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HomeMy WebLinkAboutC15-083 Lincoln National Life InsuranceLincoln Financial Group* November 17, 2014 Berniece Gutierrez Eagle County Government 500 Broadway Eagle, CO 81631 Re: Policy Number(s) 000400001000 000010149432 EAGLECNTY2 Dear Berniece Gutierrez: Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates Coverage(s) Voluntary Life Life and AD&D The Lincoln National Life Insurance Company 8801 Indian Hills Drive Omaha, NE 68114-4066 Toll free (800) 423-2765 www.LFG.com Amendment Effective Date(s) 01/01/2015 01/01/2015 Enclosed you will find amendments and revised policies. As requested, we have amended the above coverage's as follows: Life and AD&D Changed Class 1 description to "All Full -Time Employees working 30 hours per week; and Removed Class 2 for "Elected Officials" (Employees were moved to Class 1). Voluntary Life Changed Class 1 description to "All Full -Time Employees working 30 hours per week"; Removed Class 2 for "Elected Officials" (Employees were moved to Class 1); Added Class 4 for "All Participants with Approved Life Insurance Amounts under the Prior Carrier's Plan as of December 31, 2014"; Spouse Maximum Benefit for Class 1 changed to $50,000 with Guarantee Issue Amount changed to $50,000; Employee Maximum Benefit for Class 1 changed to $200,000. Please note that changes have been incorporated into your policies and certificates due to compliance updates. This does not change the original intent of your policy. Revised certificates are located on The Lincoln National Life Insurance Company website, www.lincoln4benefits.com. A supply of printed certificates can be requested from Client Services at the telephone number or email address below. It is very important that we receive a signed copy of the Amendment for our records. Please fax the signed copy to 877-573-6177. If we do not hear from you within 30 days, payment of the required premium will be considered acceptance of the amendment as issued. If you have any questions on this change, please feel free to contact your broker or Customer Service Professional at 800-423-2765, Option 2; or via email at ClientServicesnLFG.com. Thank you for giving The Lincoln National Life Insurance Company an opportunity to serve you. Sincerely, The Lincoln National Life Insurance Company Enclosures k-. AMENDMENT NO. 3 TO BE ATUCHED TO AND MADE PART OF GROUP POLICY NO.: 000400001000-14013 ISSUED TO: Eagle County Government The Participlation Agreement / Application is amended to reflect the following requested changes. The Amount of Personal Life Insurance and AD&D Insurance Principal Sum for Class 1, is amended to read: LIFE AND AD&D INSURANCE Personal Li& Insurance AD&D Insurance Principal Sum The Class Descriptions are amended to read: Benefit Amount You may elect Life Insurance in any $10,000 increment; subject to a maximum of Five times Basic Annual Earnings (rounded to the next higher $10,000). Coverage is subject to a minimum of $10,000 and an overall maximum of $200,000. If you initially become insured after attaining age 70 your benefit is subject to a maximum of $50,000. You may elect AD&D Insurance in any $10,000 increment; subject to a maximum of Five times Basic Annual Earnings (rounded to the next higher $10,000). Coverage is subject to a minimum of $10,000 and an overall maximum of $200,000. If you initially become insured after attaining age 70 your benefit is subject to a maximum of $50,000. Class 1- All Full -Time Employees working 30 hours per week Class 3- All participants with Approved Life Insurance Amounts under the Prior Carrier's Plan as of December 31, 2011 Class 4- All Participants with Approved Life Insurance Amounts under the Prior Carrier's Plan as of December 31, 2014 The effectiv( date of this amendment is January 1, 2015; but only with respect to losses incurred on or after that dat . Nothing contained in this amendment shall change any of the terms and conditions of this Policy; excel t as stated above. THE LINCOLN NATIONAL LIFE INSURANCE COMPANY C)_4 4, &a-t� Officer of the Company Accepted bythe Group Policyholder this 3rjday of 20 By Title GLI 100 AM D. J t r AMENDMENT NO. 1 TO BE ATTACHED TO AND MADE PART OF GROUP POLICY NO.: 000010149432 ISSUED TO: Eagle County Government It is agreed that the above policy be replaced with the attached Policy, which is revised and dated January 1, 2015. The effective date of this amendment is January 1, 2015; but only with respect to losses incurred on or after that date. Nothing contained in this amendment shall change any of the terms and conditions of this Policy; except as stated above. THE LINCOLN NATIONAL LIFE INSURANCE COMPANY 0.4 q, &J�2T Officer of the Company jkccepted�by the Group Policyholder ICW-1j&jfl1wA-mil LIr�� GLI 100 AMEND. day of Wu al Title 201 r] LiTIC0Thej�,� Lincoln National Life Insurance Company 111 A Stock Company Home Office Location: Fort Wayne, Indiana Finan dal Group- Group Insurance Service Office: 8801 Indian Hills Drive, Omaha, NE 681144066 (800) 423-2765 Online: www.Linco]nFinancial.com Group Policyh lder: Eagle County Government In Consideratioof the Group Policyholder's application for this Policy and payment of all premiums when due, The Lincoln N tional Life Insurance Company agrees to make the payments provided in this Policy to the persons entitle to them. The first premium for this Policy is due on its effective date. Subsequent premiums are due on February 1, 2012, and on the same day of each month after that. Policy anniversaries will be each January 161; unless shown otherwise on tho Premium Rate Schedule inside. The provisions and conditions set forth on the following pages are a part of this Policy, as fully as if recited over the signatures below. The Lincoln National Life Insurance Company has executed this Policy at its Group Insurance Service Office in Omaha, Nebraska. The issue date of this Policy is January 1, 2012. SECRETARY PRESIDENT GROUP INSURANCE POLICY No. 000010149432 PROVIDING LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE This Policy contains an Accelerated Death Benefit provision. Receipt of an Accelerated Death Benefit will reduce betlefits specified in this Policy. Accelerated Death Benefits may be taxable. As with all tax matters, the Insured Person should consult a professional tax advisor before applying for this benefit. Please read theLimitations section of the Accelerated Death Benefit included in this Policy. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. GL1101-TITLE PAGE 01/01/15 TABLE OF CONTENTS Scheduleof Insurance.............................................................................................................................................. 3 Definitions................................................................................................................................................................ 5 GeneralProvisions...................................................................................................................................................6 Eligibility and Effective Dates for Personal Insurance............................................................................................7 IndividualTerminations...........................................................................................................................................8 Continuationof Coverage........................................................................................................................................ 9 Premiumsand Premium Rates...............................................................................................................................10 GracePeriod...........................................................................................................................................................1 l PolicyTermination.................................................................................................................................................1 l Beneficiary.............................................................................................................................................................12 Assignments...........................................................................................................................................................13 Facility of Payment ............................. DeathBenefit......................................................................................................................................................... 14 SettlementOptions.................................................................................................................................................14 Extensionof Death Benefit....................................................................................................................................15 AcceleratedDeath Benefit.....................................................................................................................................17 ConversionPrivilege..............................................................................................................................................19 Claims Procedures for Life or Accidental Death and Dismemberment Benefits .................................................. 20 Accidental Death and Dismemberment Insurance.................................................................................................23 SafeDriver Benefit................................................................................................................................................ 29 Notice..................................................................................................................................................................... 