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HomeMy WebLinkAboutHR1989-0147 - Original - Standard Insurance Company - Life Insurance: Group Policy 339619 - 01/01/1985 IMPORTANT NOTICE To Members insured under Group Policy 339619 issued to City of Kent as Policyowner . Effective January 1 , 1985, Section 1 . SCHEDULE OF INSURANCE of the group policy has been amended to provide the following schedule of insurance : The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member under age 70 shall be determined from the following table : Face Amount Principal Sum Classification (Life Insurance ) (Accident Insurance) Under age 70 $10, 000 $10 , 000 Age 70 or over $ 5, 000 $ 51000 Changes in amounts of insurance because of changes in age shall be effective on the first day of the calendar month next following the date of change in age . If you are not actively at work on January 1 , 1985, any increase in your insurance shall be deferred until the next day on which you are actively at work . Please attach this notice to your certificate . STANDARD INSURANCE COMPANY 8/16/85 GROUP POLICY AMENDMENT NO . 4 Attached to and made a part of Group Policy 339619 issued to City of Kent as Policyowner . it is agreed that this policy is amended as follows � 1 . Section 1 . SCHEDULE OF INSURANCE is amended to read as follows : The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member under age 70 shall be determined from the following table : Face Amount Principal Sum Classification ( Life Insurance) ( Accident Insurance) $50 ' 000 $50 ' 800 Managers 3S, O0O 35, 000 Supervisors 25 O00 25' OOO Professionals ' '000 10 O0O All other MEMBERS 10 , 000 The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member age 70 or over shall each be equal to one-half the applicable amounts determined above . i amounts of insurance because of changes in classification Changes n the first day of the calendar month or age shall be effective on i classification or age, provided next following the date of change » c increase that if the Member is not actively at work on such date any shall be deferred until the next day on which he is actively at work . 2 . The premium rate for Life Insurance shall be $0 . 25 monthly per $1 ' 000 Face Amount ' beginning June 1 ' 1985 and continuing until changed as provided in the group policy . This amendment is effective as of January 1 ' 1985' provided that any increase in insurance for a Member who is not actively at work on »January 1 1985 shall be deferred until the next day on which he is ' actively at work . Page 1 of Amendment 4 Group Policy No . 339619 STANDARD INSURANCE COMPANY By f 1 ,.. President Secretary Regis r Page c of Amendment 4 Group Policy No . 339619 GROUP POLICY AMENDMENT NO . 5 Attached to and art of Group Policy 33�IG19 issued to City p ty of Kent as Policyowner . It is agreed that this policy is amended as follows 1 Effective October 1 1974 , the definition of the term Member as in the section entitled GENERAL DEFINITIONS is amended to rea shown as follows : the permanent employee or the mayor of Member means a regular P throughout the entire duration of Employer who is regularly working less than 30 hours per s work week , and in no event the Employer ' week . ve June 1 , 1952 , the definitFINITIONS the isterm amendedMember toaread shown as Effects entitled GENERAL DEFINITIONS in the section follows of the ect employee ular perm l Member means a regular anent employee or prt working throughout the entis••e duration tf Employer wha is regularly er ' s work week , and in no event less tegularOlyhoworking the Employ mayor of Employer the Emp y who is month, or theEmployer ' s work week , and in throughout the entire duration of the no event less than 30 hours per week . 3 . Effective January 11 1985, Section 1 SCHEDULE OF INSURANCE is amended to read as follows al Sum of Accident nt of Liberlunderncagean70the shalllbeidetermined from the The Face Amou Insurance for a Mem following table Face Amount Principal Sum Class ification (Life Insurance) (Accident Insurance) $50 , 000 �ti0 , 400 Management Group A 35, 000 35, 400 Management Group B 25, 000 25, 000 15,, Q00 Management Group C 15, 000 10 , 000 Mayor 10 , 000 All others al Sum of Accident far a The Face Amount of Life Insurance and the Principal each be equal Insurance Member age 70 or over shall one-half the applicable amounts determined a ove . Page 1 of Amendment Group Policy No . Changes in amounts of insurance because of changes in classification or age shall be effective on the first day of the calendar month next following the date of change in classification or age , provided that if the Member is not actively at work on such date any increase shall. be deferred until the next day on which he is actively at work . This amendment is effective as of the appropriate dates shown above, provided that any increase in insurance for a Member who is not actively at work on January 1 , 1955 shall be deferred until the next day on which he is actively at work . STANDARD INSURANCE COMPANY 1 �a e By w4zoge • Secretary President g Ir ar Page 2 of Amendment 5 Group Policy No . 339619 StmAaadINSURANCE COMPANY RFe P.O. BOX 711 PORTLAND,OR 97271 < / 2 Dedicated to Excellence for Policyowners S Request For Group Insurance Amendment 'lip " NG Policyowner Name: city of Kent Group Policy Number:. 339619 As an authorized representative of the Policyowner, 1. I request that STANDARD amend the above Group Policy to make the following change(s): The intent of this amendment request is to include the Mayor as an eligible member. 2. 1 request that the amendment become effective on I understand that the amendment will not become effective unless approved and issued by Standard. 3. 1 request that the amendment be approved by STANDARD subject to STANDARD'S usual underwriting requirements, including, if applicable, Evidence of Insurability or a Pre-existing Condition limitation. 4. 1 request that the amendment,if approved by STANDARD,be issued in the policy language customarily used by STANDARD. VELY day on the MEMBER'S last 5. I understand that any inches cheduledRANCE effect ve date of the amendment wr a MEMBER who is not ill b1e deferrrred until the firstday after the MEMBER regular work day before completes one full day of ACTIVE WORK. 6. 1 request that the amendment, if approved and issued by STANDARD, become effective by its terms without any further acceptance by the Policyowner,and that a copy of this Request for Group Insurance Amendment form be attached to and made a part of the amendment. I understand that if a group insurance policy is issued as a result of this request,that policy must be separately accepted by the Policyowner's signature on form 1755, Acceptance of Group Insurance Policy. al Title: / Date: �. Signed By: P n yo�e,sRepresentative Zip Code: Address �� -mod � Group Office: Seattle Group Representative: Thomas J. Simard Date Received At Group Office:— Form 3408 Rev.8/84 GROUP POLICY AMENDMENT NO . 6 Attached to and made a part of Group Policy 339619 issued to City of Kent as Policyowner . PERSONS INSURED . , A . Eligibility is It is agreed that Section ` ' persons not yet eligible for insurance on amended to read as follows for February 1 , 1986 ce of the A Member becomes eligib1efodatenherbecomesnathe Memberrst day calendar month following the This amendment is effective February 1 , 1986 . STANDARD INSURANCE COMPANY By � g �^ President Secretary Registrar RECEIVED AIAR INSURANCE COMPANY 41986 GROUP P.O. BOX 711 PORTLAND,OR 97271 Dedicated to Excellence for Policyowners U��£R4'/RIT1N� Request For Group Insurance Amendment Policyowner Name: CITY OF KENT Group Policy Number: 339619 As an authorized representative of the Policyowner, 1. 1 request that STANDARD amend the above Group Policy to make the following change(s): A member becomes eligible for insurance on the first day of the month following the date he beomes a member. 2. 1 request that the amendment become effective on Feb. 1, 1986 I understand that the amendment will not become effective unless approved and issued by Standard. 3. 1 request that the amendment be approved by STANDARD subject to STANDARD'S usual underwriting requirements, including, if applicable, Evidence of Insurability or a Pre-existing Condition limitation. 4. 1 request that the amendment,if approved by STANDARD,be issued in the policy language customarily used by STANDARD. 5. 1 understand that any increase in INSURANCE for a MEMBER who is not ACTIVELY AT WORK all day on the MEMBER'S last regular work day before the scheduled effective date of the amendment will be deferred until the first day after the MEMBER completes one full day of ACTIVE WORK. 6. 1 request that the amendment, if approved and issued by STANDARD, become effective by its terms without any further acceptance by the Policyowner,and that a copy of this Request for Group Insurance Amendment form be attached to and made a part of the amendment. I understand that if a group insurance policy is issued as a result of this request,that policy must be separately accepted by the Policyowner's signature on form 1755, Acceptance of Group Insurance Policy. ` ` L4 Signed By: Title: 'i Date: 11 PJIcyowner's Repkesentative lddress 0 J0, 2 Zip Code: 'No32 Group Representative: Dave Kible/Shelly Dion Group Office: Seattle Form 3408 Rev.8/84 Date Received At Group Office: 3 339619-01 CITY OF KENT ATTN PAYROLL 220 SOUTH 4TH KENT WA 98032 GROUP LIFE INSURANCE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE POLICY ENDORSEMENT This endorsement is attached to and made a part of each GROUP LIFE INSURANCE and ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE POLICY issued to the above POLICYOWNER by STANDARD INSURANCE COMPANY . This endorsement does not apply to any GROUP POLICY covering only ACCIDENTAL DEATH AND DISMEMBERMENT . The GROUP POLICY is endorsed as follows: SEAT BELT BENEFIT STANDARD will pay an additional accidental death benefit , called the SEAT BELT BENEFIT , if you die as a result of an AUTOMOBILE accident and you were wearing a SEAT BELT at the time of the accident . The following rules apply : 1 . The SEAT BELT BENEFIT equals $50 , 000 or the amount of the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE benefit paid because of your accidental death , whichever is less. 2- STANDARD must receive satisfactory written proof that your death resulted from an AUTOMOBILE accident and that you were wearing a SEAT BELT at the time of the accident . A copy of the police accident report should be submitted with the claim. SEAT BELT means a properly installed seat belt , lap and shoulder restraint , or other restraint approved by the National Highway Traffic Safety Administration . AUTOMOBILE means a motor vehicle licensed for use on public highways . This endorsement is effective April 1 , 1986. No action by the POLICYOWNER is required . STANDARD INSURANCE COMPANY By S'ecr etary President Registrar STANDARD INSURANCE COMPANY ' �� ►> ­90� home office: Portland.Oregon 97207 P.O.Box 711 (103)248-2700 April 18, 1986 IMPORTANT - PLEASE ROUTE TO PARTY RESPONSIBLE FOR EMPLOYEE BENEFITS TO: Our Life and Accidental Death and Dismemberment Policyowners Standard Insurance Company announces a new benefit feature called the Seat Belt Benefit. Under the Seat Belt Benefit, Standard will double the accidental death bene- fit, up to an additional $50,000. This benefit is payable upon receipt of satisfactory proof that death resulted from an automobile accident and that the insured was wearing a seat belt at the time of the accident. A copy of the police accident report should be submitted with the claim. In an effort to encourage your employees to use seat belts, and because we believe wearing seat belts will reduce death claims from automobile accidents, we have added this benefit to your group policy at no additional cost. The attached endorsement is effective April 1 , 1986 and adds the Seat Belt Benefit to your Accidental Death and Dismemberment coverage which is contained in, and issued with a Life Insurance Contract. This benefit is not being added to any policies that have Accidental Death and Dismemberment coverage only. Please file this endorsement in your Group Insurance Administration Manual tinder the Contract Section or with your group policy master contract. a ,.l �.ti a.i.!`� Important Notices w�1- --be --sef�t to you soon. These notices explain the policy change and should be distributed to all insured empoloyees. No action on your part is required for acceptance of the endorsement. If you have any questions, or would like more information about the Seat Belt Benefit, contact your Broker or Standard Group Representative. STANDARD INSURANCE COMPANY DEDICATED TO EXCELLENCE FOR POLICYOWNERS Stagy"PORTLAND, INSURANCE COMPANY OREGON /y Dedicated to Excellence for Policyowners 7 `, goo SW Fifth Avenue Portland, OR 97204-1282 y l4t Request For Group Insurance Amendment Policyowner Name: CITY OF KENT Group Policy Number: 339619 As an authorized representative of the Policyowner, 1. I request that STANDARD amend the above Group Policy to make the following change(s): 1. Please change the Life and AD&D to a 1 X annual earnings with a $50,000 maximum. 2. Please change eligibility to include all full—time employees working 21 hours or more per week. 3. Please include 45 day grace period. January 1, 1989 2. 1 request that the amendment become effective on I understand that the amendment will not become effective unless approved and issued by Standard. 3. 1 request that the amendment be approved by STANDARD subject to STANDARD'S usual underwriting requirements, including, if applicable, Evidence of Insurability or a Pre-existing Condition limitation. 4. 1 request that the amendment,if approved by STANDARD,be issued in the policy language customarily used by STANDARD. ORK day on he MEMBER'S last 5. I understand that any inc reasethe sclheduledRef effective date oANCE for a MEf thhe amendment wC be deferred BER who is not ATIVELY AT Vunntil the first t regular work day before fi st day after the MEMBER completes one full day of ACTIVE WORK. 6. 1 request that the amendment, if approved and issued by STANDARD, become effective by its terms without any further acceptance by the Policyowner,and that a copy of this Request for Group Insurance Amendment form be attached to and made a part of the amendment. I understand that if a group insurance policy is issued as a result of this request.that policy must be separately accepted by the Policyowner's signature on form 1755. Acceptance of Group Insurance Policy. Signed B Title: /•2 o g Y' c � 4Pucyo0wne,'s Representative Date: Scott Martin Group Office: Seattle Group Representative: Service Representative: Colleen Haight Date Received At Group Office: SI-18-3408 (11/86) Supplemental Information: To Be Completed by Group Representative Please be sure the policyowner clearly understands the change requested and any change in premium rates. Underwriting Are there any changes to rates. lives, and/or volume created by this requested amendment? [ Yes ❑ No If yes, complete the following information and attach census showing age. sex, and insurance amounts for persons to be added or dropped. Life Dep. Life AD&D STD LTD Dental Other Quoted Rates •19 .o6 Approximate Volume Increase (Decrease) Lives Increase (Decrease) Proposal prepared by X7, Home Office ❑ Group Office ❑ None Prepared Is any evidence of insurability required on the effective date? ❑ Yes Y No If yes, please attach forms. Important Notices/Revised Certificates When applicable, Important Notices will be prepared. If benefits differ by classification, should the entire schedule be printed in one notice (or Certificate if being revised)? Yes No, print separate notices for eac lass. if� needed? i Yes — No �� Are Revised Certificates If yes,yes, mail them to: ❑ Bro-<er Group Office Policyowner IF F. �l > Please state the amount of Revised Certificates needed. Y S� sue- arcs r�� Commissions Does this Amendment involve a change of broker? ❑ Yes X No Change of Commission Scale? Yes ❑ No. If yes, please provide name of broker, address and Commission Scale. Name Address City State Zip Code Commission Scale Standard CcimmissiQn scale Mailing Do you want the completed amendment mailed to the policyowner from the Home Office? ❑ Yes X-] No. If yes, please provide broker's name & address for mailing the copy. Name Address City State Zip Code Comments ~ ~ L . (, �cc-� l �� GROUP POLICY AMENDMENT NO . 7 Attached to and made a part of Group Policy 339619 issued to City of Kent as Policyowner . It is agreed that this policy is amended as follows ' 1 . The definition of the term Member as saowfoli in the section entitled GENERAL DEFINITIONS is amended to Member means an active employee or the mayor of the Employer, or seasonal employee, who is regularly other than a temporary t P1 hours each week . scheduled to work at leas E . The section entitled GENERAL DEFINITIONS is amended by the addition of the following definition of Basic Annual Earnings : e or salary ( not Basic Annual Earnings means basic annual wag pay, education including overtime, bonuses, commissions, in Basic pay , specialty pay and other extra compensation) . Changes shall be Annual Earnings because of changes in basic wage or salary with or effective on the first day of the calendar month coinciding If the next following the date of change in basic wage or salary . is not actively at work on the date on which an increase in Member ease Basic Annual Earnings would otherwise on effective, � Member iisrboth shall be deferred until the next day period any of eligible and actively at work . At the coQtheremlossent of Basic Annual total disability or at the time of any Earnings shall be the Member 's � 1theAnnual disabilityncommences as of tor other day of the calendar month in whichapproved after loss occurs . Any change in basic wao*her loss salaryge or p occurs shall not be total disability begins or after any considered in determining the amount of Basic Annual Earnings . 3 . Section 1 . SCHEDULE OF INSURANCE is amended to read as follows : of Acient The Face Amount of Life Insurance a end 70hwha nc ipal m lleach beequalctodthe Insurance for a Member and 9 Member's Basic Annual Earnings, rounded hto the nextmum higheFacermount 1 . 00, aif not already an even dollar amount . maximum Principal Sum shall each be $50 , 000 . The Face Amount of Life Insurance and the Principal Sum oualctod6�Y. Insurance for a Mnmwouldgbe7applicable0 through 7forhalMember undel each be r age 70 . of the amount whit Page i of Amendment 7 Group Policy No . 339619 The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member age 75 or over halMe eachmber be equal to 50% of the amount which would be applicable forChanges in amounts of insurance because of changes in age shall be effective on the first day of the calendar month next following the date of change in age . Grace Period is amended to read as 4 . Section 9 . PREMIUMS, D . follows : race period of 45 days will be granted for the payment of g which grace period premiums accruing after the first premium, during owner be the policy shall continue in force eof the premiums blaccruingsforlthe liable to Standard for the pacy ym period the policy continues in force . by the Policyowner to Standard that this If written notice is given premium due date or before the policy shall be discontinued as of ashall be discontinued as of the end of the grace period, this policy ce or the date of receipt of the notice, date specified in the noti whichever is later . 1 � S . The renewal date next following October 1 , 1986 will be January 1990 and renewal dates thereafter will occur on January 1 . 6 . The premium rate for Life Insurance shall be $ . 19 monthly per 'hanged Face Amount , beginning January 1 , 1989 and continuing until changed as provided in the group policy . This amendment is effective as of January 1 , 1989, provided that any i Member who is not actively at increase in insurance for a work on the next day on which he is January 1 , 1989 shall be deferred until actively at work . STANDARD INSURANCE COMPANY By ,02 President Secretary Page 2 of Amendment 7 Group Policy No . 339619 StandaidPORTLAND, OREGO INSURANt JMPA N Request For Group Insurance Amendment Dedicated to Excellence for Policvowners 900 SW Fttth Avenue Portland, OR 97204-1282 CITY OF KENT 339619-A Policyowner Name: Group Policy Number: As an authorized representative of the Policyowner, 1. 1 request that STANDARD amend the above Group Policy to make the following change(s): Please amend the Group Long Term Disability premium rate to a per member rate. The rate, effective January 1, 1989 will be $4.00 per member. 2. 1 request that the amendment become effective on January 1, 19$9 I understand that the amendment will not become effective unless approved and issued by Standard. 3. 1 request that the amendment be approved by STANDARD subject to STANDARD'S usual underwriting requirements, including, if applicable, Evidence of Insurability or a Pre-existing Condition limitation. 4. 1 request that the amendment,if approvedby STANDARD,be issued in the policy language customarily used by STANDARD. 5. 1 understand that any increase in INSURANCE for a MEMBER who is not ACTIVELY AT WORK all day on the MEMBER'S last regular work day before the scheduled effective date of the amendment will be deferred until the first day after the MEMBER completes one full day of ACTIVE WORK. 6. 1 request that the amendment. if approved and issued by STANDARD, become effective by its terms without any further acceptance by the Policyowner,and that a copy of this Request for Group Insurance Amendment form be attached to and made a part of the amendment. I understand that if a group insurance policy is issued as a result of this request,that policy must be separately accepted by the Policyowner's signature on form 1755, Acceptance of Group Insurance Policy. � � . Title:���z)_�rx..�� / Date: �— Signed By: Policyowner's Representative Group Representative: Scott Martin Group Office: Seattle Service Representative: Colleen Haight Date Received At Group Office: SI-18-3408 (3i 89) Supplemental Information: To Be Completed by Group Representative Please be sure the policyowner clearly understands the change requested and any change in premium rates. Underwriting Are there any changes to rates, lives, and/or volume created by this requested amendment? ❑ Yes ] No If yes, complete the following information and attach census showing age, sex, and insurance amounts for persons to be added or dropped. Life Dep. Life AD&D STD LTD Dental Other $4.00 per member Quoted Rates Approximate Volume Increase (Decrease) Lives Increase (Decrease) Proposal prepared by ❑ Home Office ❑ Group Office PQ! Client ID# None Prepared Is any evidence of insurability required on the effective date? ❑ Yes ] No If yes, please attach forms. Mailing instructions Do you want the completed Amendment mailed from the Home Office to: [ Group Office ❑ Broker (provide address) ❑ Policyowner (provide BOTH addresses) (NOTE: provide STREET address, no Post Office Boxes) Policyowner Broker Name City of Kent Name Street Street Address Inn South Ott, Avenge Address City Kent City State/Zip Code Wa 98032 State/Zip Code Important Notices/Revised Certificates When we issue an Amendment,we will also issue Important Notices.All classifications will be shown in a single Important Notice.If it is necessary to split out classifications in separate Important Notices,or if the policyowner needs new Certificates,please indicate as such in the COMMENTS section below. How many notices? N/A How many certs? Where should Important Notices/Certificates be mailed? (Check only one box): C Group Office C The above policyowner address El The above broker address Comments The group has been administering their computer system by a per member rate since Jan. 1, 19.89, by billing themselves $4 .00 per member for the core LTD coverage. (It is not being deducted from the employees payroll) Scott Martin, Sales Rep, has. approved the per member rate. Please set this up C on a new suffix -04. 9re:WU-Lk"-\ &-V-L erne �Cr sufG-y Oq kLk;t CLW'6X CL. W*A jeu\ren.ci -t) "CIT E T-'L-r STANDARD INSURANCE COMPANY P.O. BOX 711 PORTLAND, OREGON 97207 GROUP POLICY NUMBER 339619—A NAME OF POLICYOWNER CITY OF KENT TYPE OF COVERAGE LONG TERM DISABILITY INSURANCE EFFECTIVE DATE January 1 , 1989 INITIAL POLICY TERM One Year PREMIUM DUE DATES January 1, 1989 and the first day of each calendar month thereafter POLICY DELIVERED IN Washington and governed by the laws of that state. STANDARD INSURANCE COMPANY agrees to pay the benefits provided by this GROUP POLICY, in accordance with the provisions of this GROUP POLICY. The consideration for this GROUP POLICY is the application of the POLICYOWNER and the payment by the POLICYOWNER of premiums as provided herein. The GROUP POLICY is issued for the Initial Policy Term shown above,ending on the first day after the end of such policy term at 12:01 A.M. Standard Time at the POLICYOWNER'S address. This GROUP POLICY may be renewed for successive renewal periods by the payment of the premium on each renewal date,provided the number of persons insured on each renewal date is neither less than the Minimum Participation Number nor less than the Minimum Participation Percentage(shown in the Policy Data).The length of each renewal period will be determined by STANDARD,but will not be less than 12 months. All provisions on this and the following pages are a part of this GROUP POLICY.The Certificate of Insurance issued for delivery to each insured MEMBER will include Section One of this GROUP POLICY. The terms "you" and "your" used in Section One refer to the insured MEMBER. The definitions of terms in Section One apply whenever the terms are used anywhere in this GROUP POLICY. Defined terms are printed in all capital letters. STANDARD INSURANCE COMPANY By Secretary President Group Insurance Policy GP186—LTD POLICY DATA POLICY NUMBER 339619-A INITIAL MONTHLY PREMIUM RATE LONG TERM DISABILITY INSURANCE MEMBERS insured for 0 . 21 % of the first $2, 000 Plan A only of the PREDISABILITY EARNINGS of each insured MEMBER (EMPLOYER PAID) All other MEMBERS The sum of ( a) 0 .21% of the first $2, 000 of the PREDISABILITY EARNINGS of each insured MEMBER (EMPLOYER paid) , and (b) the appropriate percentage below of the first $6 , 000 of the PREDISABILITY EARNINGS of each insured MEMBER (MEMBER paid)* : MEMBER ' S age on January 1 .50% Under age 30 52% Age 30 through 34 58% Age 35 through 39 75% Age 40 through 44 1 04% Age 45 through 49 1 . 50% Age 50 through 54 2 15% Age 55 through 59 2 . 69% Age 60 through 64 3 . 54% Age 65 through 70 3 54% Age 70 or over *Changes in premium rate because of changes in age become effective on the January 1st coinciding with or next following the change . MINIMUM PARTICIPATION NUMBER 10 insured MEMBERS MINIMUM PARTICIPATION PERCENTAGE Plan A 100% of eligible MEMBERS Plan B 25% of eligible MEMBERS TABLE OF CONTENTS PAGE 1 SECTION ONE - COVERAGE PROVISI . . . Part 1 . GENERAL DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Part 2 . BECOMING INSURED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Part 3 . WHEN INSURANCE ENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Part 4 . BECOMING INSURED AGAIN AFTER INSURANCE ENDS . . . . . . . . . S Part 5 . DEFINITION OF DISABILITY . . . . . . . . . . . . . . . . S Part 6 . LONG TERM DISABILITY INSURING CLAUSE • B . . . . . . . . . . Part 7 . EXCLUSIONS AND LIMITATIONS . . . . . . . . . . . . . . . . 11 Part S . SCHEDULE OF LONG TERM DISABILITY INSURANCE . . . . . . . . . . 11 A . ELIMINATION PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B . MAXIMUM BENEFIT PERIOD . . . . . . . . . • , • . 13 C . AMOUNT OF LTD BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . 14 D . PREDISABILITY EARNINGS . . . . . . . . . . . . . . . . . . . . . . . 15 E . INCOME FROM OTHER SOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . Part 9 . OTHER LONG TERM DISABILITY BENEFITS AND PROVISIONS . . 1s A . REHABILITATION PROVISION (RETURN TO WORK) . . . . . . . . . . . . B . SURVIVORS BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 $ 19 C , WAIVER OF PREMIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D . BENEFITS AFTER INSURANCE ENDS OR IS CHANGED . . . . . . . . . . 