ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE POLICY This policy contains the terms under which the Insurance Company agrees to insure certain Employees and pay benefits. The Insurance Company and the Policyholder have agreed to all of the terms of this policy. CM5800 2DD1 Section 2 CONNECTICUT GENERAL LIFE INSURANCE COMPANY CONTENTS SECTION I. BENEFITS Insuring Provisions 11 Limitations 11 Payment of Benefits 20 The Schedule 3 II. PREMIUMS Calculation of Premiums 34 Changes in Premium Rates 34 Due Date 34 Grace Period 36 Payment of Premiums 34 Monthly Premium Rate 34 II. OTHER PROVISIONS Beneficiary, Designation and Change of 18 Cancellation of Policy 36 Certificate 40 Claims, Forms and Notice of Claim 40 Definitions 9 Effective Date of Insurance 7 Eligibility for Insurance 5 Termination of Insurance 21 This policy includes the following pages on date of issue: 1C1, 2DD1, 3DD1, 5C1, 7C2, 9C1, 11DD1, 11DD2, 18C1, 20DD1, 21DD1, 34C1, 34DD1, 36C1 V-1, 38C1, 40C1, 40C2 CM5800 2DD1 Section 2 C CONNECTICUT GENERAL LIFE INSURANCE COMPANY THE SCHEDULE Amount of Principal Sum Each Employee age 70 or older $2,500 Each Employee age 65 or older but under age 70 $3,250 Each Employee under age 65 $5,000 INITIAL AMOUNT OF PRINCIPAL BUM. The amount of Principal Sum on an Employee on the day he becomes insured is based on his age on that day. CHANGES IN AMOUNT OF PRINCIPAL SUM. Any decrease in the amount of Principal Sum on an Employee due to age will take place on his birthday. GM800 3DD1 Section 3 G 1 CONNECTICUT GENERAL LIFE INSURANCE COMPANY ELIGIBILITY FOR EMPLOYEE INSURANCE Each Employee in one of the Classes of Eligible Employees shown below will become eligible for Employee Insurance on the day he completes the Waiting Period, if any. An Employee who was previously insured and whose insurance ceased must satisfy the New Employee Group Waiting Period to become insured again. If the insurance on an Employee ceased because he was no longer employed in a Class of Eligible Employees, he is not required to satisfy any Waiting Period if he again becomes a member of a Class of Eligible Employees within one year after his insurance ceased. INITIAL EMPLOYEE GROUP. The Initial Employee Group is made up of Employees: (1) in the employ of an Employer on the Effective Date of the policy; or (Z) in the employ of an Employer on the date that Employer becomes an Affiliated Employer. NEW EMPLOYEE GROUP. The New Employee Group is made up of Employees not in the Initial Employee Group. WAITING PERIOD Initial Employee Group:. 30 days of Active Service New Employee Group: AFFILIATED EMPLOYERS None CLASSES OF ELIGIBLE EMPLOYEES Each Employee GM5800 5C1 30 days of Active Service Section 5 C N CONNECTICUT GENERAL LIFE INSURANCE COMPANY EFFECTIVE DATE OF EMPLOYEE INSURANCE Each Employee will become insured for Employee Insurance on the date he becomes eliSible for it. If an Employee is not in Active Service on the date his insurance would otherwise become effective, it will become effective on the date he returns to Active Service. GM5800 7C2 section 7 CONNECTICUT GENERAL LIFE INSURANCE COMPANY DEFINITIONS EM LOYER. The term Employer means the Policyholder and all Affiliated Employers shown in the "Eligibility for Insurance" section. EMLOYEE. The term Employee means a full time employee of the Employer, but does not include employees who are part time or temporary or who normally work less than 30 hours a week for the Employer. ACTIVE SERVICE. An Employee will be considered in Active Service with the Employer on a day which is one of the Employer's scheduled work days if he is performing in the usual way all of the regular duties of his work for the Employer on a full time basis on that day, either at one of the Employer's places of business or at some location to which the Employer's business requires him to travel. An Employee will be deemed in Active Service on a day which is not one of the Employer's scheduled work days only if he was in Active Service on the preceding scheduled work days. GM5800 9C1 section 9 C CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS For Employees ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS The Insurance Company will pay the Benefit Amount shown below when it receives due proof that: (1) the Employee received an accidental bodily injury while insured for this Accidental Death and Dismemberment Insurance; and (2) as a direct result of that injury, independently of all other causes, the Employee sustained any loss shown, in the table below; and (3) the lose occurred within 90 days after the date of that injury. BENEFIT AMOUNT, The Benefit Amount for each loss will be the amount of Principal Sum determined for the Employee from The Schedule multiplied by the percentage shown below for that loss. The maximum that will be paid for all losses resulting from injuries received by an Employee in any one accident will be the amount of Principal