30 Prior Insurance Credit Provision .................................. z� GL1101-1 2 Eagle County Government 000010149432 SCHEDULE OF INSURANCE ELIGIBLE CLASS Class 1 All Full -Time Employees working 30 or more hours per week The amount of an Insured Person's insurance is determined from the following table. The initial amount of coverage is thel amount which applies to an Insured Person's Class on the date his or her coverage takes effect. An Insured Person may become eligible for increases in the amount of insurance in accord with the table. Any such increase ill take effect on the latest of: (1) the fir t day of the Insurance Month coinciding with or next following the date on which the Insure Person becomes eligible for the increase; if Actively at Work on that day; (2) the da3 the Insured Person resumes Active Work, if not Actively at Work on the day the increase would therwise take effect; or (3) the day any required evidence of insurability is approved by the Company. Any decrease will take effect on the day of the change; whether or not the Insured Person is Actively at Work. The amount of an Insured Person's Life Insurance shall be reduced by the amount of any Life Insurance in effect as a result of exercising the rights under the Conversion Privilege section of this Policy. Facility of Payment Amount: $5,000 The following chart applies to the Extension of Death Benefit provision when benefits end upon attainment of the Social Secu ity Normal Retirement Age: Year of Birth Normal Retirement Age 1937 and prior 65 1938 65 and 2 months 1939 65 and 4 months 1940 65 and 6 months 1941 65 and 8 months 1942 65 and 10 months 1943-54 66 1955 66 and 2 months 1956 66 and 4 months 1957 66 and 6 months 1958 66 and 8 months 1959 66 and 10 months 1960 and later 67 Note: Persons born on January 1 of any year should refer to the Normal Retirement Age for the previous year. GLI 101-2 3 01/01/15 Eagle County Government 000010149432 SCHEDULE OF INSURANCE For Class 1- All Full -Time Employees working 30 or more hours per week NBNIMUM HOURS: 30 hours per week WAITING PERIOD: (For date insurance begins, refer to "Effective Date" section) 30 days of continuous Active Work CONTRIBUTIONS: Insured Persons are not required to make contributions for Personal Life & AD&D Insurance. Basic Annual Earnings means the Insured Person's annual base salary or annualized hourly pay from the Group Policyholder before taxes on the Determination Date. The "Determination Date" is the last day worked just prior to the loss. It does not include commissions, bonuses, overtime pay, or any other extra compensation. It does not include income from a source other than the Group Policyholder. It will not exceed the amount shown in the Group Policyholder's financial records or the amount for which premium has been paid; whichever is less. LIFE AND AD&D INSURANCE Benefit Amount Personal Life Insurance One times Basic Annual Earnings, rounded to the next higher $1,000; subject to a minimum of $50,000 and a maximum of $200,000. AD&D Insurance Principal Sum One times Basic Annual Earnings, rounded to the next higher $1,000; subject to a minimum of $50,000 and a maximum of $200,000. Personal Life and AD&D Insurance will be reduced as follows: - At age 65, benefits will reduce by 35% of the original amount; - At age 70, benefits will reduce an additional 20% of the original amount; - At age 75, benefits will reduce an additional 15% of the original amount; - At age 80, benefits will reduce an additional 10% of the original amount; - At age 85, benefits will reduce an additional 5% of the original amount; - At age 90, benefits will reduce an additional 5% of the original amount. Benefits will terminate when the Insured Person retires. If the Insured Person first enrolls for Personal Life and AD&D Insurance at age 65 or older, the above age reductions will apply to: - Any Guarantee Issue Amount available without evidence of insurability; and - The maximum amount of insurance for which he or she is eligible. GL1101-2 01/01/15 t�_ DEFINITIONS ACTIVE WO1tK or ACTIVELY AT WORK means an employee's full-time performance of all customary duties of his or her occupation at: (1) the GROUP POLICYHOLDER'S place of business; or (2) any other business location where the employee is required to travel. Unless disabled on the prior workday or on the day of absence, an employee will be considered Actively at Work on the following days: (1) a Saturday, Sunday or holiday which is not a scheduled workday; (2) a paid vacation day, or other scheduled or unscheduled non -workday; or (3) an excused or emergency leave of absence (except a medical leave). COMPANY means The Lincoln National Life Insurance Company, an Indiana corporation, whose Group Insurance Service Office address is 8801 Indian Hills Drive, Omaha, Nebraska 68114-4066. DAY OR DATE means at 12:01 A.M., Standard Time, at the GROUP POLICYHOLDER'S place of business; when used wit4 regard to eligibility dates and effective dates. It means 12:00 midnight, Standard Time, at the same place; when used with regard to termination dates. FULL-TIME EMPLOYEE means an employee of the GROUP POLICYHOLDER: (1) whose employment with the GROUP POLICYHOLDER is the employee's principal occupation; (2) who i$ not a temporary or seasonal employee; and (3) who is regularly scheduled to work at such occupation at least the Minimum Hours shown in the Schedule of Insurance. GROUP POLICYHOLDER means the person, partnership, corporation, or trust as shown on the Title Page of this Policy. INSURANCE MONTH means that period of time: (1) beginning at 12:01 A.M. Standard Time, at the GROUP POLICYHOLDER'S place of business on the:; first day of any calendar month; and (2) ending at 12:00 midnight on the last day of the same calendar month. INSURED PERSON means a PERSON for whom the coverages provided by this Policy are in effect. PERSON means a FULL-TIME EMPLOYEE of the GROUP POLICYHOLDER: (1) who is a member of an employee class which is eligible for coverage under this Policy; and (2) who lits completed an enrollment form. PERSONAL INfSURANCE means the insurance provided by this Policy on Insured Persons. PHYSICIAN means a licensed practitioner of the healing arts other than the Insured Person or a relative of the Insured Persona POLICY meansllthis Group Insurance Policy issued by the Company to the Group Policyholder. GLI 101-3 91 5 01/01/15 rx GENERAL PROVISIONS ENTIRE CONTRACT. The entire contract between the parties consists of: (1) this Policy and the Group Policyholder's application (a copy is attached); and (2) the Insured Persons' enrollment cards, if any. All statements made by the Group Policyholder and by Insured Persons are representations and not warranties. No statement made by an Insured Person will be used to contest the coverage provided by this Policy; unless: (1) it is contained in a written statement signed by that Insured Person; and (2) a copy of the statement is furnished to the Insured Person or Beneficiary. Only an Officer of the Company may change this Policy or extend the time for payment of any premium. No change will be valid unless made in writing and signed by an Officer of the Company. Any change so made will be binding on all persons referred,to in this Policy. INCONTESTABILITY. Except for the non-payment of premiums, the Company may not contest the validity of this Policy as to any Insured Person after it has been in force for two years during his or her lifetime. This clause will not affect the Company's right to contest claims made for disability, accidental death, or accidental dismemberment benefits. NONPARTICIPATION. This Policy will not be entitled to share in the surplus earnings of the Company. BASIS OF RESERVE. The reserve for this Policy will not be less than the reserve computed using: (1) the 1970 Intercompany Group Life Disability Valuation Table; and (2) interest at not less than three percent per annum. INFORMATION TO BE FURNISHED. The Group Policyholder may be required to furnish any information needed to administer this Policy. Clerical error by the Group Policyholder will not: (1) affect the amount of insurance which would otherwise be in effect; or (2) continue insurance which otherwise would be terminated. Once an error is discovered, an equitable adjustment in premium will be made. If a premium adjustment involves the return of unearned premium, the amount of the return will be limited to the twelve month period which precedes the date the Company receives proof such an adjustment should be made. The Company may inspect any of the Group Policyholder's records which relate to this Policy. MISSTATEMENT OF AGE. If an Insured Person's age has been misstated, premiums will be subject to an equitable adjustment. If the amount of benefit depends upon age; then the benefit will be that which would have been payable, based upon the person's correct age. CERTIFICATES. The Group Policyholder will be furnished with individual Certificates for delivery to each Insured Person. These certificates summarize the benefits provided by this Policy. If there is a conflict between the Policy and the Certificate, the Policy will control. CONFORMITY WITH STATE STATUTES. If any provision of this Policy conflicts with any applicable law, the provision will be deemed to conform to the minimum requirements of the law. WORKER'S COMPENSATION. This Policy is not to be construed to provide benefits required by Worker's Compensation laws. GL1101-4 95 01/01/15 ELIGIBILITY AND EFFECTIVE DATES FOR PERSONAL INSURANCE ELIGIBILITY. A Person becomes eligible for the coverage provided by this Policy on the later of: (1) the Policy's date of issue; or (2) the daite the Waiting Period is completed. WAITING PERIOD. (See Schedule of Insurance). EFFECTIVE TE. Personal Insurance becomes effective on the latest of. (1) the fi st day of the Insurance Month coinciding with or next following the date the Person beco es eligible for the coverage; (2) the to the Person resumes Active Work, if not Actively at Work on the day he or she beco es eligible; (3) the dale the Person makes written application for Personal Insurance; and signs: (a) it payroll deduction order, if Insured Persons pay any part of the Policy premium; or (b) an order to pay premiums from the Person's Section 125 Plan account, if Employer contributions are made through a Section 125 Plan; or (4) the date the Company approves the Person's coverage, if evidence of insurability is required. EVIDENCE OF INSURABILITY. Evidence of insurability satisfactory to the Company must be submitted when: (1) a Person makes written application for Personal Insurance more than 31 days after becoming eligible for the coverage; or (2) a Person makes written application for Personal Insurance after he or she has requested: (a) w cancel Personal Insurance; (b) w stop payroll deductions for the coverage; or (c) w stop premium payments from the Section 125 Plan account. EXCEPTIONS.!, If an Insured Person's coverage terminates due to an approved leave of absence or military leave, the Company will waive any Waiting Period or evidence of insurability requirement upon his or her return; provided: (1) the Person returns within six months after the leave begins; (2) the Pe#son applies or is enrolled within 31 days after resuming Active Work; and (3) the reinstated amount of insurance does not exceed the amount which terminated. If an Insured Person's coverage terminates due to a lay-off, the Company will waive any Waiting Period or evidence of insi rability requirement upon his or her return; provided: (1) the Pe son returns within 12 months after the date the lay-off begins; (2) the Pe son applies or is reenrolled within 31 days after resuming Active Work; and (3) the rei istated amount of insurance does not exceed the amount which terminated. Reinstatement will take effect on the date the Insured Person returns to Active Work. If an Insured Person's coverage terminates because his or her employment ends, the Company