19 Part 10 . CLAIMS PROVISIONS AND PROCEDURES FOR LTD BENEFITS . . EO PAGE Part 11 . TIME LIMITS ON LEGAL ACTIONS AND CERTAIN DEFENSES . - 23 Part 12 . ASSIGNMENT NOT PERMITTE . . . . . . . • • • • SECTION TWO - POLICYOWNER PROVISIONS . . . . . . . . . . . . Part 1 . PREMIUMS . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . Part 2 . DIVIDENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Part 3 . CERTIFICATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Part 4 . RECORDS AND REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Part S . MISSTATEMENT OF AGE . . . . . . . . . . . . . . . Part b . ENTIRE CONTRACT; CHANGES . . . . . . Part 7 . INCONTESTABLE CLAUSE . . . . . . . . . . . Part S . EFFECT ON WORKER ' S COMPENSATION . . . . . . . . . . . . INDEX OF DEFINED TERMS PAGE PAGE ACCIDENTAL BODILY INJURY . . . . . . 1 LONG TERM DISABILITY INSURANCE 1 ACTIVELY AT WORK . . . . . . . . . . . . . . 3 LTD BENEFIT . . . . . . . . . . 1 CPI-W . . . . . . . . . . . . . 8 MAXIMUM BENEFIT PERIOD . . . . . . . . 12 DISABILITY . . . . . . . . . . . . . . . . . . S MEMBER . . . . . . . . . . . . . . . . . . . . ELIMINATION PERIOD . . . . . . . . . . . . 11 MENTAL DISORDER . . . . . . . . . . . . , . 10 EMPLOYER . . . . . . . . . . . . . . . . . . . . . . 1 PHYSICIAN . . . . . . . . . . . . . . . . . . , . 10 EVIDENCE OF INSURABILITY . . . . . . 1 PREDISABILITY EARNINGS . . . . . . . 14 GROUP POLICY . . . . . . . . . . . . . . . . . . 1 PREEXISTING CONDITION . . . . . . . . . 9 HOSPITAL . . . . . . . . . . . . . . . . . . . . . . it PREGNANCY . . . . . . . . . . . . . . . . . . . , 1 INCOME FROM OTHER SOURCES . . . . . 15 SICKNESS . . . . . . . . . . INDEXED PREDISABILITY EARNINGS 7 STANDARD . . . . . . . . . . . . . . . . . . . . . . INSURANCE . . . . . . . . . . . . . . . . . . . . . 1 SURVIVORS BENEFIT . . . . . . . . . . „ 18 SECTION ONE - COVERAGE PROVISIONS Part I . GENERAL DEFINITIONS STANDARD means Standard Insurance Company, Portland, Oregon . EMPLOYER means City of Kent . GROUP POLICY means STANDARD' S group policy number 339619-A issued to the POLICYOWNER . INSURANCE means your disability insurance under LONG TERM DISABILITY the GROUP POLICY, whether under PLAN A or PLAN B . INSURANCE means your LONG TERM DISABILITY INSURANCE under the GROUP POLICY . LTD BENEFIT means the monthly LONG TERM DISABILITY INSURANCE benefit payable to you according to the terms of the GROUP POLICY . SICKNESS means your sickness, illness, or disease . PREGNANCY means your pregnancy , childbirth, or related medical conditions . means an injury to your body caused by an ACCIDENTAL BODILY INJURY accident . ENCE OF INSURABILITY if required, means you must : Providing EVID lth and medical history form provided by 1 . Complete and sign a hea STANDARD; uthorizing STANDARD to obtain information E . Sign STANDARD' S form a about your health; and our insurability 3 . Provide any additional information about Y reasonably required by STANDARD . All required information must be provided to STANDARD at your expense . C0109M _ 339619-A Printed (4/13/89 ) 1 LTD POLICY Part 2 . BECOMING INSURED To become insured You must meet each of the following requirements plus the ACTIVE WORK requirement : 1 . You must be a MEMBER . 2 . You must be eligible for INSURANCE . 3 , You must apply for INSURANCE if you wish to become insured under Plan B . CO209F A . DEFINITION OF MEMBER you are a MEMBER if you are all of the You must be a MEMBER . following 1 , An active employee of the EMPLOYER , other than a temporary or seasonal employee, who is either of the following : a . A corrections department employee who is a member of Local 1088, or b . Any other active employee , other than a member of Local 1747 or Local 1088; 2 . Regularly scheduled to work at least 21 hours each week ; and 3 . A citizen or resident of the United States or Canada . co2A1N B . ELIGIBILITY FOR INSURANCE You must be eligible for INSURC�ate°ofathere eGROUPIPOLICY , nde for A(8) on the later of (A) the effectivethe date you become a the first day of the calendar month following MEMBER . CO2B1R _ 339619-A Printed (4/13/89 ) - 2 LTD POLICY C . APPLICATION FOR INSURANCE You must apply for INSURANCE under Plan B and agree tocmake the required contributions to the POLICYOWNER by signing ed enrollment card . hthePOostYofN R determine CE the amount of your contribution toward D . PREEXISTING CONDITION EXCLUSION If you apply for INSURANCE under Plan B more than 31 days after you are first eligible for INSURANCE, you will be subject to PREEXISTING CONDITION EXCLUSION NO . 2 . See Part T . A . RISKS NOT COVERED . E . EFFECTIVE DATE OF INSURANCE tive on the Your INSURANCE under yeouPlan A meet the become ACTIVE WORKcrequirement done that you become eligible, date . ctive on Your INSURANCE under Plan thellACTIVEeWORKerequirementneonfthat the following dates if You e date - ( 1 ) The date you become eligible for INSURANCE, if you apply on or before that date . (E) The date you apply for INSURANCE under Plan B, if you apply after the date you become eligible for INSURANCE . F . ACTIVE WORK REQUIREMENT If you were DISABLED on the day before the scheduled effective date of your INSURANCE, then firstthe dayeffective after date you of your completeNoneAfullwday of ill be delayed until the ACTIVE WORK . For purposes of this ACTIVE WORK requirement , you are DISABLED if of ILY INJURY, you are unable, as aesulthetmaterial NdutiesCofDyourL D ownoccupation . or PREGNANCY, to perform ACTIVE WORK and ACTIVELY AT WORK mean performing the usual duties of your job at your EMPLOYER' S usual place of business . This ACTIVE WORK requirement also applies to any increase in your INSURANCE . CO2C9K 3 - 339619-A Printed (4/13/89 ) LTD POLICY Part 3 . WHEN INSURANCE ENDS Your INSURANCE will end automatically on the earliest of the following dates a . The date you cease to be a MEMBER as defined in Part E •A • full time member of the armed forces of b . The date you become a any country . our INSURANCE under Plan B, the last day of C . With respect to Y you made the required premium the last period for which y contribution for your INSURANCE . This provision will not end your INSURANCE under Plan A . d. The date the GROUP POLICY terminates . e , The date you cease to be ACTIVELY AT WORK for your EMPLOYER on your regular work days because of (a) a temporary layoff or (b) a general work stoppage ( including a strike or lockout ) resulting from a labor dispute . f . The date you cease to be ACTIVELY AT WORK for your EMPLOYER on your regular work days for any other reason . However, your INSURANCE may be continued (unless it endundwhiletemsyou are through e . above) during the following periods absent from ACTIVE WORK : ( 1 ) While you are receiving full salary ( including sick pay ) from your EMPLOYER; (P) During the ELIMINATION PERIOD and while LTD BENEFITS are payable; and by your EMPLOYER ( 3) During a leave of absence approved and scheduled to last for 30 days or less . C0309D Part 4 . BECOMING INSURED AGAIN AFTER INSURANCE ENDS You may become insured again under the GROUP POLICY after ouonitSURANCE ends . The general rule is that you may become insured again same provided in Part 2 . BECOMING INSURED . basis as a new MEMBER , as p However, for purposes of becoming insured again, the requirements of Part E . will be modified in specific situations as follows : 339619-A Printed (4/13/89 ) 4 LTD POLICY 1 If your INSURANCE under Plan B ends because you fail to make the required p remium contribution, you will be subject to PREEXISTING CONDITION EXCLUSION NO . 2 when You become insure again under Plan B . 2 . If your INSURANCE ends bibleS for Ya u cease to INSURANCEife you ME yo becomea will be immediately eligible MEMBER again within 90 days after your INSURANCE ends . Your INSURANCE will become effective again on the date determined from Part 2, and will not be retroactive to the date your INSURANCE ended . Your INSURANCE will be subject to the PREEXISTING CONDITION exclusion in Part 7, as follows ed again more than 90 days after your INSURANGE ( 1 ) If you become insur o any ends, the PREEXISTING CONDITION onCONDITIONexclusio insureddate you t youbecome condition which is a PREEXISTING insured again . (2) If you become insured again within 90 days after your INSURANCE ply ends, o any the PREEXISTING CONDITIPREEXISTINGexclusion CONDITIONwatlthepstarttof te condition which was a PRE ur ose only , the two periods prior period of INSURANCE . For this period of continuous INSURANCE of INSURANCE will be treated as one p and the period when you were not insured will be ignored . (The same principles will apply if your INSURANCE ends two or moThetthreeaor p you become insured again within 90 days . each time y purposes of the more periods of INSURANCE will be added together for p P PREEXISTING CONDITION exclusion) . Your LTD DISABILITY end, your Note : After Y BENEFITS for a period of interruption if you are a MEMBER and INSURANCE will continue without any urn to ACTIVE WORK for your EMPLOYER . This Part 4 will immediately ret your INSURANCE continues while you are receiving LTD not apply since BENEFITS . C0409D Part S . DEFINITION OF DISABILITY A . DEFINITION OF DISABILITY FOR SAFETY MEMBERS The definition of DISABILITY changes after LTD BENEFITS have been paid for 12 months . 1 , Until LTD BENEFITS have been paid for t2 months, you are only required to be DISABLED from your own occupation . _ 339619-A Printed (4113/89 ) S LTD POLICY occatn if as esu of You are DISABLED from your ownupor1OPREGNANCY� ryoultare SICKNESS, ACCIDENTAL BODILY INJURY EITHER : a . Unable to perform with reasonable continuity the material duties of your own occupation; OR b . Unable to earn more than 80% of your INDEXED PREDISABILITY EARNINGS while working in your own occupation . aid for 12 months, You will be Until LTD BENEFITS have been p another occupation if you considered DISABLED while working in There is no limit o are DISABLED from your own occupation . while the amount you can earn from work upationhin e occupation Your earnings will you are DISABLED from your own occ be used in determining the amount of your LTD BENEFIT . 2 . After LTD BENEFITS have been paid for 12 months , you must be DISABLED from all occupations . ations if, as a result of You are DISABLED from all occup r PREGNANCY, you are SICKNESS, ACCIDENTAL BODILY INJURY o EITHER perform with reasonable continuity the material a . Unable to P you are duties of any gainful occupation for which reasonably fitted by education, training, OR b . Unable to earn more than 50% of your INDEXED PREDISABILITY other EARNINGS while working in your own or any occupation. B . DEFINITION OF DISABILITY FOR ALL OTHER MEMBERS The definition of DISABILITY changes after LTD BENEFITS have been paid for 24 months . 1 , paid for 24 months, you are only Until LTD BENEFITS have been required to be DISABLED from your own occupation . occupation i Of you are DISABLED from your own ryoultare SICKNESS, ACCIDENTAL BODILY INJURY or PREGG as a NANCY, Y EITHER : Unable to perform with reasonable continuity the material a . 339619-A Printed (4113/89 ) 6 - LTD POLICY duties of your own occupation; OR b . Unable to earn more than 80 Ofoyourwn INDEXED PREDISABILITY EARNINGS while working ;n Y our Until LTD BENEFITS have been paid for 24 months, You will be considered DISABLED while working in another occupation if you are DISABLED from your own occupation . There is n your limitupation on the amount You can earn from work intionhecearnings will you are DISABLED from your own occupa be used in determining the amount of your LTD BENEFIT . 2 . After LTD BENEFITS have been paid for 24 months, you must be DISABLED from all occupations . You are DISABLED from all occupations if, as a result of SICKNESS, ACCIDENTAL BODILY INJURY or PREGNANCY, you are EITHER a , Unable to perform with reasonable continuity the material gainful occupation for which you are duties of any 9 and experience; reasonably fitted by education, training, OR ILITY b . Unable to earn more than 50X in yyourur lN own EDorRE any ABother EARNINGS while working occupation . INDEXED PREDISABILITY EARNINGS means an earamount determined as follows: ED Until you have been DISABLED for oneEARNINGSou yourXlastRfullA day lOf EARNINGS will equal your PREDISABILIT STANDARD will ACTIVE WORK before you became DISABLED . Thereafter, on each increase the amount of your IN becameDEXEDPDIS ISABILITY EA DISABLED . The amount of each anniversary of the date you becam increase will equal A or B, whichever is less, where: A = 10% of your INDEXED PREDISABILITY EARNINGS during the preceding year of DISABILITY . the B = The rate of increase in the multiplied PryourIndex INDEXEDI PREDISABILITY preceding calendar year muing year ofyDISABILITY . EARNINGS during the preceding y There will never be a decrease in yourPriceXIndexED ( CPI- ITY EARNINGS, W) even if there is a drop in the Consumer _ 339619-A Printed (4/13/89) 7 LTD POLICY CpI-W means the Consumer Price Index for Urban Wage Earners and Clerical Workers published by the United States Department uSeLaanother the index is discontinued or changed, STANDARD may nationally published index which is comparable to the CPI-W. C0804C Part 6 . LONG TERM DISABILITY INSURING CLAUSE Subject to all the terms of the GROUP POLICY, STANDARD will pay the LTD t of satisfactory BENEFIT described in Part 8 upon receiptory written proof that you have become DISABLED while insured under the GROUP POLICY . 1F C060 Part 7 . EXCLUSIONS AND LIMITATIONS TO LONG TERM DISABILITY INSURANCE A . RISKS NOT COVERED covered for a disability caused or not 1 . WAR : You are war or any act of war . WAR means declared or contributed to by undeclared war, whether civil en organized or onforces n ofana substantial armed co nflmilitary nature . ELF-INFLICTED INJURY : to by an e t covered for a intentionally 2 . INTENTIONALLY S disability caused or contributed self-inflicted injury . 3 . PREEXISTING CONDITION a . PREEXISTING CONDITION EXCLUSION NO . 1 : Your INSURANCE under both Plan A and Plan B is subject to the following exclusion . tributed You are not covere to by a PREEXISTING d foCONDITION llory caused or medfcalor°nsurgical both treatment of a PREEXISTING uOsDon10thenldateyoyoueebecome of the following reqiremen DISABLED : 1 ) You have been continuously insured under the GROUP POLICY for at least 12 months; and 2) You have been ACTIVELY AT WORK for at least one full _ 339619-A Printed ( 4/13/89 ) 8 LTD POLICY day after those 12 months of continuous INSURANCE . PREEXISTING CONDITION for purposes of PREEXISTING CONDITION EXCLUSION NO . 1 means a mental or physical condition for which you have done any of the following at any time during the 180 day period just before the effective date of your INSURANCE under the GROUP POLICY : 1 ) Consulted a PHYSICIAN . 2) Received medical treatment or services . 3) Taken prescribed drugs or medications . you applied b , PREEXI RANCENG NDunder Plan ITION U8 more SION Othan 31 days after you for INSURANCE were first eligible, Your INSURANCE under Plan B is subject to the following exclusion. You are not covered forONDITIONIlory caused medicalororonsurgical to by a PREEXISTING C you meet bath treatment of a PREEXISTING CONDITION unless y you become of the following requirements on the date Y DISABLED 1 ) You have been continuously insured under Plan B of the GROUP POLICY for at least 12 months; and one full 2) You have been ACTIVE2Ym� thsR WOK f or at least ofcontinuousINSURANCE day after those under Plan B . PREEXISTING CONDITION for purposes of PREEXISTING CONDITION EXCLUSION NO . 2 means a ny ofental or the fo physicowing al condition for whicih�ouggavdayonperiod just before the any time during effective date of your INSURANCE under Plan B of the GROUP POLICY . 1 ) Consulted a PHYSICIAN . 2) Received medical treatment or services . 3) Taken prescribed drugs or medications . _ 339619-A Printed (4/13/89) - 9 LTD POLICY EXCEPTION TO PREEXISTING CONDITION EXCLUSION NO . 2 : If you become DISABLED by a PREEXISTING CONDITION as defined in PREEXISTING CONDITION EXCLUSION NO . 2, LTD BENEFITS will nonetheless be payable subject to the following : a) You must meet the requirements of PREEXISTING CONDITION EXCLUSION NO . 1 ; and b) Benefits will be payable as if you were insured only under Plan A of the GROUP POLICY . C07A90 B . LIMITATIONS 1 . ELIMINATION PERIOD : No LTD BENEFITS are payable for the ELIMINATION PERIOD . 2 . MAXIMUM BENEFIT PERIOD : No LTD BENEFITS are payable after the end of the MAXIMUM BENEFIT PERIOD . 3 . REGULAR CARE OF A PHYSICIAN : No LTD BENEFITS will be paid for any period of DISABILITY when you are not under the regular care of a PHYSICIAN . PHYSICIAN means a licensed medical professional , other than yourself, diagnosing and treating you within the scope of the license. 4 . MENTAL DISORDER : Payment of LTD BENEFITS is limited to 24 months for each period of DISABILITY caused or contributed to by a MENTAL DISORDER . However, if you are a resident patient in a HOSPITAL at the end of the 24 months, this limitation will not apply while you remain continuously confined . MENTAL DISORDER means a mental , emotional or behavioral disorder . Printed ( 4/13/89 ) - 10 - 339619-A LTD POLICY HOSPITAL means a legally operated hospital providing full-time medical care and treatment under the direction af Rest ulhomes, staff g licensed convalescentans homes, Dhomes f or lthe aged, and nursing homes, custodial , educational , or facilities primarily affording rehabilitative care are not HOSPITALS . C07B2W Part S . SCHEDULE OF LONG TERM DISABILITY INSURANCE This Schedule of LONG TERM DISABILITY INSURANCE has five sections : A . ELIMINATION PERIOD B . MAXIMUM BENEFIT PERIOD C . AMOUNT OF LTD BENEFIT D . PREDISABILITY EARNINGS E . INCOME FROM OTHER SOURCES You must read each section to understand when LTD BENEFITS are payable and how LTD BENEFITS are calculated . C0803P A . ELiMINA7I0N PERIOD must be ou ELIMINATION PERIOD means the length of time Y a able . Your continuously DISABLED before LTD BENEFITStobthemePlanyunder which you OinsuredD is on yourrlastdfullodayngof ACTIVE WORK before you Yo become DISABLED . PLAN A of Your ELIMINATION PERIOD is the erist 180of s days ickleave of ach to whichdyou continuous DISABILITY , or thep are entitled under your EMPLOYER 'S sick leave program, whichever is longer . PLAN B is the first 90 days of each period of Your ELIMINATION PERIOD continuous DISABILITY, or the period of sick leave to wprogram sick leave g , are entitled under your EMPLOYER ' S whichever is longer . 339619-A Printed (4/13/89 ) - 11 - LTD POLICY Your ELIMINATION PERIOD begins on the date you become DISABLED . LTD BENEFITS are never payable for the ELIMINATION PERIOD . You must be seen regularly and treated by a PHYSICIAN during the ELIMINATION PERIOD . TEMPORARY RECOVERY DURING THE ELIMINATION PERIOD: our DISABILITY during the ELIMINATION Temporary recovery from y purposes of serving the PERIOD will have the following effect : Far ELIMINATION PERIOD, all separate period of DISABILITY from the same cause or causes will be added toyouher mustnserveathe full ELIMINATION continuous DISABILITY . However, PERIOD within a period of 35 consecutive days for each 30 days o the ELIMINATION PERIOD . C0$A9M B . MAXIMUM BENEFIT PERIOD MAXIMUM BENEFIT PERIOD means the longest period of time for which for any one period of continuous LTD BENEFITS are payable DISABILITY, whether from one or more causes . Your MAXIMUM BENEFIT PERIOD is determined as follows : Your MAXIMUM Your Age When BENEFIT PERIOD DISABILITY Begins 61 or younger To age 65 or for 5 years. Plan A whichever is shorter To age 65 Plan B . • • • • ' ' ' . . 3 years 6 months 62 . . . . . . • • • ' • . 3 years 63 . . . . . . . . . 2 years 6 months 64 . 2 years 65 • 1 year 9 months 66 . 1 year 6 months 67 . . . . . . . . . . . ' . . 1 year 3 months 68 . . . . . . . . . . • • 1 year 69 or older . • • • • • . ' . of the ON Your MAXIMUM BENEFIT PERIOD begiTs at the PERIOD, LTDdBENEFITS are Mpaid lat PERIOD . During the MAXIMUM BENEFI you ualify for LTD of each monthly period for which Y q time the end FITS will stop at your death or at any nfor LTD BENEFITS . LTD BENE during the MAXIMUM BENEFIT PERIOD when you no longer qualify _ 339619-A Printed (4/13/89) i2 LTD POLICY BENEFITS . LTD BENEFITS will stop at the end of the MAXIMUM BENEFIT PERIOD even if you are still DISABLED . TEMPORARY RECOVERY DURING THE MAXIMUM BENEFIT PERIOD : LTD BENEFITS became payable, temporary recovery from your effect : For purposes of DISABi�; "f , will have the followingtwo Li; n�r=FITS during the MAXIMUM BENEFIT PERIOD, any continuing tFe same cause or causes will be added periods of DISABILITY rs �°' _ -q of continuous DISABILITY if they together and treated as one Nei r lass than i80 days . Thus, are separated by a period of recovery a new ELIMINATION PERIOD will not be required. the PREDISAaBIdLthe EARNINGS used to compute your LTD BENEFIT will not M of the AXIM , BC'j�''TT MAXIMUM BENEFIT PERIOD will be the perbodaofe recovery . MAXIMUM PERIOD remaining unused No LTD BENEFITS will be payable under this provision after benefits ou under any other group long term disability become payable to y insurance policy . This rule prevents double coverage if you become insured under another policy while you are working during a period of temporary recovery . C08B9B C . AMOUNT OF LTD BENEFIT Your LTD BENEFIT equals your MAXIMUM LTD BENEFIT reduced by your TD is INCOME FROM OTHER SOURCES . Your MAXIMUM you insuBredEonTyourd last mfull according to the Plan under day of ACTIVE WORK before you ubecomes are yabDISABleEunder Benefits will not be Plan B . payable under Plan A if benefit PLAN A BENEFIT equals A or B, whichever is less, Your MAXIMUM LTD where : A = 50% of your PREDISABILITY EARNINGS . B = $1 , 000 . PLAN B Your MAXIMUM LTD BENEFIT equals C or D, whichever is less, where : C = 66 2f3% of your PREDISABILITY EARNINGS . _ 339619-A _ Printed (4/13/89) 13 LTD POLICY D = $4, 00t) . The minimum LTD BENEFIT is $50 . PREDISABILITY EARNINGS are defined in Part 8 . D . INCOME FROM OTHER SOURCES are defined in Part S .E . C08C9E D . PREDISABILITY EARNINGS your monthly rate of earnings from PREDISABILITY EARNINGS means but your EMPLOYER including commiss , longevity pay,coeducation n� Pay, excluding bonuses, overtime pay , rules specialty pay and any other extra compensation . The following apply to the computation of your monthly rate of earnings : e of earnings on any date includes the Commissions Your monthly rate to you by your EMPLOYER during the average monthly commission p our period of employment if preceding 12 calendar months for during y less than 12 months) . Weekly Pay Weekly earnings are multiplied by 4 . 333 to find your monthly rate of earnings . a rate is month b multiplied by the number of Hourly Pay : Your hourly p Ynot more You are regularly scheduled to work per oudo not have hours y than 1ou to find your monthly rate of earnings . If Y date will rate of earnings on any your monthly ou worked during the regular work hours, be based on the average number of hoyour period of employment if preceding 12 calendar months tar during less than 12 months ) , but not more than 173 . EFFECTIVE DATE OF CHANGES IN PREDISABILITY EARNINGS : BILITY EARNINGS used to compute If you become DISABLED, the PREDISA in nthly rate of earninngsgs your LTD BENEFIT will be based on your mo effect on your last full day of ACTIVE WORK before you become change in the amount of your monthly rate of earnings DISABLED . Any of which is approved or becomes effective aft nttoftthesPREDISABILITY ACTIVE WORK will have no effectper of EARNINGS used to compute your LTD BENEFIT for that p DISABILITY . _ 339619-A Printed (4/13/89 ) 14 LTD POLICY NOTE : Two or more separate periods of DISABILITY resulting from the same cause or causes may qualify for treatment as one continuous period of DISABILITY . If so, the PREDISABILITY EARNINGS used to compute your LTD BENEFIT for each separate period of DISABILITY will be the same amounts as for the initial period of DISABILITY . C08D9W E . INCOME FROM OTHER SOURCES INCOME FROM OTHER SOURCES is explained in the following definition, exceptions, and rules . 1 . DEFINITION OF INCOME FROM OTHER SOURCES INCOME FROM OTHER SOURCES means : a . Any sick pay or other salary continuation payable to you by your EMPLOYER , but not including vacation pay . b . One-half the amount of your earnings from work while LTD BENEFITS are payable, including earnings from your EMPLOYER, any other employer, or self-employment . C . Any amount you receive or are eligible to receive as a result of your disability under a Worker' s Compensation Act or similar law, including amounts for partial or total disability , whether permanent or temporary . d . Any amount you, your spouse or your children receive or are eligible to receive because of your disability or retirement under the Federal Social Security Act , the Canada Pension Plan, the Quebec Pension Plan, or any similar plan or act . Early retirement benefits payable prior to normal retirement age under the plan or act will not be considered INCOME FROM OTHER SOURCES unless they are actually received . e . The amount you receive or are eligible to receive because of your disability under any state unemployment compensation disability benefit law or state disability income benefit law . f . The amount you receive or are eligible to receive because of your disability under any group insurance coverage, other than group credit insurance or group mortgage disability insurance . 1S _ 339619-A Printed (4/13/89 ) LTD POLICY amounts from any disability or retirement 9 . The following result of Your plan under which you are covered as abut not limited employment with your EMPLOYER ( including state teacher to a public employee retirement system, a retirement system, or any plan arranged and maintained by a union or employee association for the benefit of its members) ( 1 ) Any disability benefits you receive or are eligible to receive because of your disability .(p) Any retirement benefits you receive or are eligible to receive because of your retirement . if the disability or retirement plan has two or more payment options, STANDARD will ofcothedeplans optionINCOME which OTHER SOURCES the amount roviding, a monthly income provides, or tames closest to p to you for life with no different optionit . This will be true even if you select benefits you receive under any unemployment h . Any compensation law . amount received by compromise, settlement or other i . Any of a . through h . method as a result of a claim for any above . CO$ESZ 2 . EXCEPTIONS TO INCOME FROM OTHER SOURCES The following will not be considered INCOME FROM OTHER SOURCES: a . Any cost of living increase in any INCOME FROM OTHER SOURCES, provided that the increase becomes effective to while you are DISABLED and while you are eligible receive the INCOME FROM OTHER SOURCES . (This exception does not apply to any increase in your earnings from any work . ) b . Any amount received as reimbursement for hospital , medical , or surgical expense . c Any amount which represents reasonable attorneys fees h the claim for INCOME FROM incurred in connection wit 339619-A Printed (4/13/89 ) 16 - LTD POLICY OTHER SOURCES . benefits under the Federal Social Security Act d Any received by , or on behalf of, your dependent child age 18 y or over . e . Benefits from any individual disability insurance policy . C08E4F 3 . RULES FOR INCOME FROM OTHER SOURCES Each month your LTD BENEFIT will be determined using the INCOME FROM same monthly period, even if you actually OTHER SOURCES for the receive the INCOME FROM OTHER SOURCES in another month . If you receive any INCOME FROM OTHER SOURCES periodically other than d use that monthly , STANDARD will determine the monthly equivalent amount in determining your LTD BENEFIT . If you receive any INCOME FROM OTHER SOURCES in a lump sum, STANDARD will prorate the lump sum over the period of time for which the lump sum was paid and use that amount to determine your LTD BENEFIT . If no period of time is stated, STANDARD will att the rimum butable period of time to which the lump sum is fairlyairly ributable prorate the lump sum over that period of time . With respect to INCOME ROM STANDARDOURCES which will offer you youare claiming the following have not yet rece options : Option 1 . STANDARD will determine your LTD oBENEFITf theINeach month using the monthly amountFROM OTHER SOURCES you expect to receive for that period . You will be reimbursed by STANDARD if this results in an underpayment of fgyour claRD im for LTD BENEFITS . You must repay this results in an overpayment of your claim for LTD BENEFITS . Option 2 . STANDARD will pay you LTD BENEFITS without any adjustment on account of that INCOME FROM OTHER SOURCES until your clairo fo vedr that INCOME r FROM M OTHER SOURCES is app meat of your STANDARD for any resulting overpay claim for LTD BENEFITS . - iT - 339619-A Printed ( 4/13/89) LTD POLICY Option 2 . becomes effective automatically if you fail to make a choice . You must notify STANDARD of the amount of the INCOME FROM H SOURCES when it is approved . If it is approved for a period when STANDARD has already paid an LTD BENEFIT, STANDARD will recompute the amount of the LTD BENEFIT which was payable to you for that period . If you have been underpaid, with interest atla pay you the amount of any such underpay rate determined by STANDARD . If you have been overpaid, STANDARD will notify you of the amount of the overpayment You oun of the must immediately reimburse STANDARD for mentsafromtSTANDARD overpayment . You will not receive anY pa Y In the meantime, until STANDARD has been reimbursed in full to reduce the any LTD BENEFITS becoming payable will be applied amount of the overpayment of your claim for LTD BENEFITS . C08E5Y Part 9 . OTHER LONG TERM DISABILITY BENEFITS AND PROVISIONS A . REHABILITATION PROVISION (RETURN TO WORK) If you work while LTD BENEFITS are payable, your earnings from that work will be used in determining the amount of your LTD BENEFIT . NOTE : All or a part of the ELIMINATION PERIOD can be satisfied while you are working if you are considered DISABLED during your period of work activity . C09A1F B . SURVIVORS BENEFIT If you die while LTD BENEFITS are payable to you, STANDARD will pay a lump sum SURVIVORS BENEFIT . The following rules will apply - 1 . The SURVIVORS BENEFIT will equal three times the amount of your MAXIMUM LTD BENEFIT . 