Sum for that Employee. GH5800 11DD1 TABLE OF LOSSES AND BENEFITS 2 of the Employee's Principal Sum Loss of Life 100% Loss of One Hand by Severance at or above the Wrist 50% Loss of One Foot by Severance at or above the Ankle 50% Entire and irrecoverable Loss of Sight in One Eye 502 Loss of more than one of the above in one Accident 100% Section 11 N CONNECTICUT GENERAL LIFE INSURANCE COMPANY INSURING PROVISIONS for Employees ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS (Continued) LIMITATIONS. Benefits will not he paid for a loss which in any way results from: (1) suicide or injury intentionally self-inflicted, while sane or insane; (2) disease or infection, except an infection resulting from an accidental cut or wound; (3) declared or undeclared war, or an act of war. GM5800 11DD2 Section 11 CONNECTICUT GENERAL LIFE INSURANCE COMPANY BENEFICIARY DESIGNATION For Employees BENEFICIARY. Each Employee will designate a Beneficiary. This designation will be filed with the Insurance Company or, if agreed to in advance by the Insurance Company, with the Policyholder. CHANGE OF BENEFICIARY. An Employee may change his Beneficiary at any time. The change must be made on a form satisfactory to the Insurance Company and signed by the Employee. No change of Beneficiary will take effect until this form is received by the Insurance Company or by the Policyholder, if it has been agreed that Beneficiary designations be filed with the Policyholder. When this form is received, the change will take effect as of the date on the form. If the Employee dies before the form is received, the Insurance Company will not be liable for any payment that was made before receipt of the form. CONSENT OF BENEFICIARY. Consent of the Beneficiary will not be required to change the Beneficiary or to effect any other changes. GM5800 18C1 Section 18 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PAYMENT OF BENEFITS Benefits for loss of life of the Employee will be paid to his designated Beneficiary. Dismemberment benefits will be paid to the Employee. Any amount of the Employee's loss of life benefit for which there is no designated or surviving Beneficiary will be paid, at the option of the Insurance Company, to any of the following living relatives of the Employee: spouse, mother, father, child or children; or to the executors or administrators of the Employee's estate. The Insurance Company will also have the right to make payment in such manner if it is not able, within what it considers a reasonable period of time, to locate the Beneficiary. If any person to whom benefits are payable is a minor or, in the opinion of the Insurance Company, not able to give valid receipt for any payment due him, such payment will be made to his legal guardian. However, if no request for payment has been made by his legal guardian, the Insurance Company may at its option, make payment to the person or institution appearing to have assumed his custody and support. Payment of loss of life benefits in this event will be made in monthly instalments of not more than $500 each. If an Employee dies while dismemberment benefits remain unpaid, the Insurance f Company may, at its option, make direct payment to any of the following living relatives of the Employees spouse, mother, father, child or children, brothers or sisters; or to the executors or administrators of the Employee's estate. kc Payment in the manner described above will release the Insurance Company from all liability to the extent of any payment made. 0!5800 20DD1 Section 20 CONNECTICUT GENERAL LIFE INSURANCE COMPANY TERMINATION OF INSURANCE For Employees The insurance on an Employee will cease on the earliest date below: (1) the date the Employee ceases to be in a Class of Eligible Employees or ceases to qualify as an Employee; (2) the last day for which the Employee has made any required contribution for the insurance; (3) the date the policy is cancelled; (4) the date the Employee's Active Service ends, except as set forth below. TEMPORARY LAYOFF OR LEAVE OF ABSENCE. If an Employee's Active Service ends due to temporary layoff or leave of absence, the insurance will be continued until the date the Policyholder: (a) stops paying premium for the Employee; or (b) otherwise cancels 'the insurance. However, the insurance will not be continued for more than 60 days past the date the Employee's Active Service ends. INJURY OR SICKNESS. If an Employee's Active Service ends due to an injury or a sickness, the insurance will be continued while the Employee remains totally and continuously disabled as a result of the injury or sickness until the date the Policyholder: (a) stops paying premium for the Employee; or (b) otherwise cancels the insurance. Any continuation of insurance must be based on a plan which precludes individual selection. GM5800 21DD1 Section 21 C. 1< L CONNECTICUT GENERAL LIFE INSURANCE COMPANY PREMIUMS PREMIUM PAYMENT. The first