will waive any Waiting Period or evidence of insurability requirement upon his or her return; provided: (1) the Person is rehired within 12 months after employment terminated; (2) the Person applies or is reenrolled within 31 days after resuming Active Work; and (3) the reinstated amount of insurance does not exceed the amount which terminated. Reinstatement Will take effect on the date the Insured Person returns to Active Work. GL1101-5 93 (FMLA) 01/01/15 INDIVIDUAL TERMINATIONS An Insured Person's coverage will terminate on the earliest of: (1) the date this Policy terminates; (2) the last day of the Insurance Month in which the Insured Person requests termination; (3) the last day of the last Insurance Month for which premium payment is made on the Insured Person's behalf; (4) the date the Insured Person ceases to be in a class of employees which is eligible for coverage under this Policy; (5) with respect to any particular insurance benefit, the date the portion of the Policy providing that benefit terminates; (6) the date the Insured Person's employment with the Group Policyholder terminates; or (7) the date the Insured Person enters the armed services of any state or country on active duty; except for duty of 30 days or less for training in the Reserves or National Guard. (If the Insured Person sends proof of military service, the Company will refund any unearned premium.) Ceasing Active Work results in termination of insurance; but coverage may be continued as follows: (1) If the Insured Person is disabled due to illness or injury, then coverage may be continued until the earliest of. (a) 12 Insurance Months after the disability begins; (b) the date the Person is no longer disabled; or (c) for Life Insurance; the date the Insured Person qualifies for any Extension of Death Benefit under this Policy; provided premium payments are made on his or her behalf. (2) If the Insured Person ceases work due to a temporary lay off, an approved leave of absence, or a military leave; then coverage may be continued: (a) for three Insurance Months after the lay off or leave begins; (b) provided premium payments are made on his or her behalf. GL 1101-5 93 (FMLA) 01/01/15 CONTINUATION OF COVERAGE This section applies to any Basic Personal Life Insurance and Accidental Death and Dismemberment Insurance provided by this Policy. Such insurance may be continued for up to 36 months, by paying the required premiums, whein: (1) an In ured Person's employment with the Employer ends for a reason other than sickness or injury or retirement; and (2) the insurance has been in force for at least 12 months in a row just prior to the date emplcjyment ends. Continuation of insurance under this provision will follow any state required continuation or other continuation allowed under the Ceasing Active Work section of this Policy. To continue m* ance, written application and the first premium payment must be made to the Company, within 31 days of the date insurance would otherwise end. The Continuation of Coverage is not available when Policy coverage terminates solely because: (1) an Insured Person's Employer ceases to be a Participating Employer; or (2) this Policy terminates. For life insurance that terminates under this Policy due to an Insured Person's termination of membership in an eligible class; see the Conversion Privilege section of this Policy. AMOUNT OF COVERAGE. The amount of continued insurance may not exceed the amount in force when employment ends. During the continuation period the amount of insurance may not be increased. Continued insurance will * subject to any reduction on account of age, as shown in the Schedule of Insurance. The Insured Pelson may decrease the amount of continued insurance at any time, by completing a request form supplied by the Company. The decrease will take effect on the first day of the Insurance Month after the Company receives the request. PAYMENT OF PREMIUM. Timely payment of premium must be made directly to the Company, throughout the period of continued insurance. Premiums will be based on attained age as shown in the premium information provided with the application. A direct billing fee will be added to the premium based on the frequency chosen. The premium frequency may be changed by sending the Company advance written request on forms supplied by the Company. Such request may be sent at any time while continued insurance is in force, except during a Grace Period. TERMINATION OF COVERAGE. Continued insurance will end on the earliest of (1) the da this Policy terminates; (2) the lasday of the Insurance Month in which termination is requested; (3) the las day of the Insurance Month for which premium is paid; (4) the dat the Insured Person dies; (5) the da insurance would otherwise end had the Insured Person remained an Active Employee; (6) the dat insurance under this provision has been continued for 36 months; or (7) the da a the Insured Person enters the armed forces of any state or country on active duty; except I for duty of 30 days or less for training in the Reserves or National Guard. (If the Insured Person sends proof of military service, the Company will refund any unearned When continued insurance ends, the Insured Person may be entitled to purchase an individual life policy, in accord with the Conversion Privilege section of this Policy. GL1101-5.5 01 TG PORT (Life, AD&D) 9 01/01/15 PREMIUMS AND PREMIUM RATES PAYMENT OF PREMIUMS. No coverage provided by this Policy will be in effect until the first premium for such coverage is paid. For coverage to remain in effect, each subsequent premium must be paid on or before its due date. The Group Policyholder is responsible for paying all premiums as they become due. Premiums are payable on or before their due dates at the Company's Group Insurance Service Office. The premium must be paid in U.S. dollars. PREMIUM RATE CHANGE. The Company may change any premium rate on any of the following dates: (1) the date this Policy's terms are changed; (2) the date the Company's liability is changed due to a change in federal, state or local law; (3) the date the Group Policyholder (or any covered division, subsidiary or affiliated company) relocates, dissolves or merges, or is added to or removed from this Policy; (4) the date any coverage for one or more classes ceases to be provided under this Policy; (5) the date the number of Insured Persons changes by 25% or more from the enrollment on the date this Policy took effect, or the most recent Rate Guarantee Date expired, if later; or (6) on any premium due date on or after this Policy's first anniversary, or any later rate guarantee date agreed upon by the Company. Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 31 days' advance written notice of any increase in premium rates. PREMIUM .AMOUNT. The amount of premium due on each due date will be the sum of the products obtained by multiplying each rate shown in the Premium Rate Schedule by the amount of insurance to which the rate applies. Premium adjustments will not be pro -rated daily. Instead, premium will be adjusted as follows. (1) When an Insured Person's insurance or increase takes effect, premium will be charged from the monthly due date coinciding with or next following that change. (2) When all or part of an Insured Person's insurance terminates, the applicable premium will cease on the monthly due date coinciding with or next following that termination. (3) When premiums are paid other than monthly, increases or decreases will result in adjustment from the premium due date coinciding with or next following that change. The above manner of charging premium is for accounting purposes only. It will not extend coverage beyond a date it would have otherwise terminated. Each premium payment will include any adjustments in past premiums, which are needed due to changes that have not yet been taken into account. If a premium adjustment involves a return of unearned premium, the refund will be limited to the prior 12 -month period. Monthly Group Life Rate Monthly AD&D Rate PREMIUM RATE SCHEDULE $.12 per $1,000 of insurance $.03 per $1,000 of insurance The above rate or rates are guaranteed until January 1, 2015; unless an exception listed in the Premium Rate Change section applies. After that, any premium rate change will be as shown in the renewal letter. The Company will send the Group Policyholder a renewal letter prior to each Policy Anniversary. GLI 101-6 04 10 0110I115 GRACE PERIOD A grace period of 31 days from the due date will be allowed for the payment of each premium after the first. This Policy will remain in effect during the grace period; unless the Group Policyholder gives the Company advance written notice of termination. The Group Policyholder will remain liable for payment of a pro rata premium for the time this Policy remained in force during the grace period. POLICY TERMINATION TERMINATION BY THE COMPANY. To terminate this Policy, the Company must give the Group Policyholder at least 31 days' advance written notice of its intent to do so. The Company may terminate this Policy coverage on the due date of any premium; if: (1) the total number of Insured Persons is less than ten; (2) all of the premium is paid by the Group Policyholder and less than 100% of those eligible for coverage are insured; (3) part of the premium is paid by Insured Persons and less than 75% of those eligible for coverage are insured; (4) the Group Policyholder, without good cause, fails to: (a) promptly furnish any information the Company reasonably requires; or (b) perform its duties pertaining to this Policy in good faith; (5) the Company terminates all other policies where permitted by their terms, which provide life insurance or weekly disability income insurance in the same state in which this Policy was issued; or (6) state law otherwise requires this Policy to be terminated. TERMINATION BY GROUP POLICYHOLDER. The Group Policyholder may terminate this Policy at any time, by giving the Company advance written notice. Coverage will then terminate: (1) on the date the Company receives the notice; or (2) any later date the Group Policyholder and the Company have agreed upon. The Group Policyholder remains responsible for the payment of premiums to the date of termination. AUTOMATIC TERMINATION. If any premium remains unpaid at the end of the Grace Period; then this Policy will automatically terminate, without any action on the Company's part, on the last day of the Grace Period. The Group Policyholder remains responsible for the payment of premiums to the date of termination. EFFECT ON INCURRED CLAIMS. Termination of this Policy will not affect benefits otherwise payable for a claim incurred while this Policy is in force. GLI 101-7 04 No Bene. -ten lives 11 01101115 BENEFICIARY PAYMENTS TO BENEFICIARY. At an Insured Person's death, the amount of his or her Personal Life Insurance will be paid