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C97-078 The United States Life Insurance Company
3600Route66P0Box1580/MSN3-ANeptuneNJ077541580THEUNITEDSTATESLIFEInsuranceCompanyCOMPANYGROUPINSURANCEPOLICYACCEPTANCEFORMFullnameofPolicyholder:EAGLECOUNTYGOVEINMENTAddress:500BroadwayCity:EagleState:COZip:81631GroupPolicyNo.:G—180,906J99CCAUUFEThepersonsigningbelowapprovesthetermsoftheGroupPolicyandacceptsitsdeliveryWitness:(TITLE---(ALICENSEDRESIDENTAGENTWHEREREQUIREDBYLAW)-DISTR)BUTION:WHITE—POLICYHOLDER(PLEASEATTACHTOYOURGROUPPOLICYICANARY—RETURNTOTHEUNITEDSTATESLIFEINSURANCECOMPANY00305201-1005-0695FORMNO.15507 CIEUNITEDSTATESLIFElnsL.eCompanyIntheCityofNewYork(CalledUnitedStatesLife)UnitedStatesLifewillpaythebenefitsofthispolicysubjecttoitsprovisions.Thispageandthepagesthatfollowarepartofthispolicy.Grouppolicyno.:G-f80,906C‘9?784Policyholder:EAGLECOUNTYGOVERNMENTPREMIUMPAYMENTSThispolicyisissuedinreturnforthepaymentbythePolicyholderofrequiredpremiums.PremiumsarepayableatthehomeofficeofUnitedStatesLifeortoitsauthorizedagent.Thefirstpremiumisdueontheeffectivedateofthispolicy.Laterpremiumsareduemonthlyinadvanceonthefirstdayofeachmonth.Thesedatesarethepremiumduedates.EFFECTIVEDATEThispolicywilltakeeffectonSeptember1,1996.POLICYANNIVERSARIESPolicyanniversarieswillbeSeptember1,1997andeachsubsequentSeptember1.APPLICABLELAWThispolicyisissuedinandgovernedbythelawsofColorado.Signedontheeffectivedate,atUnitedStatesLife’shomeofficeat125MaidenLane,NewYork,NewYork10038.97wiRegistrarChairmanoftheBoardSignedby:4.pt)(Alicensedresid,htagentwhererequiredbylaw)GROUPTERMLIFEANDACCIDENTANDHEALTHINSURANCEPOLICYG-19000FP CCPOLICYINDEXEachpageinthispolicyhasa2linecodeatthebottomleftofthepage.Thecode“G-19000”meansthatthepagebelongstothepolicyseries.Theletterorlettersbelowthepolicycoderepresentsaphoneticdescriptionoftheparticularsection(FP=Facepage;E=Eligibility).Hasectionrequiresmotethanonepage,thedescriptiveletterisfollowedbyanumberindicatingitsorderinthesection(E-2isthesecondpageintheEmployeeEligibilitysection).Thisindexrefersyoutothephoneticcodes.SECTIONPAGE(S)FacePageFPScheduleofBenefitsSCHDefinitionsDEFEmployeeEligibilityEligibleClassesOfEmployeesE-1DateEmployeesAreEligibleForInsuranceE-7DateEmployees’InsuranceTakesEffectE-2ActivelyAtWorkRequirementE-2DateEmployees’InsuranceEndsE-2ContinuationofInsuranceWithPremiumPaymentE-3LifeInsuranceBenefitsConversionOptionL-1ContinuationofInsuranceWithoutPremiumPaymentL-2AccidentalDeathAndDismembermentBenefitsADDBPremiumsPLAHEndOfInsuranceProvidedByThisPolicyENDGeneralProvisionsTheContractGP-1LimitOnAgent’sAuthorityGP-1IncontestabilityGP-1BeneficiaryGP-1CertificatesGP-1MisstatementsGP-2DataNeededGP-2PaymentForExpensesIncurredAtAnEmployee’sDeathGP-2PaymentToAMinorOrIncompetentGP-2AutopsyGP-2AssignmentGP-2PolicyNon-ParticipatingGP-2AgencyGP-2NewEntrantsGP-2ComplianceWithLawGP-2GenderGP-2GeneralProvisionsForAccidentAndHealthInsuranceFilingAClai.iiGPAHPaymentofClaimsGPAHPhysicalExamsGPAHTimeLimitOnLegalActionsGPAHG-19000INDEXG-f80,906 