premium will be due on the Effective Date. After that, premium will be due monthly unless the Policyholder and the Insurance Company agree on some other method of premium payment. The Policyholder and the Insurance Company may agree to change the method of premium payment from time to time. Premiums are payable at the Home Office of the Insurance Company or to an authorised agent of the Insurance Company. PREMIUM DUE DATE. After the Effective Date, the Premium Due Date will be the day of the month with the same number as the Anniversary Date or the last day of a month in which there is no day with the same number as the Anniversary Date. If the Policyholder and the Insurance Company agree that premiums will be paid on a quarterly, semiannual or annual basis, the Premium Due Date will be at the appropriate regular interval, quarterly, semiannually or annually. MONTHLY STATEMENT DATE. If premiums are to be paid monthly, the Monthly Statement Date will be the same as the Premium Due Date. If premiums are to be paid on a quarterly, semiannual or annual basis, 'the Monthly Statement Date will be the day in each month with the same number as the Premium Due Date, MONTHLY PREMIUM STATEMENT. If premiums are due monthly, a Monthly Premium ( Statement will be prepared as of the Premium Due Date. This Monthly Premium y.. Statement will show the premium due. If premiums are due quarterly, semiannually or annually, a Monthly Premium Statement will be prepared as of the Monthly Statement Date for the time from the Monthly Statement Date to the next Premium.Due Date. This Monthly Statement will reflect any pro rata premium charges and credits due, to changes in the number of insured persons and changes in insurance amounts that took place in the preceding month. SIMPLIFIED ACCOUNTING. To simplify the accounting process, premium adjustments will be made on the Monthly Statement Date that is the same as or next follows the date that (1)0 (2) or (3) below takes place. (1) A person becomes insured. (2) The amount of insurance on a person changes, but not due to a revision of The Schedule. (3) A person ceases to be insured. GM5800 34C1 Section 34 l� S CONNECTICUT GENERAL LIFE INSURANCE COMPANY PREMIUMS (Continued) MONTHLY PREMIUM RATE. The monthly premium rate is as follows: EMPLOYEE CLASS Each Employee RATE PER $1,000 FOR EMPLOYEE INSURANCE $ .06 CALCULATION OF PREMIUMS. The monthly premium will be the amount of Employee Insurance in force on the Premium Due Date in each rate class for Employee Insurance shown in the "Monthly Premium Bate" section multiplied by the premium rate in effect on that date for that class. If premiums are to be paid other than monthly, the method of calculation is the same. However, the rate for each class is first changed to a quarterly, semiannual or annual rate by multiplying it -by 2.9852, 5.9557 or 11.8227 respectively. All results are taken to the nearer cent. If the Policyholder and the Insurance Company agree to a change in the method of premium payment or to a change in the Anniversary Date, a pro rata adjustment will be made in the ( premium due. CHANGES IN PREMIUM RATES. Any premium rate may be changed by the Insurance Company from time to time with at least 31 days advance written notice. No change in rates will be made until 12 months after the Effective Date. An increase in rates will not be made more often than once in a 12 month period. If an increase in rates takes place on a date that is not a Premium Due Date, a pro rata premium will be due on the date of the increase. The pro rata premium will apply for the increase from the date of the increase to the next Premium Due Date. If a decrease in rates takes place on a date that is not a Premium Due Date, a pro rata credit will be granted. The pro rata credit will apply for the decrease from the date of the decrease to the next Premium Due Date, IN_ CM5800 34DD1 Section 34 N CONNECTICUT GENERAL LIFE INSURANCE COMPANY CANCELLATION OF POLICY The Policyholder may cancel the policy as of any Premium Due Date by giving written notice to the Insurance Company before that date. The Insurance Company may cancel the policy as of any Premium Due Date if the number of insured Employees is less than 25 or less than 75% of those eligible. If a premium is not paid when due, the policy will automatically be cancelled as of the Premium Due Date, except as set forth below. GRACE PERIOD. It, before a Premium Due Date, the Policyholder has not given written notice to the Insurance Company that the policy is to be cancelled, a Grace Period of 31 days will be granted for the payment of each premium after the initial premium. The policy will stay in effect during that time. If any premium is not paid by the end of the Grace Period, the policy will automatically be cancelled at the end of the Grace Period; except that, if the Policyholder has given written notice in advance of an earlier date of cancellation, the