to the surviving Beneficiary. If the Insured Person has not named a Beneficiary, or if no named Beneficiary survives the Insured Person; then payment will be made to that Insured Person's: (1) surviving spouse; or, if none (2) surviving child or children in equal shares; or, if none (3) surviving parent or parents in equal shares; or, if none (4) surviving brothers and sisters in equal shares; or, if none (5) estate, or in accord with the Facility of Payment section of this Policy. The amount payable to anyone shown above will be reduced by any amount paid in accord with the Facility of Payment section. In determining who is to receive payment, the Company may rely upon an affidavit by a member of the class of relatives to receive payment. The Company will make payment based upon the affidavit it has; unless it receives notice of a valid claim by some other person, at its Group Insurance Service Office, before paying the proceeds. Such payment will release the Company from any further obligation for the Insured Person's life insurance benefit. If an Insured Person's named Beneficiary dies: (1) within 15 days of the Insured Person's death; and (2) before the Company receives satisfactory proof of the Insured Person's death; then payment will be made as if the Insured Person had survived that Beneficiary; unless other provisions have been made. NAMING THE BENEFICIARY. An Insured Person's Beneficiary will be as shown on his or her enrollment card, unless changed. This Policy may replace a group policy providing similar coverages.. In that event, the Beneficiary which the Insured Person named under the prior policy will be the Beneficiary under this Policy, until changed. CHANGING THE BENEFICIARY. Only the Insured Person, or his or her assignee, may change the Beneficiary. A new Beneficiary may be named by filing a written notice of the change with the Company at its Group Insurance Service Office. The change will be effective as of the date it was signed; subject to any action the Company takes before receiving notice of the change. When applying for a conversion policy under the Conversion Privilege Section, an Insured Person must name a Beneficiary. The Beneficiary named for the conversion policy may be someone other than the person named under this Policy. In that event, the application for the conversion policy will be treated as a written notice of change of Beneficiary. GLI 101-7.1A 96 12 Pref. Bene 01/01/15 ASSIGNMENTS Personal Life Insurance and Accidental Death Insurance may be assigned. The assignments allowed under this Policy are absolute assignments and funeral assignments as described below. No assignment will be binding on the Company unless and until: (1) it is roade on a form furnished by the Company; (2) the o>tiginal is completed and filed with the Company at its Group Insurance Service Office; and (3) it is aproved by the Company. The Company and the Group Policyholder do not assume responsibility for the validity or effect of an assignment. ABSOLUTE AiSSIGNMENTS. An Insured Person may make an irrevocable assignment of his or her Personal Life Insurance and Accidental Death Insurance as a gift (with no consideration), providing he or she has the legal capacity 8nd the mental capacity to do so. It may be made to a trust or to one or more of the Insured Person's relatives, their estates, or to a trustee of a trust under which one of the relatives is a beneficiary. The term "relatives" includes, but is not limited to, an Insured Person's spouse, parents, grandparents, aunts, uncles, sibling% children, adopted children, stepchildren, and grandchildren. In some states, community property is an established form of ownership that must be considered in making an assignment. If an Insured Person makes an absolute assignment to two or more assignees, such assignees will be joint owners with the right of survivorship between them. An Insured Person should consult with his or her own legal advisor before making an assignment. Once the assignment has been recorded by the Company, the Insured Person can no longer change the beneficiary anq cannot apply for conversion. Only the assignee can change the beneficiary designation if the previous desiation is revocable. An assignment will have no effect on a prior irrevocable beneficiary designation. Inly the assignee can apply for conversion but only when the Conversion Privilege provision would have been available to the Insured Person in the absence of the assignment under this Policy. An absolute assignment cannot be used as a collateral assignment. FUNERAL ASSIGNMENTS. Upon an Insured Person's death, the beneficiary may assign the Personal Life Insurance bene t and Accidental Death Insurance benefit to a funeral home for payment of burial expenses. After payment ]has been made for the burial expenses to the assigned funeral home, the remaining death benefit is then paid in accord with the Beneficiary and Settlement Options sections of this Policy. GL1101-7.1C 01 13 01/01/15 FACILITY OF PAYMENT Policy benefits may become payable to an Insured Person's estate, to a minor, or to a person who the Company does not consider competent to give a valid release. In that event, the Company has the option to pay one or more of the following: (1) a person who has assumed the care and support of the Insured Person or Beneficiary; (2) a person who has incurred expense as a result of the Insured Person's last illness or death; (3) the personal representative of the Insured Person's estate; or (4) any person related by blood or marriage to the Insured Person. No payment made under this section may exceed the Facility of Payment Amount shown in the Schedule of Insurance. Any payment made in good faith under this section will fully discharge the Company to the extent of the payment. Any remaining amount of benefit will be paid as shown in the Beneficiary section. DEATH BENEFIT AMOUNT PAYABLE ON DEATH. Upon receipt of satisfactory proof of an Insured Person's death, the Company will pay a death benefit equal to the amount of Personal Life Insurance in effect on the date of death. This amount is shown in the Schedule of Insurance. The benefit will be paid as shown in the Beneficiary, Facility of Payment, and Settlement Options sections. EXCLUSION. Benefits will not be payable if the Insured Person's death: (1) results from suicide, while sane or insane; and (2) occurs within one year after the Insured Person's Personal Life Insurance or an increased amount of insurance takes effect under the Policy (or under any prior group life insurance policy which the Policy replaced within 31 days of the prior plan's termination date). This exclusion will apply only to that amount of insurance or increase which was issued subject to evidence of insurability, within the one year prior to the Insured Person's death. SETTLEMENT OPTIONS INSTALLMENTS. All or part of the death benefit may be received in installments, by making written election to the Company. ELECTION. While living, an Insured Person may direct the Company to pay the death benefit in installments. If no such direction is in effect at the time of the Insured Person's death, the Beneficiary may make such an election. CONDITIONS. Any election, whether by an Insured Person or a Beneficiary, must comply with the Company's practices at the time it is made. The amount applied under a settlement option must be at least $2,000. It must be sufficient to provide a payment of at least $20 per month. GL 1101-8 97 CO Death Ben. & Suicide Excl. 14 01/01/15 EXTENSION OF DEATH BENEFIT BENEFIT. Lil b insurance will be continued, without payment of premiums, for an Insured Person who: (1) becor. Totally Disabled while insured under this policy and before reaching age 60; (2) remaiias Totally Disabled for at least 6 months in a row; and (3) submits satisfactory proof within the 7th through the 12th months of disability; or: (a) as soon as reasonably possible after that; but (b) not later than the 24th month of disability, unless he or she was legally incapacitated. PREMIUM PAYMENT. Premium payments must continue until: (1) the dzjy the Insured Person is approved for this Extension of Death Benefit; or (2) the daffy this Policy terminates (whichever occurs first). Upon receipt of satisfactory proof, the Company will refund up to 12 months' premium paid for the Insured Person's life insurance, from the 1 st day of Total Disability. DEFINITION. For this benefit, Total Disability or Totally Disabled means an Insured Person: (1) is unable, due to sickness or injury, to engage in any employment or occupation for which such Insurod Person is or becomes qualified by reason of education, training, or experience; and (2) is not engaging in any gainful employment or occupation. AMOUNT CONTINUED. The life insurance continued by this section: (1) will be the amount of Personal Life Insurance and any Dependent Life Insurance in effect on the day the Insured Person's Total Disability begins; and (2) will bt subject to the reductions and terminations in effect under this Policy on that day. If the Insured Person receives an Accelerated Death Benefit, the amount will be reduced in accord with that provision. Any Accidental Death and Dismemberment Benefit will not be continued. ADDITIONAL PROOF. At any time during this continuation, the Company may require the Insured Person: (1) to submit further proof of his or her continued Total Disability; and (2) to be c'xamined by a Physician of the Company's choice, as often as reasonably necessary. After the first r vo years of Total Disability, the Company will not request proof or an exam more than once a year. Proof wil I be at the Insured Person's expense; unless the Company requests an exam by a Physician of its choice. When an Inured Person dies after submitting proof, further proof must be submitted to the Company showing that he or she remained continuously and Totally Disabled until death. When an Insured Person dies within 12 months after Total Disability begins, but before submitting proof, then his or her death benefit will still be paid under the terms' of this Policy. But the Company must first receive satisfactory proof of his or her continuous Total Disability, from the last day of Active Work until the date of death. TERMINATION. Any life insurance extended under this section will terminate automatically on: (1) the dad the Insured Person ceases to be Totally Disabled; (2) the da the Insured Person fails to take a required medical examination; (3) the 60 day after the Company mails a request for additional proof, if it is not given; (4) the a ctive date of the Insured Person's individual conversion policy, with respect to any ammo of life insurance converted in accord with the Conversion Privilege section; or (5) the da the Insured Person reaches Social Security Normal Retirement Age (SSNRA), as shown in the Schedule of Insurance (whichever occurs