CSCHEDULEOFBENEFITSACCIDENTALDEATHANDDISMEMBERMENTCLASSOFEMPLOYEESLIFEINSURANCEAMOUNTFULLBENEFITAMOUNTAllemployeesandelectedofficials$50,000*$50,000**Theamountoflifeinsuranceandaccidentaldeathanddismembermentbenefitsforanyemployeewhoisnow65orolder,orwhenheattainsage65,willbereducedby35%.Atage70,hisamountsoflifeinsuranceandaccidentaldeathanddismembermentbenefitswillbelimitedto50%oftheamountsineffectonthedaybeforeheattainedage65.G-19000SCHG-180,906 0DEFINITIONSACTIVEWORKorACTIVELYATWORKmeansthatanemployeeperformseachdutyofhisjobforfullpay.ThismustbedoneatthePolicyholder’splaceofbusinessoranyplacetowhichsuchbusinessrequirestheemployeetotravel.FULL-TIMEmeansactiveatworkonthePolicyholder’sregularworkschedulefortheclassofemployeestowhichtheemployeebelongs.Theworkschedulemustbe:•forelectedofficials,thenumberofhoursrequiredbythePolicyholder,and•forallotheremployees,atleast30hoursaweek.PHYSICIANmeans:•amedicalpractitionerlicensedtoprovidemedicalservicesandperformgeneralsurgery,or•anyotherpractitionerwhoseservices,bylawofthestatewheresuchservicesareperformed,mustbecoveredbythispolicy.Eachsuchpersonmustbelicensedinthestatewhereheperformstheserviceandmustactwithinthescopeofthatlicense.Hemustalsobecertifiedand/orregisteredifrequiredbysuchstate.G-19000DEF(A)Gi80,906 EMPLOYEEELIGI8ILITYC)ELIGIBLECLASSESOFEMPLOYEESAllfull-timeemployeesandelectedofficialsofthePolicyholder,butnotthosewhoatetemporary,part-timeorseasonal.DATEEMPLOYEESAREELIGIBLEFORINSURANCEEachemployeeinaneligibleclassonSeptember1,1996willbeeligibleforinsuranceonthatdate.EachemployeewhoentersaneligibleclassafterSeptember1,1996willbeeligibleforinsuranceonthefirstdayofthemonthcoincidingwithornextfollowingthedateheenterssuchclass.RehiredemployeesThePolicyholdermaychoosetohaveinsuranceforformeremployeestakeeffectonthedatetheyre-enteraneligibleclass.Thischoicemayapplytoallorsomeclassesofemployees.Suchformeremployeesmustberehiredwithin6monthsaftertheirinsuranceended.ThePolicyholdermustnotifyUnitedStatesLifeofthischoiceinwriting.Ifthischoiceismade,itwillapplytoallrehiredemployeesinthesameclass.Ifitisnotmade,rehiredemployeesmustcompletethewaitingperiodshownabove.G-19000E-IG-180,906 nCEMPLOYEEELIGIBILITY(Continued)DATEEMPLOYEES’INSURANCETAKESEFFECTEachemployeeinaneligibleclasswillbeinsuredonthedateheiseligible.ACTIVELYATWORKREQUIREMENTAnemployeemustbeactivelyatworkinaneligibleclassonthedatehisinsuranceistotakeeffect.Ifheisnot,suchinsurancewilltakeeffectonthedaytheemployeeresumessuchwork.Thedateinsuranceistotakeeffectmightnotbeascheduledworkday.Ifso,theemployeewillbeconsideredactivelyatworkonsuchdateifhewasactivelyatworkonhislastscheduledworkday.DATEEMPLOYEES’INSURANCEENDSAnemployee’sinsurancewillendattheearliestof:.thedatethispolicyends;2.thedateinsuranceendsforhisclass;3.theendoftheperiodforwhichthelastpremiumhasbeenpaidforhim;or4.theendofthemonthinwhichemploymentends;exceptasstatedintheCONTINUATIONOFINSURANCEWITHPREMIUMPAYMENTprovision,ceasingfull-timeworkinaneligibleclasswillbeconsideredtheendofemployment.G-19000E-2G-180,906 