2 . The SURVIVORS BENEFIT will first be applied to reduce the rpayment of your claim for LTD amount of any outstanding ove BENEFITS . BENEFIT will be paid to any one or more of the 3 . The SURVIVORS following at the option of STANDARD _ 339b14-A Printed (4/13/89 ) 18 LTD POLICY a , Your spouse . b . One or more of your unmarried children under age 25 . C . Any person providing the care and support of any of them The SURVIVORS BENEFIT will be paid only if you are survived by a spouse, or unmarried child under age 25 . C09B1U C . WAIVER OF PREMIUM Your LONG TERM DISABILITY IwithautE payment in of ct when o of premiumswhil become while LTD DISABLED will be continued BENEFITS are payable . If a period of continuous DISABILITY is extended by a newile You cause while LTD BENEFITS are paab�o' theLTD teEmsFofSthelGROUPtPOLICYinue hand the remain DISABLED, subject following rules (a) LTD BENEFITS will not continue beyond beyond the end of the original MAXIMUM BENEFIT (b) No LTD BENEFITS will be paid for any extension of a period aused or contributed to by a of continuous DISABILITY c risk excluded under Part 7 . C09C1B D . BENEFITS AFTER INSURANCE ENDS OR IS CHANGED Your right to receive LTD BENEFITS for a period of continuous DISABILITY which begins while you are insured under the GROUP POLICY will not be affected by : f the GROUP POLICY after the date you (a) The termination o become DISABLED; of your INSURANCE while the GROUP POLIC (b) The termination remains in force; or after the date (c) Any amendment to the GROUP POLICY approved you become DISABLED . C09D1B _ 339619-A Printed (4/13/89 ) - 19 LTD POLICY Part 10 . CLAIMS PROVISIONS AND PROCEDURES FOR LTD BENEFITS A . PAYMENT OF BENEFITS l be paid to you . Any LTD BENEFIT remaining All LTD BENEFITS wil your death will be paid to the person or unpaid at the time of RS BENEFIT . If no SURVIVORS BENEFIT is persons receiving the SURVIVO paid, the unpaid LTD BENEFIT will be paid to your estate . B . TIME LIMITS FOR FILING A CLAIM You must claim LTD BENEFITS within 120 days after the end ofathe ELIMINATION PERIOD or as soon thereafter the endrof5thab1120 day period . in any case, within one year and no LTD Claims not filed within these time limits will be denied BENEFIT will be paid . These limits will not apply 9 any period when you lacked the legal capacity to file a claim . C . FILING A CLAIM All claims for LTD BENEFITSo rm�ul From the submittedd be POLI STANDARD'S the forms . You should obtain claim Administrator . You may also request claim forms from STANDARD . If STANDARD fails to provide you with claim forms within 15 days of your request , You may submit your claim in a letter stating the occurrence, character, and extent of the event for which the claim is made . D . PROOF OF LOSS Proof of each of the following elements of proof of loss must be provided to STANDARD at your expense . No LTD BENEFITS will be paid until STANDARD receives satisfactory written proof : 1 . That you became DISABLED while insured under the GROUP POLICY . 2 . That you were DISABLED throughout the ELIMINATION PERIOD and the period for which LTD BENEFITS are claimed . 3 . That your DISABILITY results from a cause not excluded in Part 7 . 4 . That you are being seen regularly and treated by a PHYSICIAN . 5 . Of such additional information as STANDARD may reasonably require in connection with your claim for LTD BENEFITS . - 20 - 339619-A Printed (4/13/89) LTD POLICY If your claim is approved, no LTD BENEFITS will be continued Rbewond the end of the period for which you have provided satisfactory written proof of loss . E . DOCUMENTATION OF CLAIM You must submit the following documents at your expense : 1 . A completed claim statement signed by you . g . A completed claim statement signed by the POLICYOWNER . 3 . A completed claim statement signed by your treating PHYSICIAN . rs q . Your written authorizatia NDp ARD t o obtain e o religibility for LTD and information needed to determine Yo BENEFITS . 5 . Such other documents as STANDARD may reasonably require . submit additional documentation cu yare STANDARD will require you to ble intervals while y claim at your expense at reasona receiving LTD BENEFITS . F . DOCUMENTATION OF INCOME FROM OTHER SOURCES Documentation of INCOME FROM OTHER SOURCES must be provided to STANDARD at your expense . If STANDARD reasonably believes that you are receiving or are FROMtO�nEdacumentationTANDARD has the eligible to receive INCOME right to require satisfactory ( a) That you have made timely claim for the INCOME FROM OTHER SOURCES; (b) That you have properly pursued each claim; and (c) Of the amount of the INCOME FROM OTHER SOURCES . STANDARD will send you a written request for any required documentation . You must provide such documentation within 60 d at ays after the written request is mailed to you . Otherwise, STANDARD' the elect to reduce your LTD BENEFITS by its sole discretion, may you are receiving or would have amount STANDARD reasonably believes y and proper pursuit of a claim been eligible to receive upon timely for the INCOME FROM OTHER SOURCES . If your claim for LTD BENEFITS has been overpaid, STANDARD will notify you of the amount of the _ 339619-A Printed (4/13/89) 21 LTD POLICY overpayment . You must immediately reimburse STANDARD for the amount overpay a ment% from STANDARD of the overpayment . You will not receive any PIn the meantime , any until STANDARD has been reimbursed in ful . to reduce the amount LTD BENEFITS becoming payable will be applied of the overpayment of your claim for LTD BENEFITS . able If you later provide the required amountnoftLTD BENEFITS which ion within a were time, STANDARD will recompute theyou of the payable . If you have been overpaid, STANDARD will no will behandled as amount of the overpayment and the overpay you the amount If you have been underpaid, STANDARD will Pay above . rate determined by STANDARD . of the underpayment with interest at a G . INVESTIGATION OF YOUR CLAIM to conduct an investigation of STANDARD has the right at any time aid until STANDARD has had a your claim . No LTD BENEFITS will be pation . reasonable time to conduct an investig H . INDEPENDENT EXAMINATION . expense at STANDARD has the right to have you examined g LTat A DBENEFITS . Any such reasonable intervals while you are claiming examinations will be conducted by one or more PHYSICIANS or vocational specialists of STANDARD' S choice . STANDARD has the right to defer or suspend payment of LTD BENEFITS or ato ate with the if you fail to attend an examinationn suchal case oLTD rBENEFITS may person conducting the examinati o .be resumed, provided that the rariotherwi red senpayable ccur5 within a reasonable time and LTD BENEFITS e I . NOTICE OF DECISION ON CLAIM a written decision on your claim wit You will receive hin a time after STANDARD receives your claim . reasonable period of If STANDARD denies all or any part of your claim, you will receive a written notice of denial containing: ( 1 ) The reasons for the denial ; (2) Reference to the provisions of the GROUP POLICY on which the denial is based; of any additional information or documentation (3) A description to obtain bea�i��si5ndequiredplanation of why you must submit such information or document _ 339619-A Printed (4113/$9 ) 22 LTD POLICY (4) Notice of your right to a review of the denial ; and (s) A description of the review procedure . If you do not receive a written decision on your claim within 90 days after your claim is received, you will have an immediate right to request a review under the review procedure, as if your claim had been denied . J . REVIEW PROCEDURE You have a right to a review of any denial by STANDARD of all or any our claim . To obtain a review, you should send a written part of y after you receive request for review to STANDARD within 60 days notice of the denial . No special form is required . As a part of your request for review, you may submit issues and comments in writing and provide additional documentation in or y to of your claim . You may review pertinent documents related to your request for review . omptly after receiving your STANDARD will review your claim pr request for review . You will ourereq written notice uestforreviewoisSTANDA received, decision within 60 days after yo or within 120 days if speciacei�erwilltincludeances t require extension . The written decision you receiver e provisions of the GROUP POLICY on decision and reference to the p which the decision is based . You may authorize another person to act for you under this review procedure . C1001C Part 11 . TIME LIMITS ON LEGAL ACTIONS AND CERTAIN DEFENSES may be brought to recover under the GROUP No action at law or in equity roof of 1O5s has been provided to POLICY until 60 days after written p STANDARD . An statement you make to obtain INSUnA�CEyouwill will be representation reduceaor y No misrepresentation y not a warranty • of your INSURANCE unless : deny your claim or to deny the validity (a) Your INSURANCE would not have been approved except for your misrepresentation; is contained in a written instrument (b) Your misrepresentation signed by you; and _ 339619-A Printed (4/13/89 ) 23 LTD POLICY (c) You have been given a copy of the written instrument containing your misrepresentation . After your INSURANCE has been in effect for two years, no misrepresentation by you, except a fraudulent misrepresentation made with actual intent to deceive, will be used to reduce or deny your claim or to deny the validity of your INSURANCE . C1101F Part 12 . ASSIGNMENT NOT PERMITTED Your Certificate is not assignable . The INSURANCE provided and benefits payable are not assignable . C1201A SECTION TWO - POLICYOWNER PROVISIONS Part 1 . PREMIUMS A . PREMIUM CHARGES The premium charge on each premium due date will be an aggregate amount based on the sum of the premiums due for all MEMBERS then insured under the GROUP POLICY . The premium due with respect to each insured MEMBER is determined by multiplying the MEMBER ' S applicable PREDISABILITY EARNINGS by the premium rate then in effect , as noted on the POLICY DATA . POIA1F B . CONTRIBUTIONS FROM MEMBERS The POLICYOWNER determines the amount of each MEMBER 'S contribution toward the cost of INSURANCE . P01B1D C . CHANGES IN PREMIUM RATES ( 1 ) STANDARD may change any one or more premium rates at any time when a change in any law or governmental regulation affects the amount payable by STANDARD under this GROUP POLICY . Any such Printed ( 4/13/89 ) - 24 - 339619-A LTD POLICY change in premium rates will reflect only the change in rates CY STANDARD' S obligations uryy timeeuponOUP mutuallagreementubetween may also be changed at a y the POLICYOWNER and STANDARD . ot (E) Except as provided in ( 1 ) ' premium eshown ontes will the covernof this changed GROUP during the Initial Policy Term change any POLICY . After the Initial Policy Term STANDARD may mium rates upon 31 days written notice to one or more of the pre such change in premium rates may be made the POLICYOWNER . Any t as provided in ( 1 ) , effective on any Premium Due Date . Except one contract no such change will be made more than once in any periods year . Contract yendsofathe Initialre policy twelveve month PolicyTerm computed from the PO1C1A D . PAYMENT OF PREMIUMS All premiums are due on the Premium Due Dates shown on the cover of the GROUP POLICY . by the POLICYOWNER on or before its due Each premium due is payable a ment of each date direct to STANDARD at its Home Office . The payment premium as it becomes due will maintain this GPremiumLDue Dateorce through the date immediately preceding the P01D1A E . TERMINATION OF GROUP POLICY BY THE POLICYOWNER CY at any time by giving The POLICYOWNER may terminate the RD .GRO The Lleffective date of the prior written notice to STANDARD . termination will be the later of ( a) the date d by STANDARD . the notice, and (b) the date the notice is received by remium charges coverage under the GROUP POLICY will continue and at p will accrue after the effective date of the termination of the GROUP POLICY . P01EtA _ 339619-A Printed (4/13/89) 25 LTD POLICY F . TERMINATION OF GROUP POLICY BY STANDARD STANDARD may terminate the GROUP POLICY as follows : (a) On any reinimumdParticipationif the uNumbermber forelessg insured than M the Minimum than the Participation Percentage . (b) On any Premium Due Date if STANDARD, in its sole judgment , determines that the POLICYOWNER ( a) has failed to promptly furnish any necessary information oth�rrequeste by obligations relating, torthis has failed to perform any GROUP POLICY . STANDARD will give 31 days prior written notice of any such termination of the GROUP POLICY . P01F1C G . GRACE PERIOD The GROUP POLICY has a 45 day Grace Period for each premium due after the first premium . If a premium is not paid on or before the Premium Due Date, the premium may be paid during the fallowing 45 day Grace Period . The GROUP POLICY will remain in force during the Grace Period, and the POLICYOWNER is liable to STANDARD for the payment of the premium for that period . PO1G1D H . TERMINATION OF GROUP POLICY FOR NONPAYMENT OF PREMIUMS If the required premium is not paid during the Grace Period, the GROUP POLICY will terminate automatically at 12 : 01 AM on the date following the end of the Grace Period . The POLICYOWNER is liable for the payment of the premiums for the coverage continued during the Grace Period . P01H1B - 26 - 339619-A Printed (4/13/89) LTD POLICY I . PREMIUM ADJUSTMENTS Premium adjustments involving a return of unearned premiums to the POLICYOWNER will be limited to the twelve month period immediately preceding the date STANDARD an adjustment shouldgbegmadeor premium adjustment and evidence P01I1B Part 2 . DIVIDENDS During the period this GROUP POLICY is in force, it will be credited with its share , if any , of the divisible surplus in the form of dividends as declared by STANDARD P0201A Part 3 . CERTIFICATES STANDARD will issue underfithi�s to GROUP POLICYOWNER Theshowing the POLICYOWNERnswill MEMBER ' S coverage distribute a Certificate to each insured MEMBER . P0301A Part 4 . RECORDS AND REPORTS The POLICYOWNER will furnish on STANDARD'S forms all information reasonably necessary to the administration of the GROUP POLICY when required by STANDARD . STANDARD has the right at all reasonable times to inspect the payrolls and other records of the POLICYOWNER which relate to INSURANCE under this GROUP POLICY . Clerical error by the POLICYOWNER will not : ( a) Cause a MEMBER to become insured; (b) Invalidate INSURANCE otherwise validly in force; or (c) Continue INSURANCE otherwise validly terminated . P0401A _ 27 _ 339619-A Printed (4/13/89 ) LTD POLICY Part S . MISSTATEMENT OF AGE make an If the age of a MEMBER has bee u1 t msorofe STANDARD will benefits or of both . The equitable adjustment of the premi adjustment will be based on (a) The amount of the MEMBER 'S INSURANCE based on the MEMBERS correct age; and (b) The difference between the premiums paid and the premiums which would have been paid if the MEMBER' S age had been correctly stated . P0501A Part 6 . ENTIRE CONTRACT ; CHANGES The GROUP POLICY and the application of the POLICYOWNER, if any , constitute the entire contract between the parties . be changed in whole or in part . No change in the This GROUP POLICY may roved in writing by an GROUP POLICY will be valid unless it is approved executive officer of STANDARD and Noeaientehastauthority the OtoCchange this attachment to the GROUP y ofCits provisions . GROUP POLICY or to waive any P0601B Part 7 . INCONTESTABLE CLAUSE Any statement made by the POLICYOWNER to obtain the GROUP POLICY is a representation and not a warranty . the POLICYOWNER will be used to deny the No misrepresentation by a claim unless validity of the GROUP POLICY or to deny (a) The GROUP POLICY would not have been issued by STANDARD except for the misrepresentation; (b) The misrepresentation is contained in a written instrument signed by the POLICYOWNER; and (c) A copy of the written instrument has been given to the POLICYOWNER . _ 339619-A Printed (4/13/89 ) 28 LTD POLICY The validity of the GROUP POLICY will nob contested after it has been in force for two years, except fo payment P0701A Part 8 . EFFECT ON WORKER' S COMPENSATION e for The coverage provided under the dRdoes notlrelieve is otheaEMPLOYERuof any worker' s compensation insurance an obligation to provide worker's compensation insurance . PO801A _ 339619-A Printed (4/13/89) - 29 LTD POLICY i GROUP POLICY AMENDMENT NO . 1 Attached to and made a part of GROUP POLICY 339619-A issued to City of Kent as POLICYOWNER . It is agreed that the INITIAL MONTHLY PREMIUM RATE shown in the POLICY DATA is amended to read as follows : LONG TERM DISABILITY INSURANCE INITIAL MONTHLY PREMIUM RATE MEMBERS insured for $4 . 00 per insured MEMBER Plan A only (EMPLOYER paid) All other MEMBERS The sum of (a) $4 . 00 per insured MEMBER (EMPLOYER paid) , and (b) the appropriate percentage below of the first $6, 000 of the PREDISABILITY EARNINGS of each insured MEMBER (MEMBER paid )* MEMBER 's age on January 1 Under age 30 .50% Age 30 through 34 . 52% Age 35 through 39 58% Age 40 through 44 . 75% Age 45 through 49 1 . 04% Age 50 through 54 1 . 50% Age 55 through 59 2 . 15% Age 60 through 64 2 . 69% Age 65 through 70 3 .54% Age 70 or over 3. 54% *Changes in premium rate because of changes in age become effective on the January ist coinciding with or next following the change . This amendment is effective January 1 , 1989 . Page 1 of Amendment 1 Group Policy No . 339619-A i STANDARD INSURANCE COMPANY By Rlxep,ell� � _ &,A"Iftp—r e s i d Secretary Page Z of Amendment 1 Croup Policy No. 339619-A i 4citan&'act INSURAN PORT LAND, RE D, OREGOA N Request For Group Insurance Amendment �Dediccated to Excellence for Policvowners 900 SW Frdh Avenue Portland, OR 97204-1282 CITY OF KENT 339619—A tp� Policyowner Name: Group Policy Number: As an authorized representative of the Policyowner, 1. I request that STANDARD amend the above Group Policy to make the following change(s): Please amend the Group Long Term Disability premium rate to a per member rate. The rate, effective January 1, 1989 will be $4.00 per member. RECEIVED JUN 1 3 1989 GROUP UNDERWRITING 2. 1 request that the amendment become effective on January 1, 1989 I understand that the amendment will not become effective unless approved and issued by Standard. 3. 1 request that the amendment be approved by STANDARD subject to STANDARD'S usual underwriting requirements, including, if applicable, Evidence of Insurability or a Pre-existing Condition limitation. 4. 1 request that the amendment,if approved by STANDARD,be issued in the policy language customarily used by STANDARD. 5. 1 understand that any increase in INSURANCE for a MEMBER who is not ACTIVELY AT WORK all day on the MEMBER'S last regular work day before the scheduled effective date of the amendment will be deferred until the first day after the MEMBER completes one full day of ACTIVE WORK. 6. 1 request that the amendment. if approved and issued by STANDARD, become effective by its terms without any further acceptance by the Policyowner,and that a copy of this Request for Group Insurance Amendment form be attached to and made a part of the amendment, I understand that if a group insurance policy is issued as a result of this request,that policy must be separately accepted by the Policyowner's signature on form 1755, Acceptance of Group Insurance Policy. Signed By: ��y r �i ` Title: , '°,�� �f�>:� Date: S Policyowner's Representative Group Representative: Scott Martin Group Office- Seattle Service Representative: Colleen Haight Date Received At Group Office: `�'�`1;2--69 SI-18-3408 (3/89) SPORT LAND, OREGON INSURANCE COMPANY Request For Group Insurance Amendment Dedicated to Excellence for Polic-yowners 900 SW Fifth Avenue Portland, OR 97204-1282 Policyowner Name: City of Kent Group Policy Number: 339619—A As an authorized representative of the Policyowner, 1. I request that STANDARD amend the above Group Policy to make the following change(s): Please amend the Group Long Term Disability Contract as follows : Please include 24 month own occupation for all eligible employees . 2. 1 request that the amendment become effective on I understand that the amendment will not become effective unless approved and issued by Standard. 3. 1 request that the amendment be approved by STANDARD subject to STANDARD'S usual underwriting requirements, including, if applicable, Evidence of Insurability or a Pre-existing Condition limitation. 4. 1 request that the amendment,if approved by STANDARD,be issued in the policy language customarily used by STANDARD. 5. 1 understand that any increase in INSURANCE for a MEMBER who is not ACTIVELY AT WORK all day on the MEMBER'S last regular work day before the scheduled effective date of the amendment will be deferred until the first day after the MEMBER completes one full day of ACTIVE WORK. 6. 1 request that the amendment, if approved and issued by STANDARD, become effective by its terms without any further acceptance by the Policyowner,and that a copy of this Request for Group Insurance Amendment form be attached to and made a part of the amendment. I understand that if a group insurance policy is issued as a result of this request,that policy must be separately accepted by the Policyowner's signature on form 1755, Acceptance of Group Insurance Policy. r d B Title: l�'�(Gk�i�f [•t�•�'�'Date: Signed y' Policyowner's Representative Group Representative:--_Sc_ot_t_Mar_t_in Group Office:__Saar t I P Service Representative: Colleen—Haigh-t Date Received At Group Office: SI-18-3408 (3/89) Supplemental Information: To Be Completed by Group Representative Please be sure the policyowner clearly understands the change requested and any change in premium rates. Underwriting Are there any changes to rates, lives, and/or volume created by this requested amendment? ❑ Yes [% No If yes,complete the following information and attach census showing age, sex, and insurance amounts for persons to be added or dropped. Life Dep. Life AD&D STD LTD Dental Other Quoted Rates Approximate Volume Increase (Decrease) Lives Increase (Decrease) - Proposal prepared by ❑ Home Office ❑ Group Office PQ! Client ID# ----- -- None Prepared Is any evidence of insurability required on the effective date? ❑ Yes ® No If yes, please attach forms. Mailing Instructions Do you want the completed Amendment mailed from the Home Office to: [M Group Office ❑ Broker (provide address) ❑ Policyowner (provide BOTH addresses) (NOTE: provide STREET address, no Post Office Boxes) Policyowner Broker Name C-itV o f KeK -n t Name Street Street Address_ At n: Sue Viseth Address—. ----- -- City 22 0 Sn City State/Zip Code State/Zip Code Important Notices/Revised Certificates When we issue an Amendment,we will also issue Important Notices.All classifications will be shown in a single Important Notice.If it is necessary to split out classifications in separate Important Notices,or if the policyowner needs new Certificates,please indicate as such in the COMMENTS section below. How many notices? 55-0 How many cents? Where should Important Notices/Certificates be mailed? (Check only one box): ❑ Group Office Gil The above policyowner address ❑The above broker address Comments Please direct this request to Brian Hendricks . Brian has agreed to process this request without a rate impact at this time . Please mail the completed Amendment to the Seattle G.O. and the Important Notices directly to the Policyowner. Please call the Group Service Representative with any questions . F1 ti C E I V E D 8 1990 R • E ANS PERSONNEL DEPT. ( 0NIPA ), !tAt; 1210 Plaza 600 Bldg. • Seattle, WA 98101 • 206/448-7878 • FAX 206/448-3589 January 17, 1990 Mr. Donald E. Olson Personnel Director City_ of Kent 220 4th Ave South Kent, WA 98032-5895 Dear Don: I am enclosing the amendment from Standard Insurance Company. The intent of this is to amend the Group Long Term Disability contract to include a 24 month own occupation definition for all eligible employees. The current contract calls for a one year own occupation for safety employees and a two year own occ for all other employees. Standard realizes that this was what was originally communicated to the employees and, therefore, is allowing for the change without a rate impact. Please sign the amendment and return it to Standard in the envelope provided. If you should have any questions about this, give me a call. Sincerely, Douglas Evans Vice President Employee Benefits DE:kf enclosure Estate&Business Planning • Group Insurance • Financial&Insurance Planning • 401kIProfit Sharing Plans Securities offered through Royal Alliance Associates, Inc., Member NASD&SIPC Registered Investment Advisory Services offered through Evans Financial Advisory Service -. .. _ - GROUP INSURANCE CERTIFICATE �I STANDARD INSURANCE COMPANY certifies that you will be insured under the Group Policy de- scribed below during the time,in the manner, and for the amounts provided in the Group Policy. Posses- I Ji lion of this Certificate does not necessarily mean you are insured. PRESIDENT GROUP POLICY NUMBER 339619—A 'i NAME OF CITY OF KENT POLICYOWNER TYPE OF COVERAGE GROUP POLICY EFFECTIVE DATE January 1 , 1989 d b Washington and governed GROUP POLICY DELIVERED IN 9 �= the laws of that state . IMPORTANT: PLEASE READ THIS r You are insured only if you meet the requirements in Part 2. BECOMING INSURED. You will remain 1j insured only until your insurance ends, as explained in Part 3. WHEN INSURANCE ENDS. A Group Policy has been issued to the Policyowner. Your coverage under that Group Policy is shown in this Certificate.If your coverage is changed by an amendment to the Group Policy,Standard will provide the Policyowner with a revised Certificate or other notice to be given to you. PLEASE READ THIS CERTIFICATE CAREFULLY. This Certificate has a Table of Contents to help you find specific provisions. Defined terms are printed in all capital letters. GC 1 86—LTD � t TABLE OF CONTENTS PAGE OUTLINE OF YOUR LONG TERM DISABILITY INSURANCE . . . . . . . . . . . . . . 1 Part 1 . GENERAL DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Part 2. BECOMING INSURED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Part 3 . WHEN INSURANCE ENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Part 4 . BECOMING INSURED AGAIN AFTER INSURANCE ENDS . . . . . . . . . 