first). RIGHTS AFTER TERMINATION. If Total Disability ends, and the Insured Person does not return to a class eligible for Policy coverage; then he or she may exercise the Conversion Privilege. If Total Disability ends, and the Insured Person does return to an eligible class; then his or her Policy coverage will resume when premium payments are resumed, and any conversion policy is surrendered as provided below. GLI 101-9 96 15 Stand. Ext. — SSNRA 01/01/15 EXTENSION OF DEATH BENEFIT (Continued) CONVERSION POLICIES. If the Insured Person has exercised the Conversion Privilege, and the benefits payable under this Policy and the conversion policy combined would exceed: (1) the Insured Person's original amount of Policy coverage prior to the conversion; or (2) any greater amount for which he or she later becomes insured under this Policy; then benefits will be payable under the terms of this Policy. But the conversion policy must first be surrendered to the Company; and no claim may be made under the conversion policy, except for refund of premium less any dividends and policy loans. GL 1101-9 96 16 Stand. Ext. SSNRA 01/01/15 ACCELERATED DEATH BENEFIT BENEFIT. Thr, Accelerated Death Benefit is an advance payment of part of the Insured Person's Personal Life Insurance. It ay be paid to the Insured Person, in a lump sum, once during the Insured Person's lifetime. To qualify, a Terminal Insured Person must: (1) have satisfied the Active Work requirement under this Policy; (2) have been insured under this Policy for at least 12 months; and (3) have at least $2,000 of Personal Life Insurance under this Policy on the day before the Accelierated Death Benefit is paid. Receiving the ;Accelerated Death Benefit will reduce the Remaining Life Insurance and the Death Benefit payable at death, as shown on the next page. "Claimant," as Used in this section, means the Terminal Insured Person for whom the Accelerated Death Benefit is requested. "Terminal" meons the Insured Person has a medical condition which is expected to result in death within 12 months, despito appropriate medical treatment. APPLYING FOR THE BENEFIT. To withdraw the Accelerated Death Benefit, the Insured Person (or his or her legal representative) must send the Company: (1) written election of the Accelerated Death Benefit, on forms supplied by the Company; and (2) satisfactory proof that the Claimant is Terminal, including a Physician's written statement. The Company deserves the right to decide whether such proof is satisfactory. Before paying jan Accelerated Death Benefit, the Company must also receive the written consent of any irrevocable beneficiary, assignee or bankruptcy court with an interest in the benefit. (See Limitations 3, 4 and 5.) NOTE: THI IS NOT A LONGTERM CARE POLICY. RECEIVING THIS ACCELERATED DEATH BEN FIT WILL REDUCE THE BENEFIT PAYABLE AT DEATH. ANY AMOUNT WITHDRAW MAY BE TAXABLE INCOME, SO THE INSURED PERSON SHOULD CONSULT A TAX ADVISOR BEFORE APPLYING FOR THIS BENEFIT. AMOUNT OF THE BENEFIT. The Insured Person may elect to withdraw an Accelerated Death Benefit in any $1,000 increment; subject to: (1) a min um of $1,000 or 10% of the Claimant's amount of Life Insurance (whichever is greate ); and (2) a max mum of $500,000 or 75% of the Claimant's amount of Life Insurance (whichever is less). To determine the Accelerated Death Benefit, the Company will use the lesser of A or B below: A. the Cl imant's amount of Life Insurance which is in force on the day before the Accelerated Death 3enefit is paid; or B. the Cl imant's amount of Life Insurance which would be in force 12 months after that date; if the coverage is scheduled to reduce, due to age, within 12 months after the Accelerated Death Benefi is paid. CHARGE: NONE WITHDRAWAL FEE: NONE GL1101-9.8 01 v 17 ADB 01101/15 ACCELERATED DEATH BENEFIT (Continued) EFFECT ON AMOUNT OF LIFE INSURANCE. "Remaining Life Insurance" means the amount of Life Insurance which remains in force on the Claimant's life after an Accelerated Death Benefit is paid. The Remaining Life Insurance will equal: (1) the Claimant's amount of Life Insurance which was used to determine the Accelerated Death Benefit (A or B above); minus (2) any percentage by which the Claimant's coverage is scheduled to reduce, due to age; if the reduction occurs more than 12 months after the Accelerated Death Benefit is paid, and while he or she is still living; minus (3) the amount of the Accelerated Death Benefit withdrawn. PREMIUM: There is no additional charge for this benefit. Continuation of the. Remaining Life Insurance will be subject to timely payment of the premium for the reduced amount; unless the Insured Person qualifies for waiver of premium under this Policy's Extension of Death Benefit provision, if included. CONDITIONS. If the Claimant exercises the Conversion Privilege after an Accelerated Death Benefit is paid, the amount of the conversion policy will not exceed the amount of his or her Remaining Life Insurance. If the Claimant has Accidental Death and Dismemberment benefits under this Policy, the Principal Sum will not be affected by the payment of an Accelerated Death Benefit. EFFECT ON DEATH BENEFIT. When the Claimant dies after an Accelerated Death Benefit is paid, the amount of Remaining Life Insurance in force on the date of death will be paid as a Death Benefit. The Insured Person's Death Benefit will be paid in accord with the Beneficiary section of this Policy. If the Claimant dies after application for an Accelerated Death Benefit has been made, but before the Company has made payment; then the request will be void and no Accelerated Death Benefit will be paid. The amount of Life Insurance in force on the date of death will be paid in accord with Policy provisions. EFFECT ON TAXES AND GOVERNMENT BENEFITS. Any Accelerated Death Benefit amount withdrawn may be taxable income to the Insured Person. Receipt of the Accelerated Death Benefit may also affect the Claimant's eligibility for Medicaid, Supplemental Security Income and other government benefits. The Claimant should consult his or her own tax and legal advisor before applying for an Accelerated Death Benefit. The Company is not responsible for any tax owed or government benefit denied, as a result of the Accelerated Death Benefit payment. LIMITATIONS. No Accelerated Death Benefit will be paid: (1) if any required premium is due and unpaid; (2) on any conversion policy purchased in accord with the Conversion Privilege; (3) without the written approval of the bankruptcy court, if the Insured Person has filed for bankruptcy; (4) without the written consent of the beneficiary, if the Insured Person has named an irrevocable beneficiary; (5) without the written consent of the assignee, if the Insured Person has assigned his or her rights under this Policy; (6) if any part of the Life Insurance must be paid to the Insured Person's child, spouse or former spouse; pursuant to a legal separation agreement, divorce decree, child support order or other court order; (7) if the Claimant is Terminal due to a suicide attempt, while sane or insane; or due to an intentionally self-inflicted injury; (8) if a government agency requires the Insured Person or the Claimant to use the Accelerated Death Benefit to apply for, receive or continue a government benefit or entitlement; or (9) if an Accelerated Death Benefit has been previously paid for the Claimant under this Policy. GL 1101-9.8 01 ADB 18 01/01/15 CONVERSION PRIVILEGE - CONVERSION BENEFITS GENERAL BENEFIT. An individual life policy, known as a conversion policy, may be purchased from the Company without evidence of insurability if all or part of anyone's life insurance, provided by this Policy, terminates for any reason except: (1) termination or amendment of the Policy; or (2) the Insured Person's request for: (a) termination of insurance; or (b) Oancellation of payroll deduction. To purchase a 0onversion policy, application and payment of the first premium must be made within 31 days after the life insurance is terminated. Any policy issued under the General Conversion Benefit will: (1) be for an amount not to exceed the amount of the life insurance which was terminated; (2) be on I any form (except term) then issued by the Company at the age and amount for which application is made; (3) be issued at the Insured Person's age at nearest birthday; (4) be issued without disability or other supplemental benefits; and (5) requiro premiums based on the class of risk to which the person then belongs. CONVERSION BENEFIT -POLICY TERMINATION OR AMENDMENT. A conversion policy also may be purchased from the Company if. (1) all or a part of anyone's insurance terminates due to amendment or termination of this Policy; and (2) that person has been covered continuously under this Policy for at least five years. Any conversion policy issued due to Policy termination or amendment will be subject to the same conditions as a policy issued i inder the General Conversion Benefit except its amount may not exceed the lesser of - (1) f(1) $10,0(0; or (2) the Ar iount of Life Insurance which terminates less the amount of any group life insurance for which the Insured Person becomes eligible within 31 days after the termination. PROVISIONS APPLICABLE TO ALL CONVERSION POLICIES EFFECTIVE DATES. The coverage provided by a conversion policy issued under this Section will be effective on the later of (1) its date of issue; or (2) 31 days after the date on which the person's life insurance terminated. DEATH DURING CONVERSION PERIOD. The Company will pay a death benefit under this Policy equal to the amount of the life insurance which could have been converted, if the person: (1) wase rtled to purchase a conversion policy; and (2) dies within the 31 day conversion period. This death benefit will be paid even if no one applied for the conversion policy. If the first premium was paid for the conversion policy, the amount of the premium will be refunded and the conversion policy will be void. NOTICE OF CONVERSION PRIVILEGES -INSURED PERSONS. When an Insured Person's Personal Insurance terminates, written notice of the right to convert will be: (1) given I iersonally to the Insured Person; (2) mailed by the Group Policyholder to the Insured Person at his last known address; or (3) mailed i by the Company to the Insured Person at his last known address as furnished by the Group policyholder. An additional p od in which to convert will be granted if this written notice is not given to the Insured Person at least 15 daysefore the end of the 31 day conversion period. Any such extension of the conversion period will expire on th earliest of (1) 15 day4 after the Insured Person is given the written notice; or (2) 60 day$ after the end of the 31 day conversion period even if the Insured Person is never given such notice. No death benefit will be payable under this Policy after the 31 day conversion period has expired even though the right to convert may be extended. GLI 101-10 DEP. 19 01/01/15 CLAIMS PROCEDURES FOR LIFE OR ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS NOTE: This Policy may include an Extension of Death Benefit, an Accelerated Death Benefit or a Living Benefit. If so, please refer to that section for special claim procedures. NOTICE AND PROOF OF CLAIM Notice of Claim. Written notice of an accidental death or dismemberment claim must be given within 20 days after the loss occurs; or as soon as reasonably possible after that.