EMPLOYEEELIGIBILITY(Contirn.,C’CONTINUATIONOFINSURANCEWITHPREMIUMPAYMENTThePolicyholdermaychoosetocontinueinsurancebypayingpremiumsforhisemployeeswhoceasefull-timeworkforanyofthereasonsshownbelow.Thischoicemayapplytoallorsomeclassesofemployees.Ifthischoiceismade,itwillapplytoallemployeesinthesameclass.Attheendoftheproperperiodbelow,employmentwillbeconsideredtoendandinsurancewillend.Insurancewillnotendif,atthistime,theemployeeresumesfull-timeworkinaneligibleclass.Insurancewillcontinue:1.tottheperiodofadisability,upto12months.2.fortheperiodfull-timeworkstops,upto:a.31days,forlayoff,leaveofabsenceorstrike.b.thedateofreturntofull-timeworkforthoseonareducedworkschedule.Ifinsuranceendsforanyreason,contactUnitedStatesLiferightawayfordetailsoncontinuation,ifany.G-f9000E-3(XXX)G-180,906 LIFEINSURANCEBENEFITSIfaninsuredemployeedies,dueproofofhisdeathmustbesenttoUnitedStatesLife.Whensuchproofisreceived,UnitedStatesLifewillpaytothebeneficiarytheamountofinsuranceshownintheScheduleofBenefits.PAYMENTOPTIONSBenefitswillbepaideitherinonesumorunderanoptionchosenbytheemployee.Iftheemployeehasnotchosenanoptionwhichisinforceathisdeath,hisbeneficiarymaydoso.SuchchoicemustbefiledwithUnitedStatesLifeinwriting.AnyagreementwillbesubjecttoUnitedStatesLife’srulesatthetimeofthechoice.CONVERSIONOPTIONIfanemployee’sinsuranceends,hemaybuyanindividualpolicyoflifeinsurancefromUnitedStatesLifeduringtheconversionperiod.Evidenceofinsurabilitywillnotberequired.CONVERSIONPERIODmeansthe31daysafterinsuranceends.Thisoptionissubjecttotheseconditions:1.theemployeemustapplyforthenewpolicyinwritingandpaythefirstpremiumduringtheconversionperiod;2.thepremiumratesforthenewpolicywillbebasedon:•UnitedStatesLife’sratestheninuse•theplanandamountofinsurance•theemployee’sclassofrisk,and•theemployee’sagenearestbirthdaywheninsuranceends;3.thenewpolicymaybeanyformthenbeingissuedbyUnitedStatesLifewhichdoesnotprovideterminsuranceorpaydividends;4.thenewpolicywillbeissuedwithoutterm,disabilityorotherextrabenefits;and5.thenewpolicywilltakeeffectattheendoftheconversionperiod.AmountofthenewpolicyTheamountofanemployee’snewpolicydependsonthereasonhisinsuranceends.It•theemployeeceasesfull-timeworkandthispolicystaysinforce,or•amountsofinsurancedecreaseduetoareductionshownintheScheduleofBenefitsThen:theamountofthenewpolicymaybeanyamountuptotheamountwhichendsunderthispolicy.It•thispolicyends,or•thispolicyisamendedtoendinsurancefortheemployee’sclass,Andtheemployeehadbeeninsuredbythispolicyforatleast5yearsjustbeforehisinsuranceendedThen:theamountofthenewpolicymaynotexceedthelesserof:•$2,000,or•theamountwhichendsunderthispolicylesstheamountforwhichtheemployeemaybecomeeligibleunderanygrouppolicyduringtheconversionperiod.DeathbenefitduringconversionperiodIfanemployeediesduringtheconversionperiod,UnitedStatesLifewillpaytheamountwhichhewasentitledtoconvert.EffectofpreviousconversionAnemployeemayhavepreviouslyusedthisconversionoption.HemayhavedonesounderthispolicyoranypolicyissuedbyUnitedStatesLifewhichthispolicyreplaces.Ifso,UnitedStatesLifewillreducetheemployee’samountofinsurancewhichendsunderthispolicybytheamountsoconverted.UnitedStatesLifewillnotdothisiftheemployee:1.returnstheconvertedpolicy,or2.submitsevidenceofinsurabilitysatisfactorytoUnitedStatesLifefortheconvertedamount.G-19000C-IG-180,906 c.’CLIFEINSURANCEBENEFITS(Continued)CONTINUATIONOFINSURANCEWITHOUTPREMIUMPAYMENTIfanemployeebecomestotallydisabledwhileinsured,hislifeinsurancewillcontinuewithoutpremiums,asdescribedbelow.TOTALDISABILITYmeansthatanemployeecannotperformanyworkforpayorprofit.Thedisabilitymustresultfromaninjuryorsickness.IftotaldisabilItybeginsbeforeage60Insurancewillcontinueforoneyearaftertotaldisabilitybegins.Duringsuchyear.iftotaldisabilitylastsfor9monthswithnointerruption,proofofthisshouldbesentbytheemployeetoUnitedStatesLife.Thismustbedonewithin3monthsbeforethatyearends.Iftheserequirementsaremetbytheemployee,insurancewillcontinueforanotheroneyearperiod.Iftheserequirementsaremetbytheemployeeineachfutureyear,insurancewillcontinueforfurtheroneyearperiods.Whileinsuranceiscontinued,UnitedStatesLifemaychooseaphysiciantoexaminetheemployeeasoftenasneededtoverifydisability.TheseexamswillbepaidforbyUnitedStatesLife.Insurancewillcontinueuntilthedatethefirstoccurs:1.totaldisabilityends;2.proofoftotaldisabilityisnotgivenbytheemployeewhendue;or3.theemployeeisnotexaminedwhenrequired.Ifthispolicyends,thiswillnotacttoendthiscontinuation.Iftotaldisabilitybeginsonorafterage60Insurancewillcontinueuntilthedatethefirstoccurs:1.totaldisabilityends;or2.totaldisabilityexistsforoneyear.Ifthispolicyends,thiswillnotacttoendthiscontinuation.ConversionoptionwhencontinuationofinsuranceendsWhencontinuationends,anemployeemaybuyanindividualpolicyoflifeinsurancefromUnitedStatesLife.ThedetailsofthisoptionaredescribedintheConversionOptionprovisionofthissection.Forthepurposeofthatprovision,theendofcontinuationwillbeconsideredtheendofemployment.Anemployeemaynotusethisoptionif,duringtheconversionperiod:1.hereturnstofull-timeworkandbecomesinsuredbythispolicy,or2.hedoesnotreturnanypolicyheboughtifhepreviouslyusedtheconversionoption.DeathbenefitIfaninsuredemployeediesduringthiscontinuationofinsurance,dueproofofhisdeathmustbesenttoUnitedStatesLifewithinoneyearofdeath.