5 Part 5 . DEFINITION OF DISABILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Part 6 . LONG TERM DISABILITY INSURING CLAUSE . . . . . . . . . . . . . . . . 9 Part 7 . EXCLUSIONS AND LIMITATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Part S . SCHEDULE OF LONG TERM DISABILITY INSURANCE . . . . . . . . . . 12 A. ELIMINATION PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 B . MAXIMUM BENEFIT PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 C . AMOUNT OF LTD BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 D . PREDISABILITY EARNINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 E . INCOME FROM OTHER SOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Part 9 . OTHER LONG TERM DISABILITY BENEFITS AND PROVISIONS . . 19 A . REHABILITATION PROVISION (RETURN TO WORK) . . . . . . . . . . . . 19 B . SURVIVORS BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 C . WAIVER OF PREMIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 D . BENEFITS AFTER INSURANCE ENDS OR IS CHANGED . . . . . . . . . . 20 Part 10 . CLAIMS PROVISIONS AND PROCEDURES FOR LTD BENEFITS . . 21 PAGE Part 11 . TIME LIMITS ON LEGAL ACTIONS AND CERTAIN DEFENSES . . 24 Part 12 . ASSIGNMENT NOT PERMITTED . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 INDEX OF DEFINED TERMS PAGE PAGE ACCIDENTAL BODILY INJURY . . . . . . 2 LONG TERM DISABILITY INSURANCE 2 ACTIVELY AT WORK . . . . . . . . . . . . . . 4 LTD BENEFIT . . . . . . . . . . . . . . . . . . . 2 CPI-W . . . . . . . . . . . . . . . . . . . . . . . . . 9 MAXIMUM BENEFIT PERIOD . . . . . . . . 13 DISABILITY . . . . . . . . . . . . . . . . . . . . b MEMBER . . . . . . . . . . . . . . . . . . . . . . . . 3 ELIMINATION PERIOD . . . . . . . . . . . . 12 MENTAL DISORDER . . . . . . . . . . . . . . . 11 EMPLOYER . . . . . . . . . . . . . . . . . . . . . . 1 PHYSICIAN . . . . . . . . . . . . . . . . . . . . . 11 EVIDENCE OF INSURABILITY . . . . . . 2 PREDISABILITY EARNINGS . . . . . . . . 15 GROUP POLICY . . . . . . . . . . . . . . . . . . 1 PREEXISTING CONDITION . . . . . . . . . 10 HOSPITAL . . . . . . . . . . . . . . . . . . . . . . 12 PREGNANCY . . . . . . . . . . . . . . . . . . . . . 2 INCOME FROM OTHER SOURCES . . . . . 16 SICKNESS . . . . . . . . . . . . . . • . • • • • • • 2 INDEXED PREDISABILITY EARNINGS 8 STANDARD . . . . . . . . . . . . . . . . . . . . . . 1 INSURANCE . . . . . . . . . . . . . . . . . . . . . 2 SURVIVORS BENEFIT . . . . . . . . . . . . . 19 OUTLINE OF YOUR LONG TERM DISABILITY INSURANCE THIS OUTLINE IS INTENDED FOR USE WITH THIS CERTIFICATE AND CANNOT BE USED SEPARATELY CRI�LEASETION OREAD YOUR THISCOVERAGE . CERTIFICATEOTHER CAREFULLPROVISIONS ARE FOUND IN THIS CERTIFICATE Y . TYPE OF INSURANCE - LONG TERM DISABILITY INSURANCE provides you with income protection if you become DISABLED from a covered SICKNESS, ACCIDENTAL BODILY INJURY, or PREGNANCY . LONG TERM DISABILITY INSURANCE (LTD) BENEFITS - The purpose of this INSURANCE is to provide you with an LTD BENEFIT while you are DISABLED . The amount of your LTD BENEFIT is shown in Part S . C . Your INCOME FROM OTHER SOURCES is defined in Part B .E . Your ELIMINATION PERIOD is shown in Part S . A . Your MAXIMUM BENEFIT PERIOD is determined by your age when you become DISABLED . See Part S . B . DISABILITY - DISABILITY is defined in Part 5 . EXCLUSIONS AND LIMITATIONS - This INSURANCE does not cover any disability resulting from the following : ( 1 ) War; ( 2) Intentionally Self-Inflicted Injury; and (3) Preexisting Condition . This INSURANCE is also subject to limitations described under the following headings : ( 1 ) Elimination Period; (2) Maximum Benefit Period; (3) Regular Care of a Physician; and (4) Mental Disorder . A detailed explanation of these exclusions and limitations is found in Part 7 . BECOMING INSURED - Parts 2 and 3 explain when you become insured and when INSURANCE ends . The POLICYOWNER determines the amount of your contribution toward the cost of your INSURANCE . Part 1 . GENERAL DEFINITIONS STANDARD means Standard Insurance Company , Portland, Oregon . EMPLOYER means City of Kent . GROUP POLICY means STANDARD' S group policy number 339619-A issued to the POLICYOWNER . Printed (4/13/89 ) - 1 - 339619-A LTD CERT LONG TERM DISABILITY INSURANCE means your Ldisability insurance under the GROUP POLICY, whether under PLAN A or INSURANCE means your LONG TERM DISABILITY INSURANCE under the GROUP POLICY . LTD BENEFIT means the monthly LONG TERM DISABILITY INSURANCE benefit payable to you according to the terms of the GROUP POLICY . SICKNESS means your sickness, illness, or disease . PREGNANCY means your pregnancy, childbirth, or related medical conditions . ACCIDENTAL BODILY INJURY means an injury to your body caused by an accident . Providing EVIDENCE OF INSURABILITY , if required, means you must : 1 . Complete and sign a health and medical history form provided by STANDARD; 2 . Sign STANDARD' S form authorizing STANDARD to obtain information about your health; and 3 . Provide any additional information about your insurability reasonably required by STANDARD . All required information must be provided to STANDARD at your expense . C0109M Part 2 . BECOMING INSURED To become insured you must meet each of the following requirements plus the ACTIVE WORK requirement : 1 . You must be a MEMBER . 2 . You must be eligible for INSURANCE . 3 . You must apply for INSURANCE if you wish to become insured under Plan B . C0�09F Printed (4/13/89 ) - 2 - 339619-A LTD CERT A . DEFINITION OF MEMBER You must be a MEMBER . You are a MEMBER if you are all of the following : 1 . An active employee of the EMPLOYER , other than a temporary or seasonal employee, who is either of the following : a . A corrections department employee who is a member of Local 1088, or b . Any other active employee, other than a member of Local 1747 or Local 1088; 2 . Regularly scheduled to work at least 21 hours each week ; and 3 . A citizen or resident of the United States or Canada . CO2A1N B . ELIGIBILITY FOR INSURANCE You must be eligible for INSURANCE. You are eligible for INSURANCE on the later oof(thetcalendarhe tmonthive afollowing the te of the Udate Lyou� and 8 becomea the first day MEMBER . CO2B1R C . APPLICATION FOR INSURANCE You must apply for INSURANCE under Plan B and agree to make the required contributions to the POLICYOWNER by signing a completed enrollment card . The POLICYOWNER determines the amount of your contribution toward the cost of your INSURANCE . D . PREEXISTING CONDITION EXCLUSION If you apply for INSURANCE under Plan B more than 31 days after you are first eligible for INSURANCE, you will be subject to PREEXISTING CONDITION EXCLUSION NO . 2 . See Part 7 . A . RISKS NOT COVERED . Printed ( 4/13/89 ) - 3 33961E-A - LTD CERT E . EFFECTIVE DATE OF INSURANCE Your INSURANCE under Plan A will become effective on the date you become eligible, if you meet the ACTIVE WORK requirement on that date . Your INSURANCE under Plan B will become effective on one of the following dates if you meet the ACTIVE WORK requirement on that date : ( 1 ) The date you become eligible for INSURANCE, if you apply on or before that date . (2) The date you apply for INSURANCE under Plan B, if you apply after the date you become eligible for INSURANCE . F . ACTIVE WORK REQUIREMENT If you were DISABLED on the day before the scheduled effective date of your INSURANCE, then the effective date of your INSURANCE will be delayed until the first day after you complete one full day of ACTIVE WORK . For purposes of this ACTIVE WORK requirement , you are DISABLED if you are unable, as a result of SICKNESS, ACCIDENTAL BODILY INJURY , or PREGNANCY, to perform the material duties of your own occupation . ACTIVE WORK and ACTIVELY AT WORK mean performing the usual duties of your job at your EMPLOYER ' S usual place of business . This ACTIVE WORK requirement also applies to any increase in your INSURANCE . CO2C9K Part 3 . WHEN INSURANCE ENDS Your INSURANCE will end automatically on the earliest of the following dates : a . The date you cease to be a MEMBER as defined in Part 2 . A . b . The date you become a full time member of the armed forces of any country . C . With respect to your INSURANCE under Plan B, the last day of the last period for which you made the required premium Printed ( 4/13/89 ) - 4 - 339619-A LTD CERT contribution for your INSURANCE . This provision will not end your INSURANCE under Plan A . d . The date the GROUP POLICY terminates . e . The date you cease to be ACTIVELY AT WORK for your EMPLOYER on your regular work days because of (a) a temporary layoff or (b ) a general work stoppage ( including a strike or lockout ) resulting from a labor dispute . f . The date you cease to be ACTIVELY AT WORK for your EMPLOYER on your regular work days for any other reason . However, your INSURANCE may be continued (unless it ends under items a . through e . above) during the following periods while you are absent from ACTIVE WORK : ( 1 ) While you are receiving full salary ( including sick pay ) from your EMPLOYER; ( 2) During the ELIMINATION PERIOD and while LTD BENEFITS are payable; and (3) During a leave of absence approved by your EMPLOYER and scheduled to last for 30 days or less . C0309D Part 4 . BECOMING INSURED AGAIN AFTER INSURANCE ENDS You may become insured again under the GROUP POLICY after your INSURANCE ends . The general rule is that you may become insured again on the same basis as a new MEMBER , as provided in Part 2 . BECOMING INSURED . However , for purposes of becoming insured again, the requirements of Part 2 . will be modified in specific situations as follows : 1 . If your INSURANCE under Plan B ends because you fail to make the required premium contribution, you will be subject to PREEXISTING CONDITION EXCLUSION NO . 2 when you become insured again under Plan B . 2 . If your INSURANCE ends because you cease to be a MEMBER , you will be immediately eligible for INSURANCE if you become a MEMBER again within 90 days after your INSURANCE ends . Printed ( 4/13/89 ) - 5 - 339619-A LTD CERT Your INSURANCE will become effective again on the date determined from Part 2, and will not be retroactive to the date your INSURANCE ended . Your INSURANCE_ will be subject to the PREEXISTING CONDITION exclusion in Part 7, as follows : ( 1 ) If you become insured again more than 90 days after your INSURANCE ends, the PREEXISTING CONDITION exclusion will apply to any condition which is a PREEXISTING CONDITION on the date you become insured again . (2) If you become insured again within 90 days after your INSURANCE ends, the PREEXISTING CONDITION exclusion will apply to any condition which was a PREEXISTING CONDITION at the start of the prior period of INSURANCE . For this purpose only , the two periods of INSURANCE will be treated as one period of continuous INSURANCE and the period when you were not insured will be ignored . (The same principles will apply if your INSURANCE ends two or more times and each time you become insured again within 90 days . The three or more periods of INSURANCE will be added together for purposes of the PREEXISTING CONDITION exclusion) . Note : After your LTD BENEFITS for a period of DISABILITY end, your INSURANCE will continue without any interruption if you are a MEMBER and immediately return to ACTIVE WORK for your EMPLOYER . This Part 4 will not apply since your INSURANCE continues while you are receiving LTD BENEFITS . C0409D Part 5 . DEFINITION OF DISABILITY A . DEFINITION OF DISABILITY FOR SAFETY MEMBERS The definition of DISABILITY changes after LTD BENEFITS have been paid for 12 months . 1 . Until LTD BENEFITS have been paid for 12 months, you are only required to be DISABLED from your own occupation . You are DISABLED from your own occupation if, as a result of SICKNESS, ACCIDENTAL BODILY INJURY or PREGNANCY, you are EITHER : a . Unable to perform with reasonable continuity the material duties of your own occupation; OR Printed (4/13/89 ) - 6 - 339619-A LTD CERT b . Unable to earn more than 80% of your INDEXED PREDISABILITY EARNINGS while working in your own occupation . Until LTD BENEFITS have been paid for 12 months, you will be considered DISABLED while working in another occupation if you are DISABLED from your own occupation . There is no limit on the amount you can earn from work in another occupation while you are DISABLED from your own occupation . Your earnings will be used in determining the amount of your LTD BENEFIT . 2 . After LTD BENEFITS have been paid for 12 months, you must be DISABLED from all occupations . You are DISABLED from all occupations if, as a result of SICKNESS, ACCIDENTAL BODILY INJURY or PREGNANCY, you are EITHER : a . Unable to perform with reasonable continuity the material duties of any gainful occupation for which you are reasonably fitted by education, training, and experience; OR b . Unable to earn more than 50% of your INDEXED PREDISABILITY EARNINGS while working in your own or any other occupation . B . DEFINITION OF DISABILITY FOR ALL OTHER MEMBERS The definition of DISABILITY changes after LTD BENEFITS have been paid for 24 months . 1 . Until LTD BENEFITS have been paid for 24 months, you are only required to be DISABLED from your own occupation . You are DISABLED from your own occupation if , as a result of SICKNESS, ACCIDENTAL BODILY INJURY or PREGNANCY, you are EITHER : a . Unable to perform with reasonable continuity the material duties of your own occupation; OR b . Unable to earn more than 80% of your INDEXED PREDISABILITY EARNINGS while working in your own occupation . Printed ( 4/13/89 ) - 7 - 339619-A LTD CERT Until LTD BENEFITS have been paid for 24 months, you will be considered DISABLED while working in another occupation if you are DISABLED from your own occupation . There is no limit on the amount you can earn from work in another occupation while you are DISABLED from your own occupation . Your earnings will be used in determining the amount of your LTD BENEFIT . 2 . After LTD BENEFITS have been paid for 24 months, you must be DISABLED from all occupations . You are DISABLED from all occupations if , as a result of SICKNESS, ACCIDENTAL BODILY INJURY or PREGNANCY, you are EITHER : a . Unable to perform with reasonable continuity the material duties of any gainful occupation for which you are reasonably fitted by education, training, and experience; OR b . Unable to earn more than 50% of your INDEXED PREDISABILITY EARNINGS while working in your own or any other occupation . INDEXED PREDISABILITY EARNINGS means an amount determined as follows : Until you have been DISABLED for one year, your INDEXED PREDISABILITY EARNINGS will equal your PREDISABILITY EARNINGS on your last full day of ACTIVE WORK before you became DISABLED . Thereafter, STANDARD will increase the amount of your INDEXED PREDISABILITY EARNINGS on each anniversary of the date you became DISABLED . The amount of each increase will equal A or B, whichever is less, where : A = 10% of your INDEXED PREDISABILITY EARNINGS during the preceding year of DISABILITY . B = The rate of increase in the Consumer Price Index ( CPI-W) during the XED PREDISABILITY preceding calendar year multiplied by your EARNINGS during the preceding year of DISABILITY . There will never be a decrease in your INDEXED PREDISABILITY EARNINGS, even if there is a drop in the Consumer Price Index ( CPI-W) . Printed (4/13/89 ) - S - 339619-A LTD CERT CPI-W means the Consumer Price Index for Urban Wage Earners and Clerical Workers published by the United States Department of Labor . If the index is discontinued or changed, STANDARD may use another nationally published index which is comparable to the CPI-W . C0504C Part 6 . LONG TERM DISABILITY INSURING CLAUSE Subject to all the terms of the GROUP POLICY, STANDARD will pay the LTD BENEFIT described in Part 8 upon receipt of satisfactory written proof that you have become DISABLED while insured under the GROUP POLICY . C0601F Part 7 . EXCLUSIONS AND LIMITATIONS TO LONG TERM DISABILITY INSURANCE A . RISKS NOT COVERED 1 . WAR : You are not covered for a disability caused or contributed to by war or any act of war . WAR means declared or undeclared war, whether civil or international , and any substantial armed conflict between organized forces of a military nature . 2 . INTENTIONALLY SELF-INFLICTED INJURY : You are not covered for a disability caused or contributed to by an intentionally self-inflicted injury . 3 . PREEXISTING CONDITION a . PREEXISTING CONDITION EXCLUSION NO . 1 : Your INSURANCE under both Plan A and Plan B is subject to the following exclusion . You are not covered for a disability caused or contributed to by a PREEXISTING CONDITION or medical or surgical treatment of a PREEXISTING CONDITION unless you meet both of the following requirements on the date you become DISABLED : 1 ) You have been continuously insured under the GROUP POLICY for at least 12 months; and 2) You have been ACTIVELY AT WORK for at least one full Printed (4/13/89 ) - 9 - 339619-A LTD CERT day after those 12 months of continuous INSURANCE . PREEXISTING CONDITION for purposes of PREEXISTING CONDITION EXCLUSION NO . 1 means a mental or physical condition for which you have done any of the following at any time during the 180 day period just before the effective date of your INSURANCE under the GROUP POLICY : 1 ) Consulted a PHYSICIAN . 2) Received medical treatment or services . 3) Taken prescribed drugs or medications . b . PREEXISTING CONDITION EXCLUSION NO . 2 : If you applied for INSURANCE under Plan B more than 31 days after you were first eligible, your INSURANCE under Plan B is subject to the following exclusion . You are not covered for a disability caused or contributed to by a PREEXISTING CONDITION or medical or surgical treatment of a PREEXISTING CONDITION unless you meet both of the following requirements on the date you become DISABLED : 1 ) You have been continuously insured under Plan B of the GROUP POLICY for at least 12 months; and 2) You have been ACTIVELY AT WORK for at least one full day after those 12 months of continuous INSURANCE under Plan B . PREEXISTING CONDITION for purposes of PREEXISTING CONDITION EXCLUSION NO . 2 means a mental or physical condition for which you have done any of the following at any time during the 90 day period just before the effective date of your INSURANCE under Plan B of the GROUP POLICY . 1 ) Consulted a PHYSICIAN . 2) Received medical treatment or services . 3) Taken prescribed drugs or medications . Printed (4/13/89 ) - 10 - 339619-A LTD CERT EXCEPTION TO PREEXISTING CONDITION EXCLUSION NO . 2 : If you become DISABLED by a PREEXISTING CONDITION as defined in PREEXISTING CONDITION EXCLUSION NO . 2, LTD BENEFITS will nonetheless be payable subject to the following : a ) You must meet the requirements of PREEXISTING CONDITION EXCLUSION NO . 1 ; and b ) Benefits will be payable as if you were insured only under Plan A of the GROUP POLICY . C07A9Q B . LIMITATIONS 1 . ELIMINATION PERIOD : No LTD BENEFITS are payable for the ELIMINATION PERIOD . 2 . MAXIMUM BENEFIT PERIOD : No LTD BENEFITS are payable after the end of the MAXIMUM BENEFIT PERIOD . 3 . REGULAR CARE OF A PHYSICIAN : No LTD BENEFITS will be paid for any period of DISABILITY when you are not under the regular care of a PHYSICIAN . PHYSICIAN means a licensed medical professional , other than yourself , diagnosing and treating you within the scope of the license . 4 . MENTAL DISORDER : Payment of LTD BENEFITS is limited to 24 months for each period of DISABILITY caused or contributed to by a MENTAL DISORDER . However, if you are a resident patient in a HOSPITAL at the end of the 24 months, this limitation will not apply while you remain continuously confined . MENTAL DISORDER means a mental , emotional or behavioral disorder . Printed (4/13/89 ) - 11 - 339619-A LTD CERT HOSPITAL means a legally operated hospital providing full-time medical care and treatment under the direction of a full-time staff of licensed physicians (M . D . or D . O . ) . Rest homes, nursing homes, convalescent homes, homes for the aged, and facilities primarily affording custodial , educational , or rehabilitative care are not HOSPITALS . C07B2W Part 8 . SCHEDULE OF LONG TERM DISABILITY INSURANCE This Schedule of LONG TERM DISABILITY INSURANCE has five sections : A . ELIMINATION PERIOD B . MAXIMUM BENEFIT PERIOD C . AMOUNT OF LTD BENEFIT D . PREDISABILITY EARNINGS E . INCOME FROM OTHER SOURCES You must read each section to understand when LTD BENEFITS are payable and how LTD BENEFITS are calculated . C0803P A . ELIMINATION PERIOD ELIMINATION PERIOD means the length of time you must be continuously DISABLED before LTD BENEFITS become payable . Your ELIMINATION PERIOD is determined according to the Plan under which you are insured on your last full day of ACTIVE WORK before you become DISABLED . PLAN A Your ELIMINATION PERIOD is the first 180 days of each period of continuous DISABILITY, or the period of sick leave to which you are entitled under your EMPLOYER 'S sick leave program, whichever is longer . PLAN B Your ELIMINATION PERIOD is the first 90 days of each period of continuous DISABILITY, or the period of sick leave to which you are entitled under your EMPLOYER ' S sick leave program, whichever is longer . Printed (4/13/89 ) - 12 - 339619-A LTD CERT Your ELIMINATION PERIOD begins on the date you become DISABLED . LTD BENEFITS are never payable for the ELIMINATION PERIOD . You must be seen regularly and treated by a PHYSICIAN during the ELIMINATION PERIOD . TEMPORARY RECOVERY DURING THE ELIMINATION PERIOD : Temporary recovery from your DISABILITY during the ELIMINATION PERIOD will have the following effect : For purposes of serving the ELIMINATION PERIOD, all separate periods of DISABILITY from the same cause or causes will be added together and treated as one period of continuous DISABILITY . However , you must serve the full ELIMINATION PERIOD within a period of 35 consecutive days for each 30 days of the ELIMINATION PERIOD . C08A9M B . MAXIMUM BENEFIT PERIOD MAXIMUM BENEFIT PERIOD means the longest period of time for which LTD BENEFITS are payable for any one period of continuous DISABILITY , whether from one or more causes . Your MAXIMUM BENEFIT PERIOD is determined as follows : Your Age When Your MAXIMUM DISABILITY Begins BENEFIT PERIOD 61 or younger Plan A . . . . . . . . . . . . To age 65 or for 5 years. whichever is shorter Plan B . . . . . . . . . . . . To age 65 62 . . . . . . . 3 years 6 months 63 . . . . . . . . . . . . . . . . . 3 years 64 . . . . . . . 2 years 6 months 65 . . . . . . . . . . . . . . . . 2 years 66 . . . . . . . . 1 year 9 months 67 . . . . . . . . . . 1 year 6 months 68 . . . . . . . . . . . . . . . . . 1 year 3 months 69 or older . . . . . . . . . . . . 1 year Your MAXIMUM BENEFIT PERIOD begins at the end of the ELIMINATION PERIOD . During the MAXIMUM BENEFIT PERIOD, LTD BENEFITS are paid at the end of each monthly period for which you qualify for LTD BENEFITS . LTD BENEFITS will stop at your death or at any time during the MAXIMUM BENEFIT PERIOD when you no longer qualify for LTD Printed (4/13/89 ) - 13 - 339619-A LTD CERT BENEFITS . LTD BENEFITS will stop at the end of the MAXIMUM BENEFIT PERIOD even if you are still DISABLED . TEMPORARY RECOVERY DURING THE MAXIMUM BENEFIT PERIOD: After LTD BENEFITS become payable, temporary recovery frosesyour DISABILITY will have the following effect : For pu p of continuing LTD BENEFITS during the MAXIMUM BENEFIT PERIOD, any two periods of DISABILITY from the same cause or causes will be added -together and treated as one period of continuous DISABILITY if they are separated by a period of recovery of less than 180 days . Thus , a new ELIMINATION PERIOD will not be required, the PREDISABILITY EARNINGS used to compute your LTD BENEFIT will not change, and the MAXIMUM BENEFIT PERIOD will be the balance of the MAXIMUM BENEFIT PERIOD remaining unused before the period of recovery . No LTD BENEFITS will be payable under this provision after benefits become payable to you under any other group long term disability insurance policy . This rule prevents double coverage if you become insured under another policy while you are working during a period of temporary recovery . C08B9B C . AMOUNT OF LTD BENEFIT Your LTD BENEFIT equals your MAXIMUM LTD BENEFIT reduced by your INCOME FROM OTHER SOURCES . Your MAXIMUM LTD BENEFIT is determined according to the Plan under which you are insured on your last full day of ACTIVE WORK before you become DISABLED . Benefits will not be payable under Plan A if benefits are payable under Plan B . PLAN A Your MAXIMUM LTD BENEFIT equals A or B, whichever is less , where : A = 50% of your PREDISABILITY EARNINGS . B = $1 , 000 . PLAN B Your MAXIMUM LTD BENEFIT equals C or D, whichever is less, where : C = 66 2/3% of your PREDISABILITY EARNINGS . Printed ( 4/13/89 ) - 14 - 339619-A LTD CERT D = $4, 000 . The minimum LTD BENEFIT is $50 . PREDISABILITY EARNINGS are defined in Part B . D . INCOME FROM OTHER SOURCES are defined in Part B . E . C08C9E D . PREDISABILITY EARNINGS PREDISABILITY EARNINGS means your monthly rate of earnings from your EMPLOYER including commissions and deferred compensation, but excluding bonuses, overtime pay , longevity pay , education pay , specialty pay and any other extra compensation . The following rules apply to the computation of your monthly rate of earnings : Commissions : Your monthly rate of earnings on any date includes the average monthly commission paid to you by your EMPLOYER during the preceding 12 calendar months (or during your period of employment if less than 12 months) . Weekly Pay : Weekly earnings are multiplied by 4 . 333 to find your monthly rate of earnings . Hourly Pay : Your hourly pay rate is multiplied by the number of hours you are regularly scheduled to work per month (but not more than 173) to find your monthly rate of earnings . If you do not have regular work hours, your monthly rate of earnings on any date will be based on the average number of hours you worked during the preceding 12 calendar months ( or during your period of employment if less than 12 months) , but not more than 173 . EFFECTIVE DATE OF CHANGES IN PREDISABILITY EARNINGS : If you become DISABLED, the PREDISABILITY EARNINGS used to compute your LTD BENEFIT will be based on your monthly rate of earnings in effect on your last full day of ACTIVE WORK before you become DISABLED . Any change in the amount of your monthly rate of earnings which is approved or becomes effective after that last full day of ACTIVE WORK will have no effect on the amount of the PREDISABILITY EARNINGS used to compute your LTD BENEFIT for that period of DISABILITY . Printed (4/13/89 ) - 15 - 339619-A LTD CERT NOTE : Two or more separate periods of DISABILITY resulting from the same cause or causes may qualify for treatment as one continuous period of DISABILITY . If so, the PREDISABILITY EARNINGS used to compute your LTD BENEFIT for each separate period of DISABILITY will be the same amounts as for the initial period of DISABILITY . C08D9W E . INCOME FROM OTHER SOURCES INCOME FROM OTHER SOURCES is explained in the following definition, exceptions, and rules . 