* The notice must be sent to the Company's Group Insurance Service Office. It should include: (1) the Insured Person's name.and address; and (2) the number of this Policy. Claim Forms. When notice of claim is received, the Company will send claim forms for filing the required proof. If the Company does not send the forms within 15 days;. then the Insured Person or Beneficiary (the claimant) may send the Company written proof of claim in a letter. It should state the nature, date and cause of the loss. Proof of Claim. The Company must be given written proof of claim within 90 days after the date of the loss; or as soon as reasonably possible after that.* Proof of claim must be provided at the claimant's own expense. It must show the nature, date and cause of the loss. In addition to the information requested on the claim form, documentation must include: (1) A certified copy of the death certificate, for proof of death. (2) A copy of any police reportjor proof of accidental death or dismemberment. (3) A signed authorization for the Company to obtain more information. (4) Any other items the Company may reasonably require in support of the claim. * Exception: Failure to give notice or furnish proof of claim within the required time period will not invalidate or reduce the claim; if it is shown that it was done: (1) as soon as reasonably possible; and (2) in no event more than one year after it was required. These time limits will not apply while the claimant lacks legal capacity. EXAM OR AUTOPSY. At anytime while a claim is pending, the Company may have the Insured Person examined: (1) by a Physician of the Company's choice; (2) as often as reasonably required. If the Insured Person fails to cooperate with an examiner or fails to take an exam, without good cause; then the Company may deny benefits, until the exam is completed. In case of death, the Company may also have an autopsy done, where it is not forbidden by law. Any such exam or autopsy will be at the Company's expense. TIME OF PAYMENT OF CLAIMS. Any benefits payable under this Policy will be paid immediately after the Company receives complete proof of claim and confirms liability. TO WHOM PAYABLE Death. Any benefits payable for the Insured Person's death will be paid in accord with the Beneficiary, Facility of Payment, and Settlement Options sections of this Policy. If this Policy includes Dependent Life Insurance; then any benefits payable for an insured Dependent's death will be paid to: (1) the Insured Person, if he or she survives that Dependent; or (2) the Insured Person's Beneficiary, or in accord with the Facility of Payment section; if the Insured Person does not survive that Dependent. Dismemberment. If this Policy includes Accidental Death and Dismemberment Benefits; then any benefit, other than the Insured Person's death benefit, will be paid to the Insured Person. GLI 101-13A 02 L/ADD 20 01/01/15 CLAIMS PROCEDURES (Continued) NOTICE OF CLAIM DECISION. The Company will send the claimant a written notice of its claim decision. If the ompany denies any part of the claim; then the written notice will explain: (1) the re son for the denial, under the terms of this Policy and any internal guidelines; (2) how a claimant may request a review of the Company's decision; and (3) whetl*r more information is needed to support the claim. The Company will send this notice within 15 days after resolving the claim. If reasonably possible, the Company willend it within: (1) 90 days after receiving the first proof of a death or dismemberment claim; or (2) 45 days after receiving the first proof of a claim for any Extension of Death Benefit, Living Benefit or Accelerated Death Benefit available under this Policy. Delay Notice.f the Company needs more than 15 days to process a claim, in a special case; then an extension will be permitted. If needed, the Company will send the claimant a written delay notice: (1) by the 15th day after receiving the first proof of claim; and (2) every 30 days after that, until the claim is resolved. The notice will explain the special circumstances which require the delay, and when a decision can be expected. In any event, the Company must send written notice of its decision within: (1) 180 dalys after receiving the first proof of a death or dismemberment claim; or (2) 105 days after receiving the first proof of a claim for any Extension of Death Benefit, Living Benefit or Accelerated Death Benefit available under this Policy. If the Company fails to do so; then there is a right to an immediate review, as if the claim was denied. Exception: If the Company needs more information from the claimant to process a claim; then it must be supplied within 45 days after the Company requests it. The resulting delay will not count towards the above time limits for claim processing. REVIEW PROCEDURE. The claimant may request a claim review, within: (1) 60 day1s after receiving a denial notice of a death or dismemberment claim; or (2) 180 days after receiving a denial notice of a claim for any Extension of Death Benefit, Living Benefit or Accelerated Death Benefit available under this Policy. To request a review, the claimant must send the Company a written request, and any written comments or other items to support the claim. The claimant may review certain non -privileged information relating to the request for review. Notice of Decision. The Company will review the claim and send the claimant a written notice of its decision. The notice will explain the reasons for the Company's decision, under the terms of this Policy and any internal guidelines. If thle Company upholds the denial of all or part of the claim; then the notice will also describe: (1) any er appeal procedures available under this Policy; (2) the ri t to access relevant claim information; and (3) the rig t to request a state insurance department review, or to bring legal action. For a death or request for revi Death Benefit, within 45 days more time. ,memberment claim, the notice will be sent within 60 days after the Company receives the ; or within 120 days, if a special case requires more time. For a claim for any Extension of ring Benefit or Accelerated Death Benefit available under this Policy, the notice will be sent er the Company receives the request for review; or within 90 days, if a special case requires GL 1101-13A 02 L/ADD 21 01/01/15 CLAIMS PROCEDURES (Continued) Delay Notice. If the Company needs more time to process an appeal, in a special case; then it will send the Insured Person a written delay notice, by the 3011' day after receiving the request for review. The notice will explain: (1) the special circumstances which require the delay; (2) whether more information is needed to review the claim; and (3) when a decision can be expected. Exception: If the Company needs more information from the claimant to process an appeal; then it must be supplied within 45 days after the Company requests it. The resulting delay will not count towards the above time limits for appeal processing. Claims Subject to ERISA (Employee Retirement Income Security Act of 1974). Before bringing a civil legal action under the federal labor law known as ERISA, an employee benefit plan participant or beneficiary must exhaust available administrative remedies. Under this Policy, the claimant must first seek two administrative reviews of the adverse claim decision, in accord with this section. If an ERISA claimant brings legal action under Section 502(a) of ERISA after the required reviews; then the Company will waive any right to assert that he or she failed to exhaust administrative remedies. RIGHT OF RECOVERY. If benefits have been overpaid on any claim; then full reimbursement to the Company is required within 60 days. If reimbursement is not made; then the Company has the right to: (1) reduce future benefits until full reimbursement is made; and (2) recover such overpayments from the Insured Person, or from his or her Beneficiary or estate. Such reimbursement is required whether the overpayment is due to fraud, the Company's error in processing a claim, or any other reason. LEGAL ACTIONS. No legal action to recover any benefits may be brought until 60 days after the required written proof of claim has been given. No such legal action may be brought more than three years after the date written proof of claim is required. COMPANY'S DISCRETIONARY AUTHORITY. Except for the functions that this Policy clearly reserves to the Group Policyholder or Employer, the Company has the authority to: (1) manage this Policy and administer claims under it; and (2) interpret the provisions and resolve questions arising under this Policy. The Company's authority includes (but is not limited to) the right to: (1) establish and enforce procedures for administering this Policy and claims under it; (2) determine Employees' eligibility for insurance and entitlement to benefits; (3) determine what information the Company reasonably requires to make such decisions; and (4) resolve all matters when a claim review is requested. Any decision the Company makes, in the exercise of its authority, shall be conclusive and binding; subject to the Insured Person's or Beneficiary's rights to: (1) request a state insurance department review; or (2) bring legal action. GLI 101-13A 02 L/ADD 22 01/01/15 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE DEATH OR DISMEMBERMENT BENEFIT FOR AN INSURED PERSON. The Company will pay the benefit listed below, if (1) an Insured Person sustains an accidental bodily injury while insured under this provision; and (2) that injury directly causes one of the following losses within 365 days after the date of the accidont. The loss must result directly from the injury and from no other causes. LOSS Loss of Life Loss of One Member (Hand, Foot or Eye) Loss of Two or More Members BENEFIT FOR COMMON BENEFIT FOR OTHER CARRIER ACCIDENT COVERED ACCIDENT 2 Times Principal Sum Principal Sum 2 Times Principal Sum Quadriplegia (paralysis of Both Arms and Both Legs) 2 Times Principal Sum Paraplegia (Paralysis of Both Legs) Principal Sum Hemiplegia (Paralysis of Arm and Leg of Same Side) Principal Sum Principal Sum Principal Sum Principal Sum Principal Sum '/z Principal Sum Principal Sum The Principal Som for the Insured Person's class is shown in the Schedule of Insurance. MAXIMUM PER PERSON. If an Insured