“Dueproof”includesproofthattotaldisabilityexistedwithnointerruptionuntildeath.Whensuchproofisreceived,UnitedStatesLifewillpaytheamountofinsuranceforwhichtheemployeewasinsuredwhentotaldisabilitybegan,lessanyreductionwhichmayhaveappliedtohimafterhistotaldisabilitybegan.Iftheemployeehadusedhisconversionoption,paymentwillbemadeunderthisprovisiononlyiftheindividuatpolicyisreturnedtoUnitedStateslife.Ifthisisdone,UnitedStatesLifewillrefundthepremiumspaidforthatpolicy,lessanydebt.Theamountofinsurancewillbepaidtothebeneficiaryoftheindividualpolicyifdifferentfromthebeneficiarychosenforthispolicy.G-19000L-21/87 ACCIDENTALDEATHANDDISMEiRMENTBENEFITSC’)Thissectionprovidesbenefitsforaccidental:•lossoflife,and•lossofsight,handorfoot.Ifanemployeesufferssuchlosssolelyasaresultofaninjurycausedbyanaccident,dueproofofsuchlossmustbesenttoUnitedStatesLife.Theaccidentmusthappenwhiletheemployeeisinsuredandthelossmustoccurwithin365daysafterthedateofthataccident.Whentheproofisreceived,UnitedStatesLifewillpaythebenefitamountsdescribedbelow.FORLOSSOFLIFEUnitedStatesLifewillpaytothebeneficiarythefullbenefitamountshownintheScheduleofBenefits.FORLOSSOFSIGHT,HANDORFOOTLOSSOFSIGHTmeanstotallossofsightwhichcannotberestoredbysurgicalorothermeans.LOSSOFHANDmeansthatahandispermanentlyseveredatorabovethewrist.LOSSOFFOOTmeansthatafootispermanentlyseveredatorabovetheankle.UnitedStatesLifewillpaytotheemployee:7.thefullbenefitamountshownintheScheduleofBenefitsforlossof:•sightofbotheyes•bothhands•bothfeet•anycombinationoffoot,handorsightofoneeye.2.one-halfthebenefitamountshownintheScheduleofBenefitsforlossof:•sightofoneeye•onehand•onefoot.Ifanemployeesuffersmorethanonelossduetoanyoneaccident,paymentwillbemadeonlyforthatlossforwhichthelargestamountispayable.G-19000ADDB•f ACCIDENTALDEATHANDDISM[JERMENTBENEFITS(Continued)CEXCLUSIONSNobenefitswillbepaidforanylossthatresultsfromoriscauseddirectly,indirectly,whollyorpartlyby:1.suicide;orintentionallyself-inflictedinjury;2.insurrection;waroranactofwar;3.aphysicalormentalsickness,ortreatmentofthatsickness;4.voluntaryintakeofpoison,drugs,gasorfumes,unlesstakenasprescribedbyaphysician;5.committingacrime,oranattempttodoso;6.beingintoxicatedorundertheinfluenceofanydrug,unlesstakenasprescribedbyaphysician;7.flightinanytypeofaircraft.Thisitemappliesonlyto:•thepilot,whetherlicensedorunlicensed;and•themembersofthecrew.0-19000ADDB-2 CCPREMIUMSFREQUENCYOFPREMIUMPAYMENTPremiumforthispolicywit!bepaidmonthlyinadvance.ThePolicyholderandUnitedStateslifemayagreethatpaymentbemadeinadvanceevery3,6or12months.PREMIUMFORCHANGESININSURANCEForinsurancethattakeseffectafterthefirstdayofapolicymonth,premiumwillbechargedfromthefirstdayofthenextpolicymonth.However,ifapolicyamendmentorevidenceofinsurabilityisrequiredforthisinsurance,premiumwillbechargedasofthedatesuchinsurancetakeseffect.Forinsurancethatends,premiumwillbechargedtotheendofthepolicymonthinwhichinsuranceends.However,ifthispolicyends,orifinsuranceendsforaclassofemployees,premiumwillbechargedtothedateinsuranceends.RIGHTTOCHANGERATESUnitedStatesLifemaychangepremiumrates:•whenthispolicyisamended•onanydateonorafterthesecondpolicyanniversary;thiswillbedoneonlyonceevery12monthsandonlyifUnitedStatesLifenotifiesthePolicyholder,inwriting,atleast31daysbeforesuchchange.Thenewpremiumwillapplyonlytopremiumsdueonorafterthedatetheratechangetakeseffect.INSURANCEPREMIUMRATESThefirstmonthlypremiumrateswillbe:Lifeinsurance$.14peremployeeper$1,000ofbenefitamountAccidentaldeathanddismembermentbenefitsS.03peremployeeper$1000ofbenefitamount.G-19000PLAHG-180,906 ENDOFINSURANCEPROVIDEDBYa1SPOLICYLFPREMIUMISNOTPAID-GRACEPERIODEachpremium,afterthefirst,naybepaidupto31daysafteritsduedate.Thisperiodisthegraceperiod.Theinsuranceprovidedbythispolicywillstayineffectduringthisperiod.Ifthepremiumisnotpaidbytheendofthisperiod,suchinsurancewillendatthattime.UnitedStatesLifemayextendthegraceperiodbywrittennotice.Suchnoticewillstatethedateinsurancewillendifthepremiumremainsunpaid.Premiumsmustbepaidforagraceperiodandanyextensionofsuchperiod.SeparatebillingarrangementsCPremiumsforthispolicymaybepaidinseparatebillscoveringcategoriesofemployeessetupbythePolicyholder.Ifpremiumisnotpaidforacategoryofemployees,UnitedStatesLifecanendinsuranceforsuchemployeesassetforthabove.OTHERWAYSINSURANCEMAYEND1.ThePolicyholdercanendthispolicybygiving30daysadvancewrittennoticetoUnitedStatesLife.2.UnitedStatesLifecanendthelifeinsuranceunderthispolicybygiving60daysadvancewrittennoticetothePolicyholder:•iflessthan10employeesareinsured,•iftheemployeesdonotpayforthecostoftheinsurance,lessthan100%ofthoseeligibleareinsured,or•iftheemployeespayforallorpartofthecostoftheinsurance,lessthan75%ofthoseeligibleareinsured.UnitedStatesLifecanendtheaccidentandhealthinsuranceunderthispolicybygiving60daysadvancewrittennoticetothePolicyholder.IFINSURANCEENDS-PREMIUMSIfinsuranceends,allpremiumsduemustbepaid.Suchpaymentwillbeonaproratabasisforanyperiodthatinsurancewasineffectfromthedatethelastpremiumwaspaid.IfUnitedStatesLifeacceptspremiumafterthedatethispolicyends,thiswillnotactto“reinstatesthepolicy.UnitedStatesLifewillrefundanyunearnedpremium.REINSTATEMENTToreinstatethispolicy,thePolicyholdermustcompletetherequiredformandsendittoUnitedStatesLife.Ifthisrequestisapproved,thepolicywillbereinstatedonthedatestatedinwritingbyUnitedStatesLife.G-19000ENDUA&H (n.GENERALPROVISIONS(Continued)MISSTATEMENTSAperson’sage,sexoranyotherdatamaybemisstated.Ifso,thecorrectdatawillbeusedtodetermineifinsuranceisinforce.Ifinsuranceisinforce,thepremiumand/orbenefitswillbeadjustedaccordingtothefacts.DATANEEDEDThePolicyholderwillkeeparecordofallthedataneededtocomputepremiumsandcarryoutthetermsofthispolicy.UnitedStateslifecanexaminesuchdataatanyreasonabletime.ClericalerrorAclericalerrormaybemadebyUnitedStatesLifeorthePolicyholderinkeepingthedata.Ifso,whentheerrorisfound,thepremiumand/orbenefitswillbeadjustedaccordingtothecorrectdata.Anerrorwillnotendinsurancevalidlyinforce,norwillitcontinueinsurancevalidlyended.PAYMENTFOREXPENSESINCURREDATANEMPLOYEE’SDEATHitthereisnolivingnamedbeneficiary,UnitedStatesLifehastheoptiontopaypartofthebenefitstoanyonewhohasincurredexpensesforanemployee’slastsicknessordeath.Thispaymentwillnotexceedtheamountofsuchexpenses,uptothemaximumforsuchpaymentsetforthbylawinthestatewherethispolicyisissued.UnitedStatesLifewillnotbeliableforsuchpaymentafteritismade.PAYMENTTOAMINORORINCOMPETENTtfanybeneficiaryorpayeeisaminororisincompetenttoreceivepayment,UnitedStatesLifewillpayhisguardian.UnitedStatesLifewillnotbeliableforsuchpaymentafteritismade.AUTOPSYUnitedStatesLife,atitsexpense,hastherighttoorderanautopsy.Thiswillonlybedonewhereallowedbylaw.ASSIGNMENTUnitedStatesLifewillnotbeboundbyanyassignmentunlessitisinwritingandisrecordedatitshomeoffice.UnitedStatesLifeisnotresponsibleforthevaildityofanassignment.POLICYNON-PARTICIPATINGThispolicydoesnotpaydividends.AGENCYThePolicyholderisnottheagentofUnitedStatesLifeforanypurposeunderthispolicy.--NEWENTRANTSNewpersonsmaybeinsuredaccordingtothetermsofthispolicy.COMPUANCEWITHLAWOnthedatethispolicytakeseffect,someofitsprovisionsmayconflictwithanapplicablelaw.Ifso,anysuchprovisionischangedtocomplywiththeminimumsrequiredbysuchlaw.GENDERMalepronounswillbereadasfemalewhereitapplies.G-f9000GP-2LD!LTD/MC CCGENERALFROVISIONSFORACCIDENTANDHEALTHINSURANCEFILINGACLAIMTofileaclaim,followthesesteps:Step1:AclaimantshouldsendawrittennoticeofclaimtoUnitedStatesLifewithin20daysofaloss.Nospecialformisrequiredtodothis.ThenoticeneedonlyidentifytheclaimantandthePolicyholder.Step2:WhenUnitedStatesLifereceivesthenotice,itwillsendaproofofclaimformtotheclaimant.Step3:Theclaimantshouldreceivetheproofofclaimformwithin15daysofthedateUnitedStatesLifereceivedthenoticeofclaim.Iftheformisreceivedwithinsuchtime,itshouldbecompleted,asinstructed,byallpersonsrequiredtodoso.Additionalproof,ifrequired,shouldbeattachedtotheform.Iftheformisnotreceivedwithinsuchtime,theclaimantmayprovidewrittenproofofclaimtoUnitedStatesLifeonanyreasonableform.Suchproofmuststatethedatetheinjuryorsicknessbeganandthenatureandextentoftheloss.Step4:ProofofclaimmustbesenttoUnitedStatesLifewithin90daysoftheloss.Ifanoticeorproofissentlaterthanthetimesshownabove,UnitedStatesLifewillnotdenyorreduceaclaimifthenoticeorproofwassentassoonaspossible.PAYMENTOFCLAIMSAllbenefitswillbepaidastheyaccrue.PHYSICALEXAMSUnitedStatesLife,atitsexpense,hastherighttoexaminetheinsured.Thismaybedoneasoftenasneededtoprocessaclaim.TIMELIMITONLEGALACTIONSLegalactionmayonlybebroughtagainstUnitedStatesLifeduringacertainperiod.Thisperiodbegins60daysafterthedateproofofclaimwasfiledandends3yearsaftertheendoftheperiodwithinwhichsuchproofisrequired.G-f90003yrsGPAH(B)LD/MC