1 . DEFINITION OF INCOME FROM OTHER SOURCES INCOME FROM OTHER SOURCES means : a . Any sick pay or other salary continuation payable to you by your EMPLOYER, but not including vacation pay . b . One-half the amount of your earnings from work while LTD BENEFITS are payable, including earnings from your EMPLOYER , any other employer, or self-employment . C . Any amount you receive or are eligible to receive as a result of your disability under a Worker 's Compensation Act or similar law, including amounts for partial or total disability , whether permanent or temporary . d . Any amount you, your spouse or your children receive or are eligible to receive because of your disability or retirement under the Federal Social Security Act , the Canada Pension Plan, the Quebec Pension Plan, or any similar plan or act . Early retirement benefits payable prior to normal retirement age under the plan or act will not be considered INCOME FROM OTHER SOURCES unless they are actually received . e . The amount you receive or are eligible to receive because of your disability under any state unemployment compensation disability benefit law or state disability income benefit law . f . The amount you receive or are eligible to receive because of your disability under any group insurance coverage , other than group credit insurance or group mortgage disability insurance . Printed (4/13/89 ) - 16 - 339619-A LTD CERT g . The following amounts from any disability or retirement plan under which you are covered as a result of your employment with your EMPLOYER ( including but not limited to a public employee retirement system, a state teacher retirement system, or any plan arranged and maintained by a union or employee association for the benefit of its members) : ( 1 ) Any disability benefits you receive or are eligible to receive because of your disability . (2) Any retirement benefits you receive or are eligible to receive because of your retirement . If the disability or retirement plan has two or more payment options, STANDARD will consider as INCOME FROM OTHER SOURCES the amount of the plan option which provides, or comes closest to providing, a monthly income to you for life with no survivors benefit . This will be true even if you select a different option . h . Any benefits you receive under any unemployment compensation law . i . Any amount received by compromise, settlement or other method as a result of a claim for any of a . through h . above . C08ESZ 2 . EXCEPTIONS TO INCOME FROM OTHER SOURCES The following will not be considered INCOME FROM OTHER SOURCES : a . Any cost of living increase in any INCOME FROM OTHER SOURCES, provided that the increase becomes effective while you are DISABLED and while you are eligible to receive the INCOME FROM OTHER SOURCES . (This exception does not apply to any increase in your earnings from any work . ) b . Any amount received as reimbursement for hospital , medical , or surgical expense . C . Any amount which represents reasonable attorneys fees incurred in connection with the claim for INCOME FROM Printed (4/13/89 ) - 17 - 339619-A LTD CERT OTHER SOURCES . d . Any benefits under the FederalSocialSecurity ld Act received by, or on behalf of , y dependent or over . e . Benefits from any individual disability insurance policy . C08E4F 3 . RULES FOR INCOME FROM OTHER SOURCES Each month your LTD BENEFIT will be determined using the INCOME FROM OTHER SOURCES for the same monthly period, even if you actually receive the INCOME FROM OTHER SOURCES in another month . If you receive any INCOME FROM OTHER SOURCES periodically other than monthly , STANDARD will determine the monthly equivalent and use that amount in determining your LTD BENEFIT . If you receive any INCOME FROM OTHER SOURCES in a lump sum, STANDARD will prorate the lump sum over the period of time for which the lump sum was paid and use that amount to determine your LTD BENEFIT . If no period of time is stated, STANDARD will determine the maximum period of time to which the lump sum is fairly attributable and prorate the lump sum over that period of time . With respect to INCOME FROM OTHER SOURCES which you are claiming but have not yet received, STANDARD will offer you the following options : Option 1 . STANDARD will determine your LTD BENEFIT each month using the monthly amount of the INCOME FROM OTHER SOURCES you expect to receive for that period . You will be reimbursed by STANDARD if this results in an underpayment of your claim for LTD BENEFITS . You must repay STANDARD if this results in an overpayment of your claim for LTD BENEFITS . Option 2 . STANDARD will pay you LTD BENEFITS without any adjustment on account of that INCOME FROM OTHER SOURCES until your claim for that INCOME FROM OTHER SOURCES is approved . You must repay STANDARD for any resulting overpayment of your claim for LTD BENEFITS . Printed ( 4/13/89 ) - 18 - 339619-A LTD CERT Option 2 . becomes effective automatically if you fail to make a choice . You must notify STANDARD of the amount of the INCOME FROM OTHER SOURCES when it is approved . If it is approved for a period when STANDARD has already paid an LTD BENEFIT, STANDARD will recompute the amount of the LTD BENEFIT which was payable to you for that period . If you have been underpaid, STANDARD will pay you the amount of any such underpayment with interest at a rate determined by STANDARD . If you have been overpaid, STANDARD will notify you of the amount of the overpayment . You must immediately reimburse STANDARD for the amount of the overpayment . You will not receive any payments from STANDARD until STANDARD has been reimbursed in full . In the meantime, any LTD BENEFITS becoming payable will be applied to reduce the amount of the overpayment of your claim for LTD BENEFITS . C08ESY Part 9 . OTHER LONG TERM DISABILITY BENEFITS AND PROVISIONS A. REHABILITATION PROVISION (RETURN TO WORK) If you work while LTD BENEFITS are payable, your earnings from that work will be used in determining the amount of your LTD BENEFIT . NOTE : All or a part of the ELIMINATION PERIOD can be satisfied while you are working if you are considered DISABLED during your period of work activity . C09AIF B. SURVIVORS BENEFIT If you die while LTD BENEFITS are payable to you, STANDARD will pay a lump sum SURVIVORS BENEFIT . The following rules will apply . 1 . The SURVIVORS BENEFIT will equal three times the amount of your MAXIMUM LTD BENEFIT . 2 . The SURVIVORS BENEFIT will first be applied to reduce the amount of any outstanding overpayment of your claim for LTD BENEFITS . 3 . The SURVIVORS BENEFIT will be paid to any one or more of the following at the option of STANDARD : Printed ( 4/13/89) - 19 - 339619-A LTD CERT a . Your spouse . b . One or more of your unmarried children under age 25 . C . Any person providing the care and support of any of them . The SURVIVORS BENEFIT will be paid only if you are survived by a spouse, or unmarried child under age 25 . C09B1U C . WAIVER OF PREMIUM Your LONG TERM DISABILITY INSURANCE in effect when you become DISABLED will be continued without payment of premiums while LTD BENEFITS are payable . If a period of continuous DISABILITY is extended by a new cause while LTD BENEFITS are payable, LTD BENEFITS will continue while you remain DISABLED, subject to the terms of the GROUP POLICY and the following rules : (a) LTD BENEFITS will not continue beyond the end of the original MAXIMUM BENEFIT PERIOD . (b) No LTD BENEFITS will be paid for any extension of a period of continuous DISABILITY caused or contributed to by a risk excluded under Part 7. C09C1B D . BENEFITS AFTER INSURANCE ENDS OR IS CHANGED Your right to receive LTD BENEFITS for a period of continuous DISABILITY which begins while you are insured under the GROUP POLICY will not be affected by : (a) The termination of the GROUP POLICY after the date you become DISABLED; (b) The termination of your INSURANCE while the GROUP POLICY remains in force; or (c ) Any amendment to the GROUP POLICY approved after the date you become DISABLED . C09DIB Printed (4/13/89 ) - 20 - 339619-A LTD CERT Part 10 . CLAIMS PROVISIONS AND PROCEDURES FOR LTD BENEFITS A . PAYMENT OF BENEFITS All LTD BENEFITS will be paid to you . Any LTD BENEFIT remaining unpaid at the time of your death will be paid to the person or persons receiving the SURVIVORS BENEFIT . If no SURVIVORS BENEFIT is paid, the unpaid LTD BENEFIT will be paid to your estate . B . TIME LIMITS FOR FILING A CLAIM You must claim LTD BENEFITS within 120 days after the end of the ELIMINATION PERIOD or as soon thereafter as reasonably possible and, in any case, within one year after the end of that 120 day period . Claims not filed within these time limits will be denied and no LTD BENEFIT will be paid . These limits will not apply during any period when you lacked the legal capacity to file a claim . C . FILING A CLAIM All claims for LTD BENEFITS should be submitted on STANDARD ' S forms . You should obtain claim forms from the POLICYOWNER or the Plan Administrator . You may also request claim forms from STANDARD . If STANDARD fails to provide you with claim forms within 15 days of your request , you may submit your claim in a letter stating the occurrence, character , and extent of the event for which the claim is made . D . PROOF OF LOSS Proof of each of the following elements of proof of loss must be provided to STANDARD at your expense . No LTD BENEFITS will be paid until STANDARD receives satisfactory written proof : 1 . That you became DISABLED while insured under the GROUP POLICY . 2 . That you were DISABLED throughout the ELIMINATION PERIOD and the period for which LTD BENEFITS are claimed . 3 . That your DISABILITY results from a cause not excluded in Part T . 4 . That you are being seen regularly and treated by a PHYSICIAN . S . Of such additional information as STANDARD may reasonably require in connection with your claim for LTD BENEFITS . Printed (4/13/89) - 21 - 339619-A LTD CERT If your claim is approved, no LTD BENEFITS will be continued beyond the end of the period for which you have provided STANDARD with satisfactory written proof of loss . E . DOCUMENTATION OF CLAIM You must submit the following documents at your expense : 1 . A completed claim statement signed by you . 2 . A completed claim statement signed by the POLICYOWNER . 3 . A completed claim statement signed by your treating PHYSICIAN . 4 . Your written authorization for STANDARD to obtain the records and information needed to determine your eligibility for LTD BENEFITS . S . Such other documents as STANDARD may reasonably require . STANDARD will require you to submit additional documentation of your claim at your expense at reasonable intervals while you are receiving LTD BENEFITS . F . DOCUMENTATION OF INCOME FROM OTHER SOURCES Documentation of INCOME FROM OTHER SOURCES must be provided to STANDARD at your expense . If STANDARD reasonably believes that you are receiving or are eligible to receive INCOME FROM OTHER SOURCES, STANDARD has the right to require satisfactory written documentation : (a) That you have made timely claim for the INCOME FROM OTHER SOURCES; (b) That you have properly pursued each claim; and ( c) Of the amount of the INCOME FROM OTHER SOURCES . STANDARD will send you a written request for any required documentation . You must provide such documentation within 60 days after the written request is mailed to you . Otherwise, STANDARD, at its sole discretion, may elect to reduce your LTD BENEFITS by the amount STANDARD reasonably believes you are receiving or would have been eligible to receive upon timely and proper pursuit of a claim for the INCOME FROM OTHER SOURCES . If your claim for LTD BENEFITS has been overpaid, STANDARD will notify you of the amount of the Printed (4/13/89) - 22 - 339619-A LTD CERT overpayment . You must immediately reimburse STANDARD for the amount of the overpayment . You will not receive any payments from STANDARD until STANDARD has been reimbursed full . l the reducemeantime, amount LTD BENEFITS becoming payable will be applied to of the overpayment of your claim for LTD BENEFITS . If you later provide the required documentation within a reasonable time, STANDARD will recompute the amount of LTD BENEFITS which were payable . If you have been overpaid, STANDARD will notify you of the amount of the overpayment and the overpayment will be handled as above . If you have been underpaid, STANDARD will pay you the amount of the underpayment with interest at a rate determined by STANDARD . G . INVESTIGATION OF YOUR CLAIM STANDARD has the right at any time to conduct an investigation of your claim . No LTD BENEFITS will be paid until STANDARD has had a reasonable time to conduct an investigation . H . INDEPENDENT EXAMINATION . STANDARD has the right to have you examined at STANDARD ' S expense at reasonable intervals while you are claiming LTD BENEFITS . Any such examinations will be conducted by one or more PHYSICIANS or vocational specialists of STANDARD' S choice . STANDARD has the right to defer or suspend payment of LTD BENEFITS if you fail to attend an examination or fail to cooperate with the person conducting the examination . In such a case LTD BENEFITS may be resumed , provided that the required examination occurs within a reasonable time and LTD BENEFITS are otherwise payable . I . NOTICE OF DECISION ON CLAIM You will receive a written decision on your claim within a reasonable period of time after STANDARD receives your claim . If STANDARD denies all or any part of your claim, you will receive a written notice of denial containing : ( 1 ) The reasons for the denial ; (P) Reference to the provisions of the GROUP POLICY on which the denial is based; (3) A description of any additional information or documentation you must submit to obtain benefits and an explanation of why such information or documentation is required; Printed ( 4/13/89 ) - E3 - 339619-A LTD CERT (4) Notice of your right to a review of the denial ; and (5) A description of the review procedure . If you do not receive a written decision on your claim within 90 days after your claim is received, you will have an immediate right to request a review under the review procedure, as if your claim had been denied . J . REVIEW PROCEDURE You have a right to a review of any denial by STANDARD of all or any part of your claim . To obtain a review, you should send a written request for review to STANDARD within 60 days after you receive notice of the denial . No special form is required . As a part of your request for review, you may submit issues and comments in writing and provide additional documentation in support of your claim . You may review pertinent documents related to your request for review . STANDARD will review your claim promptly after receiving your request for review . You will receive written notice of STANDARD' S decision within 60 days after your request for review is received, or within 120 days if special circumstances require an extension . The written decision you receive will include the reasons for the decision and reference to the provisions of the GROUP POLICY on which the decision is based . You may authorize another person to act for you under this review procedure . C1 001 C Part 11 . TIME LIMITS ON LEGAL ACTIONS AND CERTAIN DEFENSES No action at law or in equity may be brought to recover under the GROUP POLICY until 60 days after written proof of loss has been provided to STANDARD . Any statement you make to obtain INSURANCE will be a representation and not a warranty . No misrepresentation by you will be used to reduce or deny your claim or to deny the validity of your INSURANCE unless : ( a) Your INSURANCE would not have been approved except for your misrepresentation; (b) Your misrepresentation is contained in a written instrument signed by you; and Printed (4/13/89 ) - 24 - 339619-A LTD CERT (c) You have been given a copy of the written instrument containing your misrepresentation . After your INSURANCE has been in effect for two years, no misrepresentation by you, except a fraudulent misrepresentation made with actual intent to deceive, will be used to reduce or deny your claim or to deny the validity of your INSURANCE . C1101F Part 12 . ASSIGNMENT NOT PERMITTED Your Certificate is not assignable . The INSURANCE provided and benefits payable are not assignable . C1201A Printed (4/13/89 ) - 25 - 339619-A LTD CERT i1C w 07QZJ7©1C J GROUP INSURANCE CERTIFICATE °I STANDARD INSURANCE COMPANY hereby certifies that each Member is insured under the group Q A t�l policy described below during the time,in the manner and for the amounts provided in the group policy. Provisions of the group policy principally affecting the Member's insurance are described in this 2 p' certificate.In case of conflict between policy and certificate provisions,the policy provisions will govern. , le with the Policyowner or group insurance The beneficiary designated by the Member, if any, is on fi administrator. PRESIDE`NTT L� a Q' Y GROUP POLICY REVISED April, 1989 a NUMBER 339619 OGROUP POLICY PRINTED April, 1989 EFFECTIVE DATE October 1, 1974 �I NAME OF p POLICYOWNER CITY OF KENT, WASHINGTON MIDI �I 0� 0 �? I� Section 1. SCHEDULE OF INSURANCE Ii cl `� The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member under age 70 shall each be equal to the Member's Basic Annual Earnings,rounded to the next higher$1.00,if not already an �I even dollar amount. The maximum Face Amount and maximum Principal Sum shall each be $50,000. �I oThe Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member age 70 through I P� 74 shall each be equal to 65% of the amount which would be applicable for a Member under age 70. rJ Jj�I The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member age 75 or over C11 shall each be equal to 50% of the amount which would be applicable for a Member under age 70. ofage shall be effective on the first day of the calendar Changes in amounts of insurance because of change in omonth next following the date of change in age provided that if the Member is not actively at work on such date any increase shall be deferred until the next day on which he is actively at work. J ;I 0 �I LQ L a f� I� 0 0 °D a INSURANCE COMPANY O INSURANCE I'(111ll ANO,OREGON UNDERWRITTEN BY 0edit'awd PN/-we/h,114('/or A pht vowli is �DI�t�OOaD�>G�1���7L�GC-C7DGDa�F�/IOGf7(7DGDi�LOGGDC7vGD���Oa�.7DGD'I�FZ�'OGG�DGD�t<<D��1lL'�7Dl7DGD�Je70l��DC7DGDD??lIl/�G:�DIDc_?77hLi��I GENERAL DEFINITIONS Member means an active employee or the mayor of the Employer,other than a temporary or seasonal employee, who is regularly scheduled to work at least 21 hours each week. Employer means City of Kent and such affiliated companies or organizations as shall be approved in writing by the Policyowner and Standard. Basic Annual Earnings means basic annual wage or salary (not including overtime, bonuses, commissions, longevity pay,education pay,specialty pay and other extra compensation). Changes in basic annual earnings because of changes in basic wage or salary shall be effective on the first day of the calendar month coinciding with or next following the date of change in basic wage or salary. If the Member is not actively at work on the date on which an increase in basic annual earnings would otherwise be effective,such increase shall be deferred until the next day on which the Member is both eligible and actively at work. At the commencement of any period of total disability or at the time of any other loss, basic annual earnings shall be the Member's basic annual earnings as of the first day of the calendar month in which the disability commences or other loss occurs. Any change in basic wage or salary approved after total disability begins or after any other loss occurs shall not be considered in determining the amount of basic annual earnings. A Member is considered to be actively at work only when he is present and actively employed in a full-time permanent capacity at the Employer's usual place of business and has completed one full day of such employ- ment immediately prior to the date his insurance or an increase in his insurance is to be effective. Section 2. PERSONS INSURED A. Eligibility A Member becomes eligible for insurance on the first day of the calendar month following the date he becomes a Member. However, this waiting period for eligibility shall be reduced by any continuous period of time served as a permanent part-time employee of the Employer prior to the date a person becomes a Member. MA B. Effective Dates Insurance for an eligible Member becomes effective on the date he becomes eligible,provided he is actively at work on such date. Insurance on any eligible Member who is not actively at work on the date when his insurance would otherwise become effective becomes effective on the next following day on which he is actively at work. Zoos Section 3. CESSATION OF INSURANCE A Member's insurance automatically ceases on the earliest of the following dates: a. The date of termination of his status as a Member as defined in the group policy; b. The date he becomes a full time member of the military (land, sea or air) forces of any country; or C. The date of discontinuance of the group policy; except that life insurance may be continued in force under the Benefits In Event of Disability provision beyond these dates. — 1 — Termination of employment,when necessary to determine termination of status as a Member,means cessation of active work as an employee,except that for purposes only of determining whether a Member's insurance may be continued: 1) If a Member is absent from active work because of sickness or injury,his employment shall be deemed to continue until terminated by his employer under a plan precluding individual selection, and 2) If a Member is absent from active work because of leave of absence,his employment shall be deemed to continue, for a period not to exceed six months, until terminated by his employer under a plan precluding individual selection.This leave of absence exception does not apply to absence to become an active full time member of the military (land, sea or air) forces of any country, and 3) If a Member is absent from active work because of temporary lay-off,his employment shall be deemed to continue, for a period not to exceed two months, until terminated by his employer under a plan precluding individual selection. For the purpose of determining the date of cessation of insurance under any of these exceptions,termination of employment by his employer shall be either by notification to Standard by the Policyowner or by cessation of premium payments for the Member's insurance. 399 Section 4. CONTRIBUTIONS Contributions from Members are not required. 4W Section 5. BENEFIT PROVISIONS-LIFE INSURANCE A. Insuring Clause Upon receipt by Standard of satisfactory proof in writing that any Member has died while insured under the terms of the group policy, Standard will pay, subject to the terms of the group policy, the amount of life insurance, if any, in force on the life of the Member at the date of his death. 521A B. Benefits in Event of Disability For purposes of Life Insurance,the term total disability means complete inability of the Member to engage in any employment or occupation for which he is or becomes reasonably fitted by reason of education,training or experience. If the Member,while less than 60 years of age,and while his life insurance is in force,becomes totally disabled, his life insurance shall remain in force during the continuance of total disability without payment of premiums for a term of twelve months after the end of the last period for which a premium was paid to Standard for his insurance. His life insurance will continue in force thereafter, during the continuance of total disability, for successive terms of twelve months each, provided that proof of total disability is received by Standard, at the Member's expense,within three months before the beginning of each twelve month term.Upon receipt of proof of total disability within the three month period preceding the second twelve month term,Standard will refund to the Policyowner all premiums paid for the Member's life insurance and dependents life insurance since the commencement of total disability, for a period not to exceed nine months. Standard may at its option require the Member to submit to one or more medical examinations by the medical examiners designated by Standard, but such examinations shall not be required more often than once a year after total disability has continued for two full years. The amount of insurance which remains in force under this provision for any Member shall in no case be increased or decreased during the continuance of his total disability. Written notice of death of a Member whose insurance is being continued under this provision must be furnished to Standard at its home office within twelve months after the date of death.If notice of death as required is not so furnished, Standard shall not be liable for any payment on account of such death. —2— Termination of employment,when necessary to determine termination of status as a Member,means cessation of active work as an employee,except that for purposes only of determining whether a Member's insurance may be continued: 1) If a Member is absent from active work because of sickness or injury,his employment shall be deemed to continue until terminated by his employer under a plan precluding individual selection, and 2) If a Member is absent from active work because of leave of absence,his employment shall be deemed to continue, for a period not to exceed six months, until terminated by his employer under a plan precluding individual selection.This leave of absence exception does not apply to absence to become an active full time member of the military (land, sea or air) forces of any country, and 3) If a Member is absent from active work because of temporary lay-off,his employment shall be deemed to continue, for a period not to exceed two months, until terminated by his employer under a plan precluding individual selection. For the purpose of determining the date of cessation of insurance under any of these exceptions,termination of employment by his employer shall be either by notification to Standard by the Policyowner or by cessation of premium payments for the Member's insurance. 399 Section 4. CONTRIBUTIONS Contributions from Members are not required. 4W Section 5. BENEFIT PROVISIONS-LIFE INSURANCE A. Insuring Clause Upon receipt by Standard of satisfactory proof in writing that any Member has died while insured under the terms of the group policy, Standard will pay, subject to the terms of the group policy, the amount of life insurance, if any, in force on the life of the Member at the date of his death. 521A B. Benefits in Event of Disability For purposes of Life Insurance,the term total disability means complete inability of the Member to engage in any employment or occupation for which he is or becomes reasonably fitted by reason of education,training or experience. If the Member,while less than 60 years of age,and while his life insurance is in force,becomes totally disabled, his life insurance shall remain in force during the continuance of total disability without payment of premiums for a term of twelve months after the end of the last period for which a premium was paid to Standard for his insurance. His life insurance will continue in force thereafter, during the continuance of total disability, for successive terms of twelve months each, provided that proof of total disability is received by Standard, at the Member's expense,within three months before the beginning of each twelve month term.Upon receipt of proof of total disability within the three month period preceding the second twelve month term,Standard will refund to the Policyowner all premiums paid for the Member's life insurance and dependents life insurance since the commencement of total disability, for a period not to exceed nine months. Standard may at its option require the Member to submit to one or more medical examinations by the medical examiners designated by Standard, but such examinations shall not be required more often than once a year after total disability has continued for two full years. The amount of insurance which remains in force under this provision for any Member shall in no case be increased or decreased during the continuance of his total disability. Written notice of death of a Member whose insurance is being continued under this provision must be furnished to Standard at its home office within twelve months after the date of death.If notice of death as required is not so furnished, Standard shall not be liable for any payment on account of such death. —2— A Member's rights under this provision will automatically and immediately cease: 1) When he ceases to be totally disabled, 2) At the end of any twelve month term if proof of total disability is not received during the last three months of that term, 3) When he fails to submit to any medical examination required by Standard, or 4) When an individual policy has been issued to him under the provision hereof entitled Conversion of Life Insurance. 