Person sustains more than one loss resulting from the same accident, the benefit: (1) will bO the one largest amount listed; (2) will not exceed two times the Principal Sum for all of that person's combined losses resulting from 4 Common Carrier Accident; and (3) will n�t exceed the Principal Sum for all that person's combined losses resulting from any other covered accident. TO WHOM PAYABLE. Benefits for the Insured Person's loss of life will be paid in accord with the Beneficiary section. All other benefits will be paid to the Insured Person. LIMITATIONS. Benefits are not payable for any loss to which a contributing cause is: (1) intentional self-inflicted injury or self-destruction; (2) diseas¢, bodily or mental infirmity, or medical or surgical treatment of these; (3) participation in a riot; (4) duty as a member of any military, naval or air force; (5) war ori any act of war, declared or undeclared; (6) participation in the commission of a felony; (7) voluntary use of drugs; except when prescribed by a Physician; (8) volunt$ry inhalation of gas, including carbon monoxide; (9) travel or flight in any aircraft, including balloons and gliders; except as a fare paying passenger on a r ularly scheduled flight; or (10) driving a vehicle while intoxicated. GLI 101-14.3A 01 COMMON CARRIER - PAR, REPAT 23 01/01/15 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE CONTINUED DEFINITIONS. "Beneficiary" means the person(s) named on the Insured Person's enrollment form. The Insured Person may change the Beneficiary by filing a written notice of the change with the Company at its Group Insurance Service Office. "Common Carrier Accident" means a covered accidental bodily injury, which is sustained while riding as a fare paying passenger (not a pilot, operator or crew member) in or on, boarding or getting off from a Common Carrier. "Common Carrier" means any land, air or water conveyance operated under a license to transport passengers for hire. "Intoxicated" shall be defined by the jurisdiction where the accident occurs. The exclusion will apply whether or not the driver is convicted. "Loss of a Member" includes the following: (1) "Loss of Hand or Foot," means complete severance through or above the wrist or ankle joint. (In South Carolina, "Loss of Hand" can also mean the loss of four whole fingers from one hand.) (2) "Loss of an Eye," means total and irrevocable loss of sight in that eye. "Paralysis" means complete and irreversible loss or use of an arm or leg (without severance). REPATRIATION BENEFIT. The Company will pay a Repatriation Benefit, if - (1) f(1) the Insured Person dies as a result of a covered accident at least 150 miles from his or her principal place of residence; and (2) expense is incurred for the preparation and transportation of ,the Insured Person's body to a mortuary. This benefit will be in addition to all other benefits payable under this Policy. This benefit will equal the expenses incurred for the preparation and transportation of the Insured Person's body to a mortuary subject to a maximum of $5,000. This benefit will be paid: (1) when the benefit for accidental loss of life is paid; or (2) when the Company receives proof of expense incurred, if later. PROOF. In order for this benefit to be payable, proof of payment for any expenses incurred for Repatriation must be provided to the Company. TO WHOM PAYABLE. Benefits for Repatriation will be paid in accord with the Beneficiary and/or Facility of Payment sections of this Policy. Benefits will not be payable for any loss excluded under the Accidental Death and Dismemberment Insurance Limitations section. GLI 101-143A 01 COMMON CARRIER - PAR, REPAT 24 01/01/15 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE CONTINUED EDUCATION BENEFIT. The Company will pay an Education Benefit for each of the Insured Person's eligible Dependent Children, if the Insured Person: (1) is injured in a covered accident while insured under this Policy; (2) dies as a direct result of such injuries within 365 days after the accident; and (3) is survived by one or more Dependent Children who are eligible for the benefit. To be eligible tor the Education Benefit, a Dependent Child: (1) must be dependent on the Insured Person for principal support; (2) must be enrolled as a Full -Time Student on the date of the Insured Person's death or within 365 days after that date; and (3) must incur expenses after the date of the Insured Person's death for tuition, fees, books, room and board, or any other costs payable directly to (or approved and certified by) that school. This benefit will be paid in addition to all other benefits payable under this Policy. The benefit will equal the actual expense incurred after the date of the Insured Person's death up to 5% of the Insured Person's Principal Sum, subject to a maximum of $5,000 for each eligible Dependent Child per year, for up to 4 consecutive years or until age 25. The benefit will be paid to the Dependent Child, if the child has reached the age of majority. Otherwise, benefits will be paid to the child's legal guardian. The first payment will be made: (1) when the benefit for accidental loss of life is paid; or (2) when the Company receives proof of payment for the expenses incurred and that an eligible Dependent Child meets the above requirements, if later. Subsequent paylments will be made when the Company receives: (1) verifi0ation that the eligible Dependent Child continues to be a Full -Time Student during each additional semester/year; and (2) proof Of payment for the expenses incurred. "Full -Time Student" means a Dependent Child who: (1) is attending a licensed or accredited college, university or vocational school (beyond the 12th grade); (2) is considered a full-time student based upon that school's standards; and (3) incurs expenses for tuition, fees, books, room and board, or other costs payable directly to (or approved or certified by) that school. "Child" includes the Insured Person's naturally born child, legally adopted child, stepchild, and foster child. SPOUSE TRAINING BENEFIT. The Company will pay a Spouse Training Benefit to the Insured Person's surviving SpousMe, if the Insured Person: (1) is injuited in a covered accident while insured under this Policy; (2) dies asi a direct result of such injuries within 365 days after the accident; and (3) is survived by a Spouse who is eligible for the benefit. To be eligible fclr the Spouse Training Benefit, the Insured Person's Spouse: (1) must npt be legally separated from the Insured Person on the date of the accident; (2) must be enrolled as a student on the date of the Insured Person's death or within 365 days after that date in any school to retrain or refresh skills needed for employment; and (3) must idcur expenses after the date of the Insured Person's death for tuition, fees, books, room and board or other costs payable directly to (or approved or certified by) that school. GLI 101-14.7 01 25 EDUC, SP. TR. 01101115 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE CONTINUED This benefit will be paid in addition to all other benefits payable under this Policy. The benefit will equal the actual expense incurred after the date of the Insured Person's death up to 5% of Insured Person's Principal Sum; subject to a maximum of $5,000. The benefit will be paid for one year. Payment will be made: (1) when the benefit for accidental loss of life is paid; or (2) when the Company receives proof of payment for the expenses incurred and that the Spouse meets the above requirements, if later. EXCLUSIONS. Benefits will not be payable for any loss excluded under the Accidental Death and Dismemberment Insurance Limitations section. GL 1101-14.7 01 EDUC, SP. TR. 26 01/01/15 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE CONTINUED CHILD CARE BENEFIT. The Company will pay a Child Care Benefit for each of the Insured Person's eligible Dependent Children, if the Insured Person: (1) is injured in a covered accident while insured under this Policy; (2) dies a� a direct result of such injuries within 365 days after the accident; and (3) is survived by one or more Dependent Children who are eligible for the benefit. To be eligible $or the Child Care Benefit, a Dependent Child must: (1) be deendent on the Insured Person for principal support; (2) be under age 13 on the date of the accident; and (3) attend a licensed Child Care Center on a regular basis on the date of the Insured Person's death or within 365 days after that date. The Child Carey Benefit is paid in addition to all other Policy benefits. The benefit will equal the actual expense incurred after a date of the Insured Person's death, up to 5% of the Insured Person's Principal Sum; subject to a maximum of;ependent 5,000 for each eligible Dependent Child per year. The benefit will be paid to the legal guardian of the eligible Child: (1) for uplto 4 consecutive years; or (2) until the Dependent Child's 13th birthday (whichever occurs first). The first payment will be made: (1) when the benefit for accidental loss of life is paid; or (2) when :he Company receives proof of expense incurred and that an eligible Dependent Child meets ffie above requirements; if later. Subsequent pay nents will be made quarterly on a reimbursement basis when the Company receives: (1) verific ition that the eligible Dependent Child continues to attend a licensed Child Care Center on a r gular basis; and (2) satisfactory proof of payment for the child care expense incurred. DEFINITIONS. "Child Care Center" means any facility (other than a family day care home) which: (1) is licensed as such by the state; and (2) provid s non-medical care and supervision for children in a group setting; and (3) cares r children at least 6 but less than 24 hours per day. "Child" includes the Insured Person's naturally born child, legally adopted child, stepchild, and foster child. "Expense Incurred" means the cost for the supervision and care of a Dependent Child, excluding any fees for extra activities, Which are directly payable to a Child Care Center. EXCLUSIONS Benefits will not be paid: (1) when the Dependent Child's care is provided by (or at a facility operated by) the child's grandparent, parent, aunt, uncle or sibling; or (2) for any loss excluded under the Accidental Death and Dismemberment Insurance Limitations section of this Policy. GL1101-14.13 01 27 CH. CARE 01/01/15 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE CONTINUED COMA BENEFIT. The Company will pay a Coma Benefit, when the Insured Person remains in a coma; provided: (1) the coma is caused by an Injury sustained while insured under this Policy; (2) the coma begins within 365 days after the date of the accident; and (3) the person remains in a continuous coma for at least 31 days in a row. The coma must result directly from the Injury and from no other causes. This benefit will be paid in addition to all other benefits payable under this Policy. The Coma Benefit will equal a one-time payment of 5% of the Insured Person's Principal Sum; subject to a maximum of $5,000. PROOF. Proof of the coma must be provided to the Company. The Company retains the right to investigate and to determine whether the coma exists. TO WHOM PAYABLE. Upon receipt of satisfactory proof, the Coma Benefit will be paid to the Insured Person. "Coma" means being in a state of complete mental unresponsiveness, with no evidence of appropriate responses to stimulation. EXCLUSIONS. Benefits will not be paid: (1) when the Insured Person remains in a coma for less than 31 days in a row; or (2) for any loss excluded under the Accidental Death and Dismemberment Insurance Limitations section of this Policy. GL1101-14.14 01 COMA 28 01/01/15 SAFE DRIVER BENEFIT BENEFIT. If an Insured Person dies as a direct result of a covered auto accident, for which Accidental Death and Dismembc rment Benefits are payable; then: (1) an ad litional Seat Belt Benefit will be payable, if the Insured Person was wearing a properly faster ed seat belt at the time of the accident; and (2) an additional Air Bag Benefit will be payable, if the auto was equipped with air bag(s). The Seat Belt $enefit equals $10,000 or 10% of the Principal Sum, whichever is less; and the Air Bag Benefit equals $10,0001 or 10% of the Principal Sum, whichever is less. The Seat Belt Benefit and the Air Bag Benefit will not be less than$1,000 per Insured Person. The Principal Sum is the amount payable because of the Insured Person's accidental death. A copy of the police report must be submitted with the claim. The position of the seat belt or presence of an air bag must be cettified by: (1) the official accident report; or (2) the coroner, traffic officer or other investigating officer. Upon receipt o� satisfactory written proof, the additional benefit will be paid in accord with the Beneficiary section. DEFINITIONS' As used in this provision: "Auto" means a 4 -wheel passenger car, station wagon, jeep, pick-up truck or van -type car. It must be licensed for use on publip highways. It includes a car owned or leased by the Group Policyholder. "Intoxicated," "Impaired," or "Under the Influence of Drugs" shall be defined as by the jurisdiction where the accident occurs; "Seat Belt" mes a properly installed: (1) seat b It or lap and shoulder restraint; or (2) other restraint approved by the National Highway Traffic Safety Administration. LIMITATIONSi. Safe Driver Benefits will not be paid if. (1) the Accidental Death and Dismemberment Benefits is not paid under this Policy for the Insured Person's death; or (2) at the time of the accident, the Insured Person or any other person who was driving the auto in which the Insured Person was traveling: (a) was driving without a valid drivers' license; (b) was driving in excess of the legal speed limit; or (c) was driving while intoxicated, impaired, or under the influence of drugs (except for drugs taken as prescribed by a Physician for the driver's use). The above limitations will apply, whether or not the driver is convicted. GLI 101-14.15A Seat Belt & Air Bag 29 01/01/15 SUNIlVIARY OF THE LIFE AND HEALTH INSURANCE PROTECTION ASSOCIATION ACT AND NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS INTRODUCTION Residents of Colorado who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the Life and Health Insurance Protection Association. The purpose of this Association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in Colorado and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Association is limited, however. As noted in the box below, this protection is not a substitute for consumers' care in selecting companies that are well- managed and financially stable. IMPORTANT DISCLAIMER The Life and Health Insurance Protection Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require residency in Colorado. You should not rely on coverage by the Life and Health Insurance Protection Association in selecting an insurance company or in selecting an insurance policy. Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the association to induce you to purchase any kind of insurance policy. SUMMARY The state law that provides for this safety -net coverage is called the Life and Health Insurance Protection Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the Association. Coverage. Generally, individuals will be protected by the Life and Health Insurance Protection Association if they live in this state and hold a life or health insurance contract, or an annuity, or if they hold certificates under a group life or health insurance contract or annuity, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. Certain parties to structured settlement annuity contracts may be entitled to coverage benefits as well based on defined circumstances. This Information is Provided By: Life and Health Insurance Colorado Division of Insurance Protection Association 1560 Broadway P.O. Box 36009 Suite 850 Denver, CO 80236 Denver, CO 80202 303 292-5022 303 894-7499 GAN -GRP -CO NOTICE - POL 10 30 01/01/15 Exclusions From Coverage.. Persons holding such policies or contracts are not protected by this Association if- they fthey arO not residents of the State of Colorado, except under certain very specific circumstances; • the insurer was not authorized or licensed to do business in Colorado at the time the policy or contract was iss ed; • their pty was issued by a nonprofit hospital or health service corporation, an HMO, a fraternal benefit society,; a mandatory state pooling plan, a mutual assessment company or similar plan in which the policyholder is subject to future assessments, or by an insurance exchange. The Associatio also does not provide coverage for: • any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk; • any policy or reinsurance (unless an assumption certificate was issued); • plans of employers, associations or similar entities to the extent they are self-funded or uninsured (that is, not insured by an insurance company, even if an insurance company administers them); • interest rate yields, crediting rate yields or other factors employed in calculating returns, including but not limited to indexes or other external references stated in the policy or contract, that exceed an average rate specified in the association Act; • dividends; • experience rating credits; • credits ven in connection with the administration of a policy or contract; • any unallocated annuity; • annuity contracts or group annuity certificates used by nonprofit insurance companies to provide retirement benefits for nonprofit educational institutions and their employees; • policies# contracts, certificates or subscriber agreements issued by a prepaid dental care plan; • sicknes and accident insurance when written by a property and casualty insurer as part of an automooile insurance contract; • unalloc ed annuity contracts issued to an employee benefit plan protected under the federal Pension Benefit uaranty Corporation; • policies or contracts issued by an insurer which was insolvent or unable to fulfill its contractual obligations as of July 1, 1991, except for annuity contracts issued by a member insurer which was placed ito liquidation between July 1, 1991 and August 31, 1991; • policies for contracts covering persons who are not citizens of the United States; • any kind of insurance or annuity, the benefits of which are exclusively payable or determined by a separate account required by the terms of such insurance policy or annuity maintained by the insurer or by the s$parate entity. Limits On Amg$mt of Coverage. The Act also limits the amount the Association is obligated to pay out. The Association cannot pay more than what the insurance company would owe under a policy or contract. Also, for any one insured' life, no matter how many policies or contracts were issued by the same company, even if such contracts provided different types of coverages, the Association will pay a maximum of: • $300,00 in net life insurance death benefits and no more than $100,000 in net cash surrender and net cash withdrawal values for life insurance; • for health insurance benefits, $100,000 for coverages not defined as disability, basic hospital, medical and sur 'cal, or major medical insurance, including any net cash surrender and net cash withdrawal values, 300,000 for disability insurance; or $500,000 for basic hospital, medical and surgical, or major medical surance; • $250,000 in the present value of annuity of annuity benefits, including net cash surrender and net cash withdrav ral values; or • with resect to each payee of a structured settlement annuity, $250,000 in present value annuity benefits, in the aggregate, including net cash surrender and net cash withdrawal values; or • $300,00 for long term care benefits. The Association shall not be liable to expend more than $300,000 in the aggregate, with- respect to any one life except that with) respect to benefits for basic hospital, medical and surgical and major medical insurance, the aggregate liability of the Association shall not exceed $500,000 with respect to any one individual. GAN -GRP -CO NOTICE - POL 10 31 01/01/15 AMENDMENT TO BE ATTACHED TO AND MADE PART OF GROUP POLICY NO: 000010149432 ISSUED TO: Eagle County Government The Policy is amended by the addition of the following provisions. PRIOR INSURANCE CREDIT UPON TRANSFER OF LIFE INSURANCE CARRIERS This provision prevents loss of life insurance coverage for an Insured Person, which could otherwise occur solely because of a transfer of insurance carriers. This Policy will provide the following Prior Insurance Credit, when it replaces a prior plan. "Prior Plan" means a prior carrier's group life insurance policy, which this Policy replaced within 31 days of the prior plan's termination date. FAILURE TO SATISFY ACTIVE WORK RULE. Subject to payment of premiums, this Policy will provide life coverage for a Person who: (1) was insured under the prior plan on its termination date; (2) was otherwise eligible under this Policy; but was not Actively -At -Work due to Injury or Sickness on its Effective Date; (3) is not entitled to any extension of life insurance under the prior plan; and (4) is not Totally Disabled (as defined in the Extension of Death Benefit section of this Policy) on the date this Policy takes effect. AMOUNT OF LIFE INSURANCE. Until the Person satisfies this Policy's Active Work rule, the amount of his or her group life insurance under this Policy will not exceed the amount for which the Person was insured under the prior plan on its termination date. This Amendment takes effect on the effective date of coverage under this Policy. In all other respects, this Policy remains the same. GLI 101 -AMEND. PCI CO THE LINCOLN NATIONAL LIFE INSURANCE COMPANY 32 0-4q,&-j�?T Officer of the Company Prior Ins. Cred. - Life 01/01/15