policy will be cancelled as of the earlier date. The Policyholder will be liable to the Insurance Company for any unpaid premium for the time the policy was in force. GM5800 36C1 section 36 V-1 CONNECTICUT GENERAL LIFE INSURANCE COMPANY MISCELLANEOUS PROVISIONS EXECUTION OF POLICY. The policy is executed at the Home Office of the Insurance Company. The Post Office address of the Insurance Company is Hartford, Connecticut. CONSIDERATION. The policy is issued to the Policyholder in consideration of the application and payment of premiums. INSURANCE DATA. The Policyholder will give the Insurance Company all of the data that it needs to calculate the premium and all other data that it may reasonably require. Failure of the Policyholder to give this data will not void or continue an Employee's insurance. The Insurance Company has the right to examine the Policyholder's records relative to these benefits at any reasonable time while the policy is in effect. It also has this right until all rights and obligations under the policy are finally determined. MALE PRONOUN. The male pronoun as used herein will be deemed to include the female. CM5800 38C1 Section 38 f �1 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PROVISIONS ENTIRE CONTRACT. The entire contract will be made up of the policy, the application of the Policyholder, a copy of which is attached to the policy, and the applications, if any, of the Employees. POLICY CHANGES. Changes may be made in the policy only by amendment signed by the Policyholder and by the Insurance Company acting through its President, Vice President, Secretary, or Assistant Secretary. No agent may change or waive any terms of the policy. STATEMENTS NOT WARRANTIES. All statements made by the Policyholder or by an insured Employee will, in the absence of fraud, be deemed representations and not warranties. No statement made by the Policyholder or by the Employee to obtain insurance will be used to avoid or reduce the insurance unless it is made in writing and is signed by the Policyholder or the Employee and a copy is sent to the Policyholder, the Employee or his Beneficiary. NOTICE OF CLAIM. Written notice of claim must be given to the Insurance Company within 30 days after the occurrence or start of the loss on which claim is based. If notice is not given in that time, the claim will not be invalidated or reduced if it is shown that written notice was given as soon as was reasonably possible. CLAIM FORMS. When the Insurance Company receives the notice of claim, it will give to the claimant, or to the Policyholder for the claimant, the claim forms it uses for filing proof of loss. If the claimant does not get these claim forms within 15 days after the Insurance Company receives notice of claim, he will be considered to have wet the proof of lots requirements if he submits written proof of loss within 90 days after the date of loss. This proof must describe the occurrence, character and extent of the loss for which claim is made. PROOF OF LOSS. Written proof of loss must be given to the Insurance Company within 90 days after the data of the loss for which claim is made. If written proof of loss is not given in that time, the claim will not be invalidated nor reduced if it is shown that written proof of loss was given as soon as was reasonably possible. PHYSICAL EXAMINATION. The Insurance Company, at its own expense, will have the right to examine any person for whom claim is pending as often as it may reasonably require. GH5800 40C1 Section 40 CONNECTICUT GENERAL LIFE INSURANCE COMPANY PROVISIONS (Continued) LEGAL ACTIONS. No action at law or in equity will be brought to recover on the policy until at least 60 days after proof of loss has been filed with the Insurance Company. No action will be brought at all unless brought within 3 years after the time within which proof of lose is required by the policy. TIME LIMITATIONS. If any time limit set forth in the policy for giving notice of claim or proof of loss, or for bringing any action at law or in equity is less than that permitted by the law of the state in which the Employee, lives when the policy is issued, than the time limit provided in the policy is extended to agree with the minimum permitted by the law of that state. PHYSICIAN/PATIENT RELATIONSHIP. The Employee will have the right to choose any physician who is practicing legally. The Insurance Company will in no way disturb the physician/patient relationship. CERTIFICATES. The Insurance Company will issue to the Policyholder for delivery to each insured Employee an individual certificate. The Policyholder will be responsible for distributing the certificates to its Employees. The certificate will show the benefits provided under the policy. It will set forth any changes in benefits due to age and to whom benefits will be paid. Nothing in the certificate will change or void the terms of the policy. G G145800 40C2 Section 40