529E C. Conversion of Life Insurance 1. A Member, upon written application and payment of the applicable premium to Standard within 31 days after one of the following: a. The date his insurance ceases because of termination of employment or of termination of membership in the class or classes eligible for insurance under the group policy, b. the date of any reduction in the amount of insurance because of a change in classification of the Member, C. the date of cessation of insurance as defined in(1),(2)or(3)of the Life Insurance Benefit Provision entitled Benefits in Event of Disability, or d. the date of discontinuance of the group policy,provided such date is five years or more after the effective date of the Member's insurance, will be entitled, without evidence of insurability, to an individual policy of life insurance on the Member's life without disability or double indemnity benefits. The following conditions and provisions will apply to the individual policy of life insurance: 1) the Member may select any form of individual policy, except term insurance, then customarily issued by Standard at the age and for the amount applied for, 2) the premium for the individual policy will be the premium applicable to the class of risk to which the Member belongs and to the form and amount of the individual policy at the Member's attained age (nearest birthday) on the effective date of the individual policy, and 3) the amount of the individual policy will be equal to(or at the option of the Member less than)the amount of the Member's life insurance or the reduction in the amount of life insurance,as the case may be,on whichever of the dates in a,b,c or d above is applicable.However,if the Member's life insurance ceases because of the discontinuance of the group policy five years or more after the effective date of the Member's insurance the amount of the individual policy may not exceed the lesser of a) the amount of the Member's life insurance at the date of cessation of such insurance,reduced by any life insurance for which he may become eligible under any group policy issued or reinstated by Standard or by any other insurer within thirty-one days after such cessation, and b) $2,000. 2. Any individual policy so issued shall become effective on the date of expiration of the thirty-one day period during which application may be made. However, if the Member should die during such thirty-one day period, Standard will pay, whether or not the Member has made application for such individual policy, the maximum amount of life insurance for which an individual policy could have been issued. In no event,however, will payment be made under this provision if payment is made under the Life Insurance Benefit Provision entitled Insuring Clause or Benefits in Event of Disability. 3. If an individual policy is issued to a Member in accordance with the provisions of this subsection,such Member shall not thereafter become insured under the group policy unless he shall, at his own expense, furnish evidence of insurability satisfactory to Standard, any other provisions of the group policy to the contrary notwithstanding. 522C —3— Section 5. BENEFIT PROVISIONS-ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE Upon receipt by Standard of notice and satisfactory proof that any Member while insured under the group policy has sustained any of the losses shown in the Schedule of Indemnities as a direct result of accidental bodily injuries, independently of all other causes and within 90 days of the date of such injury, Standard will pay,subject to the terms of the group policy,the amount specified for such loss in accordance with the Schedule of Insurance and the Schedule of Indemnities, provided however, that even though such loss results from accidental bodily injury,no payment will be made for any loss caused directly or indirectly by any of the following and no payment will be made for any loss if the accident is caused directly or indirectly by any of the following: a) any insurrection, war, or act of war. War includes declared or undeclared war, whether civil or international, and any substantial armed conflict with organized forces of a military nature. b) suicide or injuries intentionally inflicted by the Member, while sane or insane. c) committing or attempting to commit an assault or felony,or participating in a violent disorder. d) hernia of any kind, stroke,coronary occlusion or rupture, any self-administered drug, poison or chemical compound,bodily or mental infirmity,sickness,disease or infection existing at the time of the accident, or medical or surgical treatment for any of the foregoing. SCHEDULE OF INDEMNITIES Benefit for Loss of Life Through Common Carrier Accident*. . . . . . . . . . . . . . . . . . . . . . . . Two Times The Principal Sum Life Through Other Accident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Principal Sum Both Hands or Both Feet or Sight of Both Eyes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Principal Sum One Hand and One Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Principal Sum Either Hand or Foot and Sight of One Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Principal Sum Either Hand or Foot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . One-Half The Principal Sum Sight of One Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . One-Half The Principal Sum *Common carrier accident means an accident sustained while a fare-paying passenger in a public conveyance provided by a common carrier for passenger service. Loss shall mean,with regard to hands and feet, actual severance through or above wrist or ankle joints; with regard to eyes, entire and irrecoverable loss of sight. No more than the Principal Sum shall be paid for all losses through one accident, except that if loss of life is caused by a common carrier accident no more than two times the Principal Sum shall be paid. Accidental death and dismemberment insurance under the group policy is not in lieu of and does not affect any requirement for coverage by workmen's compensation insurance. SEAT BELT BENEFIT Standard will pay an additional accidental death benefit,called the Seat Belt Benefit,if you die as a result of an Automobile accident and you were wearing a Seat Belt at the time of the accident.The following rules apply: 1. The Seat Belt Benefit equals $50,000 or the amount of the accidental death and dismemberment insurance benefit paid because of your accidental death, whichever is less. 2. Standard must receive satisfactory written proof that your death resulted from an Automobile accident and that you were wearing a Seat Belt at the time of the accident.A copy of the police accident report should be submitted with the claim. —4— Seat Belt means a properly installed seat belt, lap and shoulder restraint, or other restraint approved by the National Highway Traffic Safety Administration. Automobile means a motor vehicle licensed for use on public highways. 511 Section 6. PAYMENT OF CLAIMS A. Payment of Benefits All benefits provided in the group policy shall be paid as stated in this section upon receipt of written proof on Standard's forms or if such forms are not furnished by Standard, within 15 days after demand therefor, then upon receipt of written proof covering the occurrence,character and extent of the event for which claim is made. Any indemnity for loss of life provided by the group policy will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. Any other accrued indemnities unpaid at the insured Member's death may, at the option of Standard,be paid either to the beneficiary or to the Member's estate.All other indemnities will be payable to the insured Member. 611A B. Proof of Loss Written proof of loss must be furnished to Standard in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss,within 90 days after the first month or lesser period for which Standard may be liable,and in case of claim for any other loss,within 90 days after the date of such loss. In the event of claim for total disability subsequent written proofs of continuance of total disability must be furnished to Standard,at the Member's expense,at such intervals as Standard may reasonably require.Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the Member, later than one year from the time proof is otherwise required. Standard shall have the right to require as part of the proof of loss with respect to Long Term Disability Insurance satisfactory evidence(a)that the Member has made application for all Deductible Benefits,(b)that he has furnished all required proofs for such benefits and (c) of the amount of such benefits payable. 6068 C. Physical Examination and Autopsy Standard at its own expense shall have the right and opportunity to examine the person of any individual whose injury or sickness is the basis of claim when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death, where it is not forbidden by law. 605C —5— D. Beneficiary Provisions Death benefits, if included in the group policy,will be paid to the beneficiary(ies) designated to receive them. When more than one class of beneficiary is named, payment will be made to those in the highest beneficiary class;the classes ranking in the order:primary,first contingent,second contingent,etc.Should one beneficiary class include more than one person, any benefits payable to that class will be paid in equal shares to the surviving beneficiaries of that class unless otherwise provided. If no designated beneficiary survives the Member the benefits will be paid to the first surviving class of the following classes of successive preference beneficiaries:The Member's(a)spouse;(b)children;(c)parents;but if no class survives,the benefits will be paid to the Member's executors or administrators. If two or more persons become entitled to benefits as preference beneficiaries,they shall share equally.Standard may rely on an affidavit or other evidence deemed satisfactory to it in determining the identity or the nonexistence of beneficiaries not identified by name,and any payment made by Standard in reliance thereon shall to the extent of such payment be a valid discharge of Standard's obligations. The beneficiary(ies)may be designated(or changed)by the Member at any time.The designation or change will take effect as of the date it is signed except that it will not apply to any payment made by Standard before receiving the designation or change.A beneficiary designation or change must be made,dated and signed by the Member in a written instrument relating to the insurance provided under the group policy and delivered to the Policyowner during the lifetime of the Member. A written beneficiary designation dated and signed by the Member under a previous policy will be accepted as a beneficiary designation under the group policy if the previous policy relates to the same policyowner group insurance program as the group policy, and if the insurance under the group policy replaces all or part of the insurance previously in force under that program. If any beneficiary dies simultaneously with the Member or within 15 days after the Member, and before due proof of the Member's death satisfactory to Standard has been received at Standard's home office,the proceeds will be paid as if that beneficiary had died before the Member. The amount payable to a beneficiary may be paid in installments over a period of years upon mutual agreement with Standard. To the extent permitted by law amounts payable to beneficiaries shall not be subject to the claims of any creditor or any representative of such creditor, or to any legal process against a beneficiary. If an individual policy has been issued as a result of application made in accordance with the Benefit Provision entitled Conversion of Life Insurance the designation by the Member of a beneficiary under such individual policy other than the beneficiary of record of the Member under the group policy, will, notwithstanding any other provisions of this Section to the contrary, effect a change of beneficiary under the group policy to the beneficiary of record under such individual policy. If any indemnity of the group policy shall be payable to the estate of the insured Member, or to an insured Member or beneficiary who is a minor or otherwise not competent to give a valid release,Standard may pay such indemnity up to an amount not exceeding$500 to any relative by blood or connection by marriage of the insured Member or beneficiary who is deemed by Standard to be equitably entitled thereto. Any payment made by Standard in good faith pursuant to this provision shall fully discharge Standard to the extent of such payment. 606D E. Assignment The Member's certificate is non-assignable and the insurance and benefits are non-assignable. 600E —6— Section 7. TIME LIMITS ON LEGAL ACTIONS AND CERTAIN DEFENSES After the group policy has been in force for two years,its validity shall not be contested,except for non-payment of premiums.No statement by any Member made in an application for life insurance shall be used to reduce or deny a life insurance claim after the insurance with respect to which claim has been made has been in force for two or more years.No statement,except a fraudulent misstatement,by any Member made in an application for insurance other than life insurance shall be used to reduce or deny a claim after the insurance with respect to which claim has been made has been in force for two or more years. No action at law or in equity shall be brought to recover on the group policy prior to the expiration of.60 days after written proof of loss has been furnished in accordance with the requirements of this policy.No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished. 712 Section 8. MISSTATEMENT OF INFORMATION In the event of the misstatement of the age of any Member,there will be made an equitable adjustment of the premiums or of benefits or of both, such adjustment to be based on the difference between the total premiums paid and the total premiums which would have been paid had the information been correctly stated. 802 —7— LLC t919 Request For Group Insurance Amendment Standard Insurance Company 900 SW 5TH AVE PORTLAND OR 97204-1282 Employee Benefit Representative/Group Office: Tammy Bucy / Seattle Group Office Service Contact: Luke Gordon / Laura Turner Policyowner Name: City of Kent Group Policy Number: 339619 As an authorized representative of the Policyowner, I request Standard amend the above Group Policy as follows, subject to Standard's usual underwriting requirements: Change Life / AD&D schedule to include a $25,000 minimum benefit. I request the amendment, if approved by Standard, become effective on June 1, 1995, and be issued in the policy language customarily used by Standard. I understand the amendment will be subject to the terms and conditions of the Group Policy including, if applicable, Evidence Of Insurability or a Preexisting Condition limitation. I understand any increase in Insurance for a Member who is not Actively At Work on the day before the scheduled effective date of the amendment will be deferred until the Member meets the Group Policy's Active Work requirement. I request the amendment, if approved by Standard, become effective by its terms without any further acceptance by the Policyowner, and a copy of this Request For Group Insurance Amendment form be attached to and made part of the amendmen . c Signed By: Title: Date: � _ wry �- imn.-.,-.:,2.a'xssz. ;'•W'°��".� �.1-.."w'�:a::a`�°��r.�,'s:'..'.�n.�::g+�- �4,. T N C� COMPANYSTANDARD INS RA PORTLAND, OREGON 339619 POLICY NUMBER Y OF KENT r CITY POLICYOWNER r'+I EFFECTIVE DATE October 1, 1974' u' y INITIAL POLICY TERM Two Years DUE DATES October 1, 1974 and the first day of each calendar month thereafter ` and governed by the laws of that state. t., POLICY DELIVERED IN Washington l'. STANDARD INSURANCE COMPANY agrees to pay the benefits provided by this policy,in accordance with the provisions of this policy. F< The consideration for this policy is the application of the Policyowner and the payment by the Policyowner of premiums as provided herein. This policy is issued for the Initial Policy Term shown above, ending on the first day after the end of such policy term at or 12:01 A.M. Standard Time at the Policy owner's idd;e`m At }ch renle ewal dat of thee,providednitial 2the cy mnnber f persons s it may ons insuredewed lon successive renewal periods by the payment of the p ` each renewal date is neither less than the Minimum�articipation Number nor less than the Minimum Participation Percentage ; (shown in the Policy Data) of the total number eligible. The length of each renewal period shall be determined by Standard, but shall not be less than 12 months in any case. This policy, the application of the Policyowner, if any,and the individual applications,if any,of the Members constitute the entire contract between the parties, and any resentation and byatement made the a warranty No succyowner orh statemy any ent person insured be used ner this defenseoto a shall, in the absence of fraud,be deemed a representation p claim hereunder unless it is contained in a written application signed by the Policyowner or the Member,a copy of which has been furnished to the Policy owner, the person insured or the beneficiary. No change in this policy shall be valid unless approved by an executive officer of Standard and evidenced by endorsement , ner and by an executive officer of Standard.No agent has authority hereon, or by amendment hereto signed by the Policyow ; to change this policy or to waive any of its provisions. All provisions on this and the following pages are a part of this policy.On the following pages the term"group policy" refers a" insurance" refers to the insurance under this group policy unless clearly indicated to this group policy, and the term "group ' otherwise. STANDARD INSURANCE COMPANY By President Secretary D 1 U Registrar i Group Insurance Policy i GP 970 POLICY DATA POLICY NUMBER 339619 INITIAL PREMIUM RATE $.26 monthly per $1,000 Pace Amount Life Insurance Accidental Death and $.06 monthly per $1,000 Principal Sum Dismemberment Insurance MINIMUM PARTICIPATION 10 Number Percentage 100`% GENERAL DEFINITIONS Member means a regular permanent employee of the Employer who is regularly working throughout the entire duration of the Employer's work week,and in no event less than 30 hours per week. Employer means City of Kent and such affiliated companies or organizations as shall be approved in writing by the policyowner and Standard. A Member is considered to be actively at work only when he is present and actively employed in a full-dune I>crmanent capacity at the Employer's usual place of business and has completed one full day of such employment immediately prior to the date his insurance or an increase in his insurance is to be effective. Section 1. SCHEDULE OF INSURANCE The Pace Amount of life insurance and the Principal Surn of accident insurance for a Member under age 65 shall be determined from the following table: Face Amount Principal Sum Classification (Life Insurance) (Accident Insurance) 000 $15,000 Department Heads $15, 10,000 All Other Members 10,000 I he F;ice Amount of life insurance and the Principal Sunn of accident insurance for a Member age 65 or over shall each be ,1.d t, half the applicable amounts indicated above. C}nangcs ill :uununts' of insurance because of changes in age or classification hallat if tbhe Memberffective oi nowt first day atowor tile oilcalendctr month next following the date of change in age or classification, provided date any increase shall be deferred until the nest day on which lie is actively at work. 199 Section 2. PERSONS INSURED A. Eligibility A Member becomes eligible for insurance as follows: 1. If he is a Member on the ef(cctivc date of the group policy, he is eligible on that date. 2. If he becomes a MCrnber after the effective date of the group policy, he is eligible on the first day after six months as a Member. 299A B. Effective Dates the date he becomes eligible, provided he is actively at work on such Insurance for an eligible Member becomes effective on date. Insurance on any eligible member next following dtiv of wh which Ile isjactively the at wlork.en his insurance would otherwise become wor effective becomes effective o 200B Section 3. CESSATION OF INSURANCE A Member's insurance automatically ceases on the earliest of the following dates: a. The date of termination of his status as a Member as defined in the group policy; b. The date he becomes a full time member of the military (land, sea or air) forces of any country; or c. The date of discontinuance of the group policy; except that life insurance may be continued in force under the Benefits In Event of Disability provision beyond these dates. mination of status as a Member, means cessation of active work Termination of employment, when necessary to determine ter as an employee, except that for purposes only of determining whether a Member's insurance may be continued: 1) if a Member is absent from active work because of sickness or injury, leis employment shall be deemed to continue until terminated by his employer under a plan precluding individual selection, and 2) If a Member is absent from active work because of leave of absence or temporary lay off, his employment shall be inate by deemed to continue, for a period of absot to exccedtg ncc exception ocosnnots, until term t apply to absence to become canyactivcdfull dmc member' of individual selection. This lc:�vc c the military (land, sea or air) forces of any country. For the purpose of determining the date of cessation of insurance under either of these exceptions, termination of employment by his employer shall be either by notification to Standard by the Policyowuer or by cessation of premium payments for the Member's insurance. 350 Section 4. CONTRIBUTIONS Contributions from Members are not required. 400 Section 5. BENEFIT PROVISIONS—LIFE INSURANCE A. Insuring Clause IJpou receipt by Standard of satisfactory proof in writing that Zany Member has died while insured under the terms of the group policy. Standard will pay, subject to the terms of the group policy, the amount of life insurance, if any, in force on the life of the Member at the date of his death. 52 t A B. Benefits in Event of Disability Por purposes of Life Insurance, the term total disability means complete inability of the Member to engage in any employment or occupation for which he is or becomes reasonably fitted by reason of education, training or experience. If the Member, while less than 60 years of age, and while Iris life insurance is in force, becomes totally disabled, his life insurance shall remain in force during the continuance of total disability without payment of premiums a term of twelve f or Moo after the end of the last period for which a prenlitnn was paid to Standard for his insurance. His life insurance will continue in farce thereafter, during the continuance of total disability, for successive terms of twelve n!onths each, provide(' that proof of total disability is received by Standard, at the Member's expense, within three months before the beginning of each twelve month tens. Upon receipt of proof of total disability within the three month period preceding the second twelve month tern,, Standard will refund to the Policyowner all premiums pail for the Member's life insurance and dependents life insurance since the commencement of total disability, for a period not to exceed nine months. Standard ntay at its option require the Member to submit to one or more medical examinations by the medical examiners designated by Standard, but such esanlinations shall not be required more often than once a year after total disability has continued for two full years. The anu,unt of insurance which remains in force under this provision for any Member shall in no case be increased or decreased during the continuance of his total disability. Written notice of death of a Member whose insurance is being contint!e(I under this provision must be furnished to Stimdaud A its home office within twelve months after the date of death. If notice of death as required is not so furnished, Standard shall not be liable for any payment on account of such death. A Member's rights under this provision will automatically and immediately cease: I) When he ceases to be totally disabled, 2) At the cold of any t%vclvc month term if proof of total disability is not received during the last three months of that term, 3) When he fails to submit to any n!edical cxan,ination required by Standard, or 4) When an individual policy has been issued to him under the provision hereof entitled Conversion of Life Insurance. C. Conversion of Life Insurance 1. A Member, upon written application and payment of the applicable premium to Standard within 31 days after one of the following: s because of termination of employment or of termination of membership in the class or a. The date his insurance cease classes eligible for insurance under the group policy, b. the date of any reduction in the amount of insurance becau3 f ��ge �lnsurnnce Benefitcation of tProv�ision entitled Benefits c. the date of cessation of insurance as defined in rse(l), (2) ( ) f the L fe in Event of Disability, or f group policy, provided such d m ate is five years or ore after the effective date of tile d. the date o discontinuance of the Member's insurance, will be entitled, without evidence of insurability, to an individual policy of life insurance on the Member's life without disability or double indemnity benefits. 'File following conditions and provisions will apply to the individual policy of life insurance: 1) the Member may select any form of individual policy, except term insurance, then customarily issued by Standard at the age and for the amount applied for, to 11 be ber belongs 2) the premium for the individual f Policy tile individual tpoliile cy��it the�lMelmbe�r'sle ta�ttainedle �agess (,nearest(nearest birthday)on�the effective and to the form and amo date of the individual policy, and 3) the amount of the individual policy will be equal to (or at the option of the Member less than) the amount of tie Members life insurance or the reduction in the amount of life insurance, as the case may be, on whichever of the dates ' in u, b, or d above c applicable. However, if the Me" life insurance ceases because of the discontinuance of the �e amount of the individual policy group policy five years or more after the effective date of the Meniber's insurance tl niay not exceed the lesser of by a) the amount of the Member's life insurance y roup policyle date Of cissued�lor)reinstIatledUby Standnrd olr by anylothersins urer for which he may become eligible under any group within thirty-one days after such cessation. and b) ;2,000. 2. Any individual policye so issued shall become effective on the date of expiration of the thirty-one day period during which application ma), be made. However, the Member should die during such thirty-one day period, Standard will pay, whether or not the Member has made application for such individual policy, the maximum amount of life insurance for which an individual policy could have been issucd. however, will payment be made under this provision if payment is made under the Life Insurance Benefit In no event. Provision entitled Insuring Clause or Benefits in Event of Disability. 3. If an individual policy is issued to a Member in accordance with the provisions of this subsection, such Member shall not thereafter become insured under the group policy unless he shall, at his own expense, furnish evidence of insurability satisfactory to Standard, any other provisions of the group policy to the contrary notwithstanding. 522C Section 5. BENEFIT PROVISIONS.-ACCIDENTAL DEATH AND DISMEIVIBER.-]V.NT INSURANCE Upon receipt by Standard of notice and satisfactory prw-,f that any Member while insured under the group policy has sustained any of the losses shown in the Schedule of Indemnities as a direct result of accidental bodily injuries, independently of all other causes and within 90 days of the date of such injury, with tile Standard will pay, subject to the terms of ln le grOL11), provided tile amount Schedule of insurance and the Sc that ever, �or � � �ss � accordance by bodily injury, no payment will be made for ally yreoss caused dirctlly orandirecy oftly follmy o the following and no payment will be made for any loss if the accident is Y a) any insurrection, war, or act of war. War includes declared or undeclared war, whether civil or international, and any substantial armed conflict with organized forces of a military nature. b) suicide or injuries intentionally inflicted by the Member, while sane or insane. c) committing or attempting to commit an assault or felony, or participating in a violent disorder. d) hernia of any kind, stroke, coronary occlusion or rupture, any self-administered drug, poison or chemical compound, bodily or mental infirmity, sickness, disease or infection existing at the time of the accident, or medical or surgical treatment for any of tine foregoing. SCHEDULE OF INDEMNITIES Benefit for Loss of Two Times The Principal Sum Life Through Common Carrier Accident* . . • • • • • • • . • . • . . . . . . . . _ . . The Principal Sum Life Through Other Accident . . . . . . . . . . . . . . . . . . . The Principal Sum Both Hands or Both Feet or Sight of Both Eyes . . . . . . . . . . . The Principal Sum One Hand and One Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. . . The Principal Sum Either Hand or Foot and Sight of One Eye . . . • . • • . • • • • . . . . . . . . . One-Half The Principal Sum Either Hand or Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . One-Half The Principal Sum Sight of One Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *Common carrier accident means an accident sustained while a fare-paying passenger in a public conveyance provided by a common carrier for passenger service. ance through or above wrist or ankle joints;with regard to eyes, Loss shall mean, with regard to hands and feet, actual sever entire and irrecoverable loss of sight. No more than the Principal Sul', shall be paid ore than two times r all losses through one l Sum pall beep dent, except that if loss of life is caused by a common carrier accident, no m d. Accidental death and dismemberment insurance under the group policy is not in lieu of and does not affect any requirement for coverage by workmen's compensation insurance. 599 Section 6. PAYMENT OF CLAIMS A. Payment of Benefits on n receipt of ten All benefits provided in the got furnished dsbalSandard,e paid awitlin15tdayssaftertdemo d therefor, thentupon ref on Standard's ceipt pt of written forms or if such forms are Y proof covering the occurrence, character and extent of the event for which claim is made. in the beneficiary designation Any indemnity for loss oflifesuchwed the whigroup ch may becy will be pr scribed herein and effective at he time of payment. Any other and the provisionsunpaid respecting payment accrued indemnities unpaid at the insured Member's death may, at the option of Standard, be paid either to the beneficiary or to the Member's estate. All other indemnities will be payable to the insured Member. 611 A B. Proof of Loss his cy ic Written proof of loss must be.fuints los,twt h n 90 days aftero Standard in case otheafirstf month oor loss orrl sserhperiod for whi h1Standard des any pmay dbe payment contingent up g date of such loss. in the event liable, and in case of wn m rior any roofs Cherof los,uance of 0toa 1 disability ys after emust be furnished to Standard,oatcthe Mlaim ember's disability subsequentpfurish expense, at such intervals asStanda It way reasonably ea o not ably require. ably possibler toogivenp o fcwithin such within required shall time, p ovidedsuchproof is invalidate nor r any claim furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the Member,later than one year from the time proof is otherwise required. of of oss with ct to g Term ce Standard shall have (a that i to the Member hauire as s rt of madepelicpation forlall DeductibleBeneftsn(b) that hehalstfurnishednall satisfactory ( ) required proofs for such benefits and (c) of the amount o such benefits payable. 606E C. Physical Examination and Autopsy Standard at its own expense shall have the right and opportunity to examine the person of any individual whose injury or sickness is the basis of claim when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death,where it is not forbidden by law. 605c D. Beneficiary Provisions Death benefits, if included in the group policy, will be paid to the beneficiary(ies) designated to receive them. When more than one class of beneficiary is named, payment will be made to those in the highest beneficiary class;the classes ranking in the order: primary, first contingent, second contingent, etc. Should one beneficiary class include more than one person, any benefits payable to that class will be paid in equal shares to the surviving beneficiaries of that class unless otherwise provided. If no designated beneficiary survives the Member the benefits will be paid to the first surviving class of the following classes of successive preference beneficiaries: The Member's (a) spouse; (b) children; (c) parents; but if no class survives, the benefits will be paid to the Member's executors or administrators. If two or more persons become entitled to benefits as preference beneficiaries, they shall share equally. Standard may rely on an affidavit or other evidence deemed satisfactory to it in fied determining the the reon shallttoy or the the extent of such payment nexistence of be ataries valid d�chargelof Standard's,oblgatio any nsyment made by Standard in reliance The beneficiary(ies) may be designated (or changed) by the Member at any time.The designation or change will take effect as of the date it is signed except that it will not apply to any payment made by Standard before receiving the designation or change. A beneficiary designation or change must be made, dated and signed by the Member in a written instrument relating to the insurance provided under the group policy and delivered to the Policyowner during the lifetime of the Member. A written beneficiary designation dated and signed by the Member under a previous policy will be accepted as a beneficiary designation under the group policy if the previous policy relates to the same policyowner group insurance program as the group policy, and if the insurance under the group policy replaces all or part of the insurance previously in force under that program. er the the hin 15 ys If any beneficiary dies simultaneously with the Member o received at Standard's home office, procd ds will be p id as if that Member's death satisfactory to Standard has been beneficiary had died before the Member. upon mutual The amount payable to a beneficiary may be paid ininstallbents ovriesasha111od of not be subjectt agreement the claims of any creditor l er creditor Standard. To the extent permitted by law am payable or any representative of such creditor, or to any legal process against a beneficiary. vision If an individual policy has been issued as designation nreby thefMpmbertion of a beneficiary under accordance su suchwith individual policyoother thantthe Conversion of Life Insurance the deer under t Y ic yy provisions of this beneficiary of record of the beneficiary Mn fc iar Wunder t}1he ge gro proup opolicy to thetbenefici dry of record u der such individualepolicy.ction the contrary,effect a change o Y er' or to an in if any indemnity of the group policy Holt comaet payable to give astate valid orelease,insured Standa de may pay such indemsurenity tyl up toer an ciary who is beneficiary who is a minor or otherwiseP enef amount not exceeding $500 to any relative bentitled blood or connection nyti Yn1e marriage of the Standar insured good faith pursuant to this deemed by Standard to be equitably provision shall fully discharge Standard to the extent of such payment. 606D E. Assignment ssignable and the insurance and benefits are non assignable. 600E The Member's certificate is non-a Section 7. TIME LIMITS ON LEGAL ACTIONS AND CERTAIN DEFENSES of exce for non After the group policy has been in force ma wiyears, for lifelin ur nce oshall b eused tot reduce orPdeny at dnot belife den an a premiums. No statement by any Member application de has been rce or ore th respect which claim has insurance claim after the insurance sst�tementt, bytany Member made been anappli application for insuoranceootl other than life ins insurance statement, except ith respect to which claim has been made has been in force for shall be used to reduce or deny a claim after the insurance w two or more years. I y prior to ays after No action at law or in equity shall in beaccordancebog with the requirements of this policy. Nolsuch action shall of 60 d shall be brought written ught after the proof of loss has been furnish expiration of three years after the time written proof of loss is required to be furnished. 712 Section 8. MISSTATEMENT OF INFORMATION le ment of the In the event of the misstatement of the t age of any Member, there o be based on he differencelbetweeu the totale an tpremiuJmstpaid and the premiums premiums benefits or of both, such adjustment which would have been paid had the information been correctly stated. 802 PREMIUMS Section 9. A. Premium Charges following applicable Each premium charge for the insurance n undid ihetlgrog o poP�jic consists all amount qualtto the p duct of,th s<rver e life determined according to the coverages force on all lus insurance premium rate in effect on the due d remiumand trlatehe rin effeount ct for dependents 1 feln insurance on the du date Membanders pthe (2) an amount equal to the product of the p respect to ment premium their anPurance onenents lthe due date oand equal to the prouct o of accidental number of Members then insured with edeath and rate in effect for accidental death aof tile pium em te dismemberment insurance then nsurance onitilesdue date an amount of weekly indemnity insuranceh iforce on en inrfor e onaall in effect for weekly indemnity nin insured Members plus (5) an 1 on that date o the e prct,oduct of the premium rate to premium adjustments,t for any)g term disability insurance an the amount of Insured Payroll dard om When Life Insurance is included an average lieInitialinsurance cec.dale rate per Life insurance of life insurance ms set is c in Sectionyl3the eof. Pu as of the effective date of this policy, using t Said average premium rate is shown in the policy data as the initial premium rate for life insurance. Upon any renewal of this policy, or whenever the terms of this policy are changed. Eft}1er th of lifeyowne n or using Standard r such require a reco�nputation as of such date of e life insurance premium rate per $1, the era recomputation such schedule of life insurance premiums a insurance then in force at the respective attained es of the insured Members may then mbeso determined n such date by Standard and the amount of g on The initial premium rates for all other ea gts policy are shown policy na n mutual agreement between the Policyowncr and Standard, orupon thirty-one days wrrittennotceo the Poccyower, Sadard maychange any be one or more of said premium rates, effective on any renewal date or on the date of any change in the terms of this Policy- Instead of the methods of determination and cu itio oe U1tium charges above provided, ytt charges determined and computed by any method mutually to Standard and olicownerwhtchproduces approximately the same total amount. 930A B. Premium Adjustments ted to Premium adjustments involving return oof f receipt unearned premiums remi rdsot tilenPo1icy tha�such adjustmner shall eentslshould beemad period of twelve months immediately preceding the date p Y 9018 C. Payment of Premiums Premiums are due and payable on the due dates shown on the front of this policy. licyowner or thereof, if any, are payable by All premiums falling due duetdates directtoto Standard ts,Home[Office•The payment of any prremiumtshall not maintain nthe before their respective insurance under this policy in force beyond the date immediately preceding the next due date, except as provided in the provision entitled Grace Period. On written request of the Policyowner, approved by Standard, premium payments may, if not then so payable, be changed at any premium due date of this policy so as to be payable annually, semi-annually, quarterly, or monthly. 901C D. Grace Period ums accruing after the t premium, race A grace period of 31 days willl continlu ei granted force buotrtilee payment of Policyownershalltbe liable to Standard forsthe payment of he p elm period t ums he policy shall accruing for the period the policy continues in force. that this iscontinued as of a e date or If written notice is given grace period, thisvner to policy shall bediscontinued policy as of the date specified m he noticeuor the date of before the end of the g p receipt of the notice,whichever is later. 903D CERTIFICATES Section 10. Standard will issue to the Policyowner, for delivery to uachinsuredc dMo whom beneber, an fitsarelpayable,dte and willh will state tile summarize the insurance to which such Member is entitled under the group policy provisions of the group policy principally affecting the Member. loos Section 11. RECORDS AND REPORTS cy henever The Policyowner shall furnish on Standard's ltforms ner shall not invalidate as iinsurance necessary otherwisewalidly in this fopce'norycontinue required by Standard. Clerical error by the Po y insurance otherwise validly terminated. Standard shall have the right and opportunity at all reasonable times to inspect the payrolls and other records of the Policyowner for any purpose relating to insurance under this policy. 1100 DIVIDENDS Section 12. in force, it shall be credited with its share of the divisible surplus in the form of dividends as During the period this policy is declared by Standard. 1204 Section 13. INITIAL SCHEDULE OF LIFE INSURANCE PREMIUMS per $1,000 of Life Insurance Rating Amount None Premium Factor 0.68 The Basic Monthly Premium Schedule shown below when modified by adding the Rating Amount to each premium and multiplying the total by the Premium Factor is the Initial Schedule of Monthly Group Life Insurance Premiums per $1,o00 of life insurance. BASIC MONTHLY PREMIUM SCHEDULE MonthlyAttained* Monthly Attained* Monthly Attained* premium Age Premium Age Premium Age 16 $ .15 41 $ .41 66 $ 3.26 67 3.54 17 .15 42 47 68 3.84 18 .15 43 69 4.16 19 .15 45 .56 70 4.52 20 .16 4.90 21 .16 46 .67 71 72 5.30 22 .17 47 73 5.74 23 .17 48 .73 74 6.22 24 .18 49 88 7S 6.73 25 .18 50 . 7.28 26 .19 51 1.04 77 7.87 27 .19 52 1.12 78 8.50 28 1.21 79 20 53 9.18 29 .20 55 1.32 80 9.91 30 .21 1.43 81 io.69 21 56 11.52 31 .22 57 1.SS 82 12.41 33 24 58 1.68 84 13.36 34 .25 60 1 83 85 14.37 35 27 1.99 36 .29 61 2.16 37 .31 62 2.34 38 .33 63 2.55 39 .35 64 2.76 40 .38 65 3.00 *At Nearest Birthday ,goo GROUP POLICY ENDORSEMENT Effective January 1,1992,this endorsementis attached to and made apart feac info coverages Group underyour Gr issued to oup above Policyownerby Standard Insurance Company.This endorsementyapplies Policy(ies)which are subject to a state-mandated fay or medicalieave act or law.Ifyour Group Policy(ies)does not include a coverage which is subject to such an act or law,this endorsement does not apply. The Group Policy is endorsed as follows: will be continued,upon payment of premium, 1. The Group Policy is endorsed to provide that your insul'ance ceder the Group Policy is required by the during a leave of absence if continuation of your insurance state-mandated family or medical leave act or law.,, 2. The Group Policy is endorsed to providetbat ifyour insurance ends because you are on a state-mandated family or medical leave of absence,and you become a member again immediately following the period allowed, your insurance will be reinstated pursuant to the state-mandated family or medical leave act or law. 3. If your plan includes a Long Term Disability or Short Term Disability insurance policy which includes a Preexisting Condition Exclusion,it is endorsed to provide that if your insurance ends after you were as n there sured and you become insured again as a new member,the Preexisting ConditionExclusion wMbe applied had been no break in coverage in the following instances: a. If you become insured again within 90 days. b. If required by a state-mandated family or medical leave act or law and you become insured again immediately following the period allowed under the family or medical leave act or law STANDARD INSURANCE COMPANY By President Secretary t: QOQ POLICY 339619 CITY OF KENT lPER;iJN�"lf L A`IALYS T ATTN: [%ECKY FOALER 2L() StItiTH 4TH KENT WA 9k3032 ACCELERATED BENEFIT ENDORSEMENT THIS ENDORSEMENT APPLIES TO EACH INSORCE URANCEpUP LIFE INSURANCE POLICY COMPANY, PROVIDED GROUP POLTO L ABOVE ppLICYOWNER BY STAND CONTAINS A PROVISION ENTITLED LLIINS SCE DURING TR OF �� DISABILITY. THIS NDORSEMENT BENEFITS IN EVENT OF TOTAL DISABILITY OR CONTINUED WILL NOT BECOME EFFECTIVE AND WILL BE OF NO FORCE IF THE GROUP POLICY CONTAINS NO SUCH PROVISION. Medicaid or The receipt of an Accelerated Benefit may be taxable t should consult your personal tag and/or ly for gal advisor before affect your e other government benefits or before you apply for an Accelerated Benefit. A. Accelerated Benefit If you qualify for Waiver of premium(Continued Life Insurance or Benefits in Event of Disability)and give us satisfactory proof of having a Qualifying Medical Condition whip you axe"insured under the Group Policy,you may have the right to receive during your lifetime a portion of your Insurance as an Accelerated Benefit.You must have at least$10,000 of Insurance in effect to be elig�ble. " Qualifying Medical Condition means: 1. You are terminally ill,with a life expectancy of less than 12 months;or 2. You are permanently confined to a Nursing Home have been in residence there for at least 60 days. We may have you examined at our expense 37gcpalnectlon withyour claim for an Accelerated Benefit.Any such examination will be conducted by one or more Physicians of our choice. B. Application For Accelerated Benefit You must apply for an Accelerated Benefit.To apply you must give us satisfactory Proof Of Loss on our forms. Proof Of Loss must include a statement from a Physician that you have a Qualifying Medical Condition. C. Amount Of Accelerated Benefit You may receive an Accelerated Benefit of up to 50%of your Insurance.The maximum Accelerated Benefit is $250,000. The minimum Accelerated Benefit is$5000 or 10%of your Insurance,whichever is greater. If the amount of your Insurance is scheduled to reduce within 1.2 months following the date you apply for the Accelerated Benefit,your Accelerated Benefit will be based on the reduced amount. The Acceleicing ated Benefit will.Medical Conditionbafter receiving id to an Acceou once in lerated Benefit,we will ask you for a refund.our lifetime in a lump slim If You recover from your �a�g D. Effect On Insurance And Other Benefits The amount of your Insurance after payment of the Accelerated Benefit will be: 1. The amount of your Insurance as if no Accelerated Benefit had been paid;minus 2. The amount of the Accelerated Benefit;minus 3. An interest charge calculated as follows: A times B times C divided by 365=interest charge. A= The amount of the Accelerated Benefit. B= The monthly average of our variable policy loan interest rate. C= The number of days from payment of the Accelerated Benefit to the earlier of(1)the date you die, and(2)the date you have a right to convert to an individual policy of life insurance. You.AD&D Insurance,if any,is not affected by payment of the Accelerated Benefit. E. Exclusions No Accelerated Benefit will be paid if 1. All or part of your Insurance mustbe paid to your child(ren),or your spouse or former spouse as part agreement. a court approved divorce decree,separate maintenance agreement,or property settlement agree 2. You are married and live in a community property state unless you give us a signed written consent from your spouse. 3. You have made an assignment of all or part of your Insurance unless you give us a signed written consent from the assignee. 4. You have filed for bankruptcy, unless you give us written approval from the Bankruptcy Court for payment of the Accelerated Benefit. 5. You are required by a government agency to use the Accelerated B enefit to apply for,receive,or continue a government benefit or entitlement. 6. You have previously received an Accelerated Benefit under the Group Policy. F. Definitions For Accelerated Benefit Insurance means your Life Insurance and Supplemental Life Insurance,if any,under the Group Policy. Nursing Home means a licensed institution operated for the purpose of providing nursing care and treatment for individuals which provides 24-hour nursing services under the direction and supervision of a Physician. Physician means a licensed M.D.or D.O.,other than yourself,diagnosing and treating you within the scope of the license. You and your mean the Member. STANDARD INSURANCE COMPANY By 07'`� President Secretary Please sign, date, and return this endorsement if you do not accept this endorsement as part of your group life insurance policy. Return to: STANDARD INSURANCE COMPANY ATTN GUPI PROJECT SPECIALIST G-18A 900 SW 5TH AV PORTLAND OR 97204 Signature and Title Date I 339619—Cl CITY OF KENT ATTN PAYROLL k20 SOUTIJ 4TH K .NT wh 93, 31 GROUP LIFE INSURANCE AND GROUP ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE POLICY ENDORSEMENT This endorsement is attached to and made a part of the GROUP POLICY identified by the POLICYOWNER and policy number above. - 1. Any reference to age that serves to restrict your eligibility to become insured for Life or Accidental Death and Dismemberment Insurance is deleted. 2. Any provision that terminates Life or Accidental Death and Dismemberment Insurance under the Group Policy because of your age is deleted. and 3. All Life Insurance and Accidental Death In urance,earee endorsed ismmberment st r provide asance follows: les der the Group Policy, follow excluding the schedule of Supplemental If any schedule currently (a) terminates benefits because of age, or (b) reduces benefits by more than 35% beginning at age u or older, then that schedule is changed to provide that benefits will be reduced at age 70 to 659c of the amount to which you would otherwise be entitled without reference to age, and to 50% of that amount at age 75. 4. The SCHEDULE OF SUPPLEMENTAL RANOUP LIFE CE will beN ed ued acEordin is g�o the folio rsed to ang table:e that amounts of SUPPLEMENTAL GROUP LIFE INSU Percentage of Amounts Age Available Before Age 70 70-74 65c1c 75-79 45�l( 80-84 30% 85-89 20% 90-94 15(Ic 95 or over 10% This endorsement is effective January 1, 1987. If you were not actively at work on December too 1986. the effective dactive to of this endorsement will be deferred with respect to you until the day after you complete LIFE If(a) your insurance under the Policyowner's group life insurance program was terminated before January 1. 1987 solely because of a�_e. or(b) you were ineligible for that program before January 1. 1987 solely because of age. you may become insured under the Group Policy subject to the following rules: Eligibility for Insurance ( 1) If you have been continuously employed as an active Member since the date your insurance ended or you became ineligible. you will be eligible for insurance on January 1. 1987. s an active since e your insurance ended or (2) if you have not been continuously employed for incur nce ab e t according Member eligibility requirements of _you became ineligible. you will become eligible the Group Policy. but not before January 1. 1987. Effective Date of Insurance Your insurance will become effective according to the terms of the Group Policy. but not before January 1. 1987. The terms "vou" and "your" refer to the Member as defined in the Group Policy. STANDARD INSURANCE COMPANY By D GROUP LIFE INSURANCE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE POLICY ENDORSEMENT This endorsement is attached to and made a part of each GROUP LIFE INSURANCE and ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE POLICY issued to the above POLICYOWNER by STANDARD INSURANCE COMPANY . This endorsement does not apply to any GROUP POLICY covering only ACCIDENTAL DEATH AND DISMEMBERMENT . The GROUP POLICY is endorsed as follows: SEAT BELT BENEFIT STANDARD will pay an additional accidental death benefit , called the SEAT BELT BENEFIT , if you die as a result of an AUTOMOBILE accident and you were wearing a SEAT BELT at the time of the accident . The following rules apply : 1 . The SEAT BELT BENEFIT equals $50 , 000 or the amount of the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE benefit paid because of your accidental death , whichever is less. 2. STANDARD must receive satisfactory written proof that your death resulted from an AUTOMOBILE accident and that you were wearing a SEAT BELT at the time of the accident . A copy of the police accident report should be submitted with the claim. SEAT BELT means a properly installed seat belt , lap and shoulder restraint , or other restraint approved by the National Highway Traffic Safety Administration . AUTOMOB.ILE means a motor vehicle licensed for use on public highways . This endorsement is effective April 1 , 19B6. No action by the POLICYOWNER is required . STANDARD INSURANCE COMPANY By President SecretaryILIrl E(��U' T&E K Registrar Lily ur General ADEA Amendment - Life Insurance and Accidental Death and Dismemberment Insurance �.' derstood and agreed that in order to provide Life Insurance coverage (and Accidental Death and am has vo he described �hhembearment Insurance coveraf orsactively employed Members Members der age 66,the group policy y e same ' `.basis�,at such insurance is provided above' hereby amended as follows: a less than 70 shall occur 70th birthday. t rance scheduled to occur because of age at any age Any such ter- Any teraiinatiem of insu { r... utit�ttbad'oh'the first day of a d 70 or over shall oc urar month next followinghas scheduled tMnation scheduled to occur at any age 2. Any reduction in insuranead any age less than 7 ce scheduled to occur ext following thee at Member's 70th birthday,hexCept that the ojjthe first day, of the calendar month n aigvuntof insurance so determined shall no case exceed the amount previously scheduled to be in force upon the Member's attainment of age age less than 70 that serves to restrict any Memb g, Ay reference spy ember's eligibility for insurance is Arty 10 g diogted 4, he on ? ;Th18�tlliendmegt is effective as of January 1, 1979 for any Member who was insured under the group policy ,Thee.` Mer g]'?1a7$.continuation of such a Member's insurance is conditioned upon all the terms of the group including.but not limited to payment of all required premiums. i han ,. r att ingtlYince terminated solely 31u1978se ethen such insurance ained may be reinstated,imiting age less tsubject to the ,. . ';gU�!`tpeuraTt 4 erminated before Decemb , ' a �loo4iag prav}sibne: 104ibility for Reinstatement ? employe Member has continued without interruption since the a , If the Member's status as an actively emp y 1, 1979. r, date of sugh cessation, the Member shall be eligible for insurance on January #. ,foments If the Member's status as an actively employed Member has been wit r�utp�ed e� 1 the e to such .insura�ee-i�-a of the group policy, but not before January 1, 1979. }ti vkl ctive Date'of Reinstatement ate (Z) '. If contributions from the Member are not �fortvereinstatement under a.or beabo e, her's insurance shall be the date the Member becomes eligible provided the Member is actively at work on such date. (2) If contributions from Members are required and the Member desires to be insured,the Member must quir apply iutions to n writing for the insurance and must agree to m ke the 'sinsurance shaed ll become effece PP Policyowner.If the Member applies before June 1, 1979, t e provided the tive on the date the Member becomes eligible for reinstate Member applies onment noreafter Juneb1, 1979, the Mem- Member is actively at work on such date policy without ber's insurance shall become effective in accordance with the terms of the group Po Y reference to a. or b. above. ould se It,the Member,1s not actively at work datee effective until the next day on which hens actively at ,'� bicotne effective, such insurance shall n of become *ork. ( 1' x� raj V. If a'Member's insurance terminated for any reason other than age, the reinstatement of such Member's j insur ce shall be govern d by the terms of the group poligy without reference to a., b., (1) or (2) above. t Date� ' 1979 at By STANDARD INSURANCE. COMPANY ;; By Presid Secretaryent gi; r ' 14OTI.CE TO POLICYOWNERS: This is a form amendment. Its purpose is to provide insurance coverage 1 ; }yrp age 69 without reduction because of age. If the wording of this amendment does not serve to so �tlre�,:your.group policy,please notify Standard Insurance Company in writing,and another amendment will P#41Pared. t r y 15.. i' rr r T ii i 1 is r SUPPLEMENTAL GROUP LIFE INSURANCE AMENDMENT Attached to and Made a part of Group Policy 339619 issued to City of Kent as Policyowner It is understood and agreed that the Group Policy is hereby amended by the addition of Supplemental Group Life Insurance. Supplemental Group Life Insurance is governed by the following provisions ; A . EFFECTIVE DATE OF SUPPLEMENTAL GROUP LIFE INSURANCE An eligible Member who desires to be insured for Supplemental Group Life Insurance must apply in writing for 'the insurance and agree to make the required contributions to the Policyowner . Supplemental Group Life Insurance will become effective on the date of approval of evidence of insurability satisfactory to Standard , provided the Member is actively at work on that date . If the Member is not actively at work on that date, his Supplemental Group Life Insurance will become effective on the next following day on which he is actively at work . However , the effective date of the Member 's Supplemental Group Life Insurance may not be earlier than the effective date of his basic Life Insurance under the Group Policy - B . SCHEDULE OF SUPPLEMENTAL GROUP LIFE INSURANCE The Member selects the amount of Supplemental Group Life Insurance at the time he applies for Supplemental oupLife Insurance , The Member, may select an amount equal to any multiple , 10 a maximum of $250 , 000 . Any decrease in the amount of Supplemental Group Life Insurance .will become effective on the first day of the calendar month next following the date the Policyowner or Employer receives the Member ' s written request for the decrease . Any increase in the amount of Supplemental Group Life Insurance will become effective on the date Standard approves the Member's evidence of insurability , provided the Member is actively at work on that date . C . PREMIUM RATES Premium rates and payment of premiums for Supplemental Group Life Insurance are subject to all - the applicable provisions in Section 9 of the Group Policy . In addition , Standard may change premium rates for Supplemental Group Life Insurance effective on any Premium Due i Date , independently of any other premium rates under the Group Policy , upon 31 days written than oncecintanyhecalendarowner . No such ycar . Initial change may be made n premium rates for Supplemental Group Life Insurance are shown below ; Attained Age of the insured Monthly Premium Rate Per person on January Ist $1 , 000 Supplemental Group Life Insurancex- $0 . 10 Under age 40 0 . 21 Age 40 through 44 0 .37 Age 45 through 49 0 , 60 Age 50 through 54 0 .93 Age 55 through 59 1 , 40 Age 60 through 64 2 . 10 Age 65 through 69 *Changes in premium rate because of changes in age become effective on the January Ist coinciding with or next following the change , D . INSURING CLAUSE Upon receipt by Standard of satisfactory written proof that the Member has died while insured for Supplemental Group Life Insurance , Standard will pay , subject to the terms of the Group Policy and this amendment , the amount of Supplemental oGroup f his Life 111surance in force on the life of the Memberat E . EXCLUSION Until the Member' s Supplemental Group Life Insurance has been in force for two years , it does not cover death which is caused or contributed to by : (a) Suicide or any other intentionally self-inflicted injury ; or (b ) Self-destruction or any other self-inflicted injury , occurring while the Member is unable to form the intent to harm himself . If the Member ' s, death results from either of those excluded causes during the first two years, Standard ' s sole liability with respect to the Member ' s Supplemental Group Life Insurance will be to pay an amount equal to the premiums the Member paid for Supplemental Group Life Insurance . This exclusion also applies to any increase in the Member 's Supplemental Group L.i.fe Insurance , until the i.nr_rea�=e has, been in effect for two years . F . BENEFITS IN EVENT OF DISABILITY If- the Member becomes totally disabled as defined in the BENEFITS IN EVENT OF DISABILITY provision of the Group Policy before his 60th birthday and while his Supplemental Group Life Insurance is in force, his premiums for Supplemental Group Life Insurance may be waived during total disability , subject to the provisions of the Group Policy governing waiver of premium for the Basic Life Insurance . However , all Supplemental Group Life Insurance continued under this provision will terminate on the Member ' s 70th birthday . G . PAYMENT OF CLAIMS The PAYMENT OF CLAIMS provisions of the Group Policy govern the payment of Supplemental Group Life Insurance death benefits . H . ASSIGNMENT The ASSIGNMENT provision of the Group Policy governs the assignability of Supplemental ' Group Life Insurance . I . TERMINATION OF SUPPLEMENTAL GROUP LIFE INSURANCE The Member 's Supplemental Group Life Insurance will end automatically on the earliest of the following dates ; ( a ) The date the Member " s Basic Life Insurance under the Group Policy ends . (b ) The first day of the calendar month next following the Member ' s 70th birthday . (c ) The date the Group Policy terminates, unless the Member qualifies for Supplemental Group Life Insurance benefits during total disability under F . ( d ) The last clay of the last period for which the Member made the required premium contribution for Supplemental Group Life Insurance . If the Member ' s Supplemental Group Life Insurance ends for any reason , the Member must submit new evidence of insurability to become insured again for Supplemental Group Life Insurance . J . CONVERSION OF SUPPLEMENTAL GROUP LIFE INSURANCE If the Member ' s Supplemental Group Life Insurance ends for any reason other than the Member 's failure to make the required premium contribution , the Member has a Right To Convert . Right To Convert entitles the Member to buy an individual policy Theg of life insurance without submitting evidence of insurability within 31 days after the date the Member ' s Supplemental Group Life Insurance ended . The maximum amount the Member has a Right To Convert is the amount of his Supplemental Group Life Insuranc::e which ended . Conversion Period means the 31 day period during which the Member G can exercise the Right To Convert . The Member must exercise his Right To Convert before the end of the Conversion Period by both ( 1 ) applying to Standard in writing for an individual policy of life insurance and (b ) paying Standard the first premium for the individual policy of life insurance , If the Member exercises his Right To Convert , the individual policy of life insurance will become effective on the day after the end of the Conversion Period . If the Member dies during the Conversion Period , Standard will pay a death benefit equal to the maximum amount of life insurance hF? had p a Right To Convert , whether or not he applied for an indi policy . The death benefit will be aid as if he had died while his Supplemental Group Life Insurance was in effect . If -the Member exercises his Right To Convert , he may not spt ect a term insurance policy or a life insurance policy with disabi ) � tyyjioh ar_cidenial death benefits , or any Diber addilionai benefits life these limitations, he may select any form of indi.vidual � s age insurance policy then being issued by Standard to persons olera= than and for the amount he wishes to convert . He may apply for for the maximum amount shown above , but if he does he may r1o , apPay less than the minimum amount being issued by Standard f'nr thr form of life insurance he selects , w 1 be The premium for the individual life insurance pol .i( V i ': determined from Standard 's published rates for standard r• 1sks . This amendment is effective as of November 1 , 1963 and replaces the Supplemental Group Life Insurance Amendment which became effective under the group policy as of October 1 , 1982 , The Evidence of Insurability requirement in Part A . of this amendment will not apply on November 11 1983 to any Member who applies for an amount of Supplemental Group Life Insurance equal to or less than that Member ' s current amount of Supplemental Group Life Insurance . 3 ------------ _ __ p/1__Z -__- Datcad —__._� —__------ 19 —__ at -------- CITY OF KE.NT --------------- STANDARD INSURANCE COMPANY By President Secretary Reg:i.strar St.iP A-17 ` ^ SUPPLEMENTAL GROUP LIFE INSURANCE AMENDMENl Attached To and made a part of Group Policy 339619 issued to City of Kent as Policyowner . IY is understood and agreed that the Group Policy is hereby amended by the addi1ion of Supplemental Group Life [nsorance . Supplemental Group Life Insurance is governed by the following provisions ; A . EFFEClIVE DATE OF SUPPLEMENTAL CROUP LIFE INSURANCE An eligible Member who desires to he insured for Supplemental Group Life � [nsoraoce most apply in writing for the insurance and *g,== " ....e The required contributions To the Policyowner . Supplemental Group Life Insurance will become effective on the date «f l f evidence of insurability satisfactory To urm"d u.d provided ' . , ^d-- approval » k n that date If the Member is not the Member is actively at work » ' Lif Insurance actively at work on that dotel his Supplemental Group eis actively on the"next following day on which he Will become effective e e�h ffoctive date of the Member ' s Supplemental Group at work , However , li than the effective date of his hasic Life Insurance may not be ear er Life Insurance under the Group Pnlicy , B . INSURING CLAUSE i t b Standard of satisfactory written proof that the Member' Up«» rece pil y insured for supplemental Croop Life Insurance , Standard has died while c � �» the terms » will pay / sob f the Group policy and this amendment , �e the amount o" Supplemental Group Life (nsorance in force on the life of the Member at the date of his death . C . EXCLUSION i\� �il the Member 's supplemental Group Life Insurance has been forTo by ; / r death which is caused or contributed for two years/ it does not cove by ; (a ) Suicide or any other intentionally self-inflicted injory ) or (b ) Self-destruction or any other self-inflicted injury , occurring while the Member, is unable to form the intent to harm himself . results from either of those excluded causes If the Member ' s death S�andard 's sole liability with respect to during the first Two years/ Insurance will be t» pay an amount The Life Member 's Supplemental Group id for Supplemental Cr»»p Life equal to the premiums the Member, pa Insorance . D . SCHEDULE OF SUPPLEMENTAL GROUP LIFE INSURANCE The Member may select one of the following amounts of Supplemental Group Life Inso/ancei $250 $50/ 000 000 /200 4O / 800 000 /150 30 / 800 00U /108 / 00 20 / 000 0 1 80 / 000 0 / 000 6U / 000 Any increase in the Member 's Supplemental o' evidence^^Life oIns»rancebiuill become effec�ive on the Jate of approval , ivc� y ."t work on satisfactory to Siandard / provided the Membertzs�ac� ^te such zncrease s If he is not oc�ively a � work »n »a date , ~ k that da �e ' d on which he is actively at work . will be deferred on�il the next day E . pAYMLNT OF CLAIMS The PAYMENT OF CLAIMS provisions of the Group policy govern the payment death benefits , ' '- ` Life Insurance of Supplemental Group ' .^- '. - - F . ASSIGNMENT The ASSIGNMENT provision of the Group Policy governs the assignability of Supplemental Group Life Insurance , C . BENLFITS IN EVENT OF DISABILITY If the Member becomes to�ally disabled as defined ine the eBENEFITS0IN |'VENT \)F DISABILITY provision of the Group p »�zcy v ` v' is ,^~fo-c � �ir �hday and while his Supplemental Croup Life Insurance is do' i= / o i s for Supplemental Group Life Insurance may ^�e =" Policy . '� his prem »m � � the provisions of the Cr »«P total disability / subject » the basic Li �e Insurance . H«wo»er / all goveroin1 waiver of premium for continued under this provision will Supplemental Group Life Insurance Terminate on the Member ' s 70th birthday . H . CONVERSION OF SUPPLEMENTAL GROUP LlFE INSURANCE If the Member 's Supplemental Group Life Insurance terminates or is the Member may be entitled to boy an individual T'Policy nufrlife reduced / t without sobmi�� iog evidence of insurability . ^�i`° .^ons o f-- r ' i»s»'awce CONVERSION OF LIFF INSURANCE provzs `/." right is subject to the Group Policy . the Group Policy , the maximum amount In the event of the termination of ce The Member may convert °`^l be ' of Supplemental Group Life Insoran addition to The maximum amount of basic Life Insurance The Member may convert . I . TERMINA7I0N OF SUPPLEMENTAL GROUP LIFE INSURANCE The Member ' s Supplemental Croop Life Insurance will end automatically on the earliest of the following dates ; (a) The date the Member ' s basic Life Insurance under the Group Policy ends . (b ) The first day of the calendar month next following the Member ' s 70th birthda9 . (c ) The date the Croup Policy terminates/ unless the Member, qualifies for Supplemental Group Life Insurance ocne` i `s "". ^.g total disability under C . The last day of the last period for which the Member made the (d ) required premium contribution for supplemental GroupLife ^ . = Insurance, If the Member 's Supplemental Group Life Insurance ends for any reason / the Member most submit new evidence of insorabilty to become ,.,,. `d again for Supplempntal Group Life Insorance , J . PREMIUM RATES Premium rates and payment of premiums for Supplemental Group Life are subject 'to all the applicable provzszons o C ` ` "= . ~.r Insurance �policy . Initial premium rates for Supplemental Group Life Insurance are shown below . Attained Age of Member Monthly Premium Rate Per' $1 U0U Supplemental Group on Premium 0oe Date /Life Insurance* $0 . 15 Under age 30 0 2O Age 30 through 39 . - - 0 . 35 Age 40 through 44 0 . 50 Age 45 through 49 0 , 30 Age 59 through 54 1 . 20 Age 55 through 59 1 . 90 Age 60 through 64 3. U8 Age 65 through 69 h es in i s»red Member because of c *Changes in premium rate for an n ��he Janoary 1st cozncidaog zng will'' H+mber ' s mqe hecone effeclive on nr next following the changp . This amendment is effective October 1 / 1982 . �u~ _ �'/ --------' -- 1p'°-=- a� -~~--- ' Dated ----- CITY OF KENT �' --_--_---- STANDARD INSURANCE COMPANY By Presiden ~~ U y K-, Registrar SUpA14 (C) City of Kent #339619 220 South 4th Kent, WA 98032 SUPPLEMENTAL GROUP LIFE INSURANCE ENDORSEMENT This endorsement is attached to and made a part of the Group Life Insurance Policy identified by the Policyowner and policy number above. The Supplemental Group Life Insurance Amendment to your Group Life Insurance Policy is changed as follows: CE changed 1. The SCHEDtUL�O�umpamoun�t of SupplemNTAL ental GrUP oup Life UR su Insurance $30,000� provide that MEMBERS CURRENTLY INSURED*: If a Member is insured on December 31, 1989, for any amount of Supplemental Group Life Insurance which is less than $30,000, the Member may continue that amount of Supplemental Group Life Insurance. However, if the Member chooses to increase the amount of Supplemental Group Life Insurance on or after January 1, 1990, the amount after the increase shall not be less than $30,000. *The same rules apply to a Member's spouse who has Supplemental Group Life Insurance on December 31, 1989. 2. The SCHEDULE OF SUPPLEMENTAL GROUP LIFE INSURANCE is changed to provide that the maximum amount of Supplemental Group Life Insurance is$300,000. 3. The section entitled PREMIUM RATES is changed to provide the following premium rates: Attained Age of the Insured Monthly Premium Rate Per Person on January 1st Multiple of$10,000 Before Reduction Under age 30 $ 1'00 Age 30 through 39 1.10 Age 40 through 44 2.20 Age 45 through 49 3.90 Age 50 through 54 6.40 Age 55 through 59 9.90 Age 60 through 64 14.80 Age 65 or over 22.30 nonca-end 4. Any increase in the amount of Supplemental Group Life Insurance on the life of the Member (or the life of the Member's spouse) will become effective on the date Standard approves Evidence of Insurability in connection with the increase. For an increase in the amount of Supplemental Group Life Insurance on the life of the Member, the Member must also meet the Active Work Requirement on the date of the increase. This endorsement is effective January 1, 1990. STANDARD INSURANCE COMPANY BY Rzi��P7 Secretary President nonca-end SUPPLEMENTALINSURANCE IMPORTANT NOTICE Effective January 1, 1990, the Supplemental Group Life Insurance Amendment to your Group Life Insurance Policy has been changed as follows: 1. The SCHEDULE OF SUPPLEMENTAL GROUP LIFE INSURANCE has been changed to provide that the minimum amount of Supplemental Group Life Insurance is $30,000. MEMBERS CURRENTLY INSURED*: If a Member is insured on December 31, 1989,for any amount of Supplemental Group Life Insurance which is less than $30,000,the Member may continue that amount of Supplemental Group Life Insurance. However, on or after if the I Jar chooses to increase the anuary 1, 1990,the mount after the incunt of rease shall Group Life Insurance not be less than $30,000. *The same rules apply to a Member's spouse who has Supplemental Group Life Insurance on December 31, 1989. s been 2. The SCHEDULE OF SUPPLEMENTAL thePmaxlimumTamou amount UP LIFE ofSupplementa INSURANCE a changed to p up Life Insurance is $300,000. 3. The section entitled PREMIUM RATES has been changed to provide the following premium rates: Attained Age of the Insured Monthly Premium Rate Per Multiple of$10,000 Person on January 1st Before Reduction Under age 30 $ 1.00 Age 30 through 39 1.10 Age 40 through 44 2.20 Age 45 through 49 3.90 Age 50 through 54 6.40 Ag e 60 through 6e 55 through 59 9.90 Ag4 14.80 Age 65 or over 22.30 4. Any increase in the amount of Supplemental Group Life Insurance on the life of the Member(or the life of the Member's spouse) will become effective on the date Standard approves Evidence of Insurability in connection with the increase. For an increase in the amount of Supplemental Group Life Insurance on the life of the Member, the Member must also meet the Active Work Requirement on the date of the increase. Please attach this notice to your certificate. If your group insurance is subject to the Employee Retirement Income; Security Act(ER1SA), this document shall also act as notice to you of corresponding changes in your Summary Plan Description (SPD). nonca-note GROUP POLICY AMENDMENT NO. 1 Attached to and made a part of Croup Policy :'33_9619 issued to City of Kent as Policyowner. It is understood and agreed that the termination provisions shown in Section 3. , CESSATION OF INSURANCE are hereby amended to read as follows: Termination of employment, when necessary to determine termination of status as a Member, means cessation of active work as an employee, except that for purposes only of determining whether a Member's insurance may be continued: 1) If a Member is absent from active work because of sickness or injury, his employment shall be deemed to continue until terminated by his employer under a plan precluding individual selection, 2) If a Member is absent from active work because of leave of absence, his employment shall be deemed to continue, for a period not to exceed six months, until terminated by his employer under a plan precluding individual selection. This leave of absence exception does not apply to absence _to become an active full time member of the military (land, sea or air) forces of any country, and 3) If a Member is absent from active work because of temporary lay—off, his employment shall be deemed to continue, for a period not to _ exceed two months, until terminated by his employer under a plan precluding individual selection. For the purpose of determining the date of cessation of insurance under any of these exceptions, termination of employment by his employer shall be either by notification to Standard by the Polcyowner or by cessation of premium payments for the Member's insurance. This amendment is effective as of May 1 , 1975. � i'rr. Dated 1975 at CITY OF KENT By STANDARD INSURAN E COMPANY By t PR D ► OCESSE Secretary ; President U 1919 This document bears a received date stamped on the reverse side.This received date,as it appears ' on the reverse, is being transferred to the front ' x of this document for microfilming purposes., Date SU� GROUP POLICY AMENDMENT NO . 2 Attached to and made a part of Group Policy 339619 issued to City of Kent as Policyowner . It is. understood and agreed that this policy is hereby amended as follows: 1 . The definition of the term Member as shown in the section entitled GENERAL DEFINITIONS is amended to read as follows: Member means a regular permanent employee or project emplouee of the Employer who is regularly working throughout the entire duration of the Employer ' s work week , and in no event less than 130 hours per month . The waiting period for elioibilitu requirement contained i Secti respect 2 . ectUN INRClbly is waiyed on lwho become o to persons who are project employees only Members on June 1 , 1982. phis amendment is ef*f,ectiye as of June 1 , 1982- Dated --- ----- +- --------- 19-9-- at - ------- - CITY OF' KENT B u - ' � _x:�" -------------- S,TAN DAR D INSURANCE COMPANY Bu_ ('ec �� %�/ President r e t a r, u k�, � F egistrar GROUP POLICY AMENDMENT NO , 3 Attached to and Made a part of Group Policy 339619 issued to City of Kent as Policyowner , It is understood and agreed that SE:ctiori 2 . PERSONS INSURED , A . or Eligibility is hereby amended to provide Thai thE'cowai ngsperioddfof eligibility for a Member shall be rte�.diMeeci �r,�.�:loyeH of the Employer time served as a permanent part-time prior to the date he becomes:; a No mber . This amendment is effective as of June 1 , 19B2, "hawk—� --- 19i = at —�-' =— `�----------- Dated - ------- �- CITY OF KENT By STANDARD INSURANCE COMPANY Tjy Prcas;ident Regis-rrar GROUP POLICY AMENDMENT NO . 5 Attached to and made a part of Group Policy 339619 issued to City of Kent as policyowner . It is agreed that this policy is amended as follows : 1 . Effective October 11 1974, the definition of the term Member as shown in the section entitled GENERAL DEFINITIONS is amended to read as follows : Member means a regular permanent employee or the mayor of the Employer who is rekuwQeky wandlnintnooeventt the lessethane30uhoursnper of the Employer' s wor week . 2 . Effective June 1 , 1982 , the definition of the term Member as shown in the section entitled GENERAL DEFINITIONS is amended to read as follows : Member means a regular permanent employee or project employee of the Employer who is regularly working throughout the entire duration of the Employer ' s work week , and in no event less than 130 hours egulrly working throu per who is houttthe m o entiredurationthe Eoflther Employer ' srworkaweek , and in throng no event less than 30 hours per week . 3 . Effective January 1 , 1985, Section 1 . SCHEDULE OF INSURANCE is amended to read as follows : he pal of The Face AoorntaofMemberlunderncagean70tshall be determinedAccident ined from f the Insurance following table : Face Amount Principal Sum Classification (Life Insurance ) ( Accident Insurance ) Management Group A $50 , 000 $50 , 000 35 , 000 Management Group B 35, 000 25, 000 Management Group C 25, 000 Mayor 15, 000 15, 000 All others 10 , 000 10 , 000 The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member age 70 or over shall each be equal to one-half the applicable amounts determined above . Page 1 of Amendment 5 Group Policy No . 339619 Changes in amounts of insurance because of changes theclassification r month or age shall be effective on the first day rovided next following the date of change in classification or age' increase that if the Member is not actively at work owhich such da he tis aactively at shall be deferred until the next day on work . This amendment is effective as of the appropriate dates shown above , provided that any increase in insurance for a Member who is not actively at work on January 1 , 19S5 shall be deferred until the next day on which he is actively at work . STANDARD INSURANCE COMPANY By President Secretary U n Registrar Page 2 of Amendment 5 Group Policy No . 339619 1 GROUP POLICY AMENDMENT NO . 6 Attached to and made a part of Group Policy 339619 issued to City of Kent as Policyowner . ibility is It is agreed that Secfollows n a .for ersonsNnotlyetReligible foriginsurance on amended to read as Poll P February 1 , 1986 : A Member becomes eligible for insurance on the first day of the calendar month following the date he becomes a Member . This amendment is effective February 1 , 1986 . STANDARD INSURANCE COMPANY By P ( RnPresident SecretaryH Registrar GROUP POLICY AMENDMENT NO . 7 Attached to and made a part of Group Policy 339619 issued to City of Kent as Policyowner . It is agreed that this policy is amended as follows : 1 The definition of the term Member as shown owfolin the section entitled GENERAL DEFINITIONS is amended Member means an active employee or the mayor of tie regularly h Employer, other than a temporary or seasonal employee, who scheduled to work at least 21 hours each week . 2 . The section entitled GENERAL DEFINITIONS is amended by the addition of the following definition of Basic Annual Earnings : (not Basic Annual Earnings means basic annual wage or salary of including overtime, bonuses, commissions, longevity Pa yes ucat Basic pay , specialty pay and other extra compensation) . Chang e or salary shall be Annual Earnings because of a fathes in calendarcmonth coinciding with or effective on the first day a or salary . If the next following the date of change in basic wag Member is not actively at work on the date on which an increase in Basic Annual Earnings would otherwise on effective, M such i crease shall be deferred until the next day any period of is both eligible and actively at work . At the commencement of Basic Annual total disability or at the time of any other Earnings shall be the Member' s Basic Annual Earnings as of the other first day of the calendar month in which the disability approved after loss occurs . Any change in basic wage or salary a total disability begins or after any other loss occurs shall not be considered in determining the amount of Basic Annual Earnings . 3 . Section 1 . SCHEDULE OF INSURANCE is amended to read as follows : The Face Amount of Life Insurance and 70the Principal each Sum eof Accident Insurance for a Member under age to the if Member 's Basic Annual Earnings, amountrounded Theo the maximumnext hi FaceeAmount0, and not already an even dollar maximum Principal Sum shall each be $50, 000 . The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member age 70 through 74 shall each be equal to 65% of the amount which would be applicable for a Member under age 70 . Page 1 of Amendment 7 Group Policy No . 339619 ce and the al Sum The Face Amount of Life aneu75naT over shallreachpbe equalftoc50Y.eof Insurance for a Member g the amount which would be applicable for a Member under age 70 . Changes in amounts of insurance because of changes in age shall be effective on the first day of the calendar month next following the date of change in age . 4 . Section 9 . PREMIUMS, D . Grace Period is amended to read as follows : period of 45 days will be granted for the payment of A grace p remium, during which grace period premiums accruing after the first p the policy shall continue in force but the Policyowner shall be liable to Standard for the payment of the premiums accruing for the period the policy continues in force . If written notice is given y the of a premium due date Plr Standard before this the policy shall be discontinued as end of the grace period, this policy shall be discontinued as of the date of receipt of the notice, date specified in the notice or the whichever is later . S . The renewal date next following n October tober1 ,ll occur 1986on will January January 1 , 1990 and renewal dates thereafter 6 . The premium rate for Life Insurance shall be * . 19 monthly per $1 , 000 Face Amount , beginning January 1 , 1989 and continuing until changed as provided in the group policy . This amendment is effective as of January 1 , 1989, provided that any increase in insurance for a Member who is not actively at work on January 1 , 1989 shall be deferred until the next day on which he is actively at work . STANDARD INSURANCE COMPANY By 1 . 11 President Secretary LU Page 2 of Amendment 7 Group Policy No . 339619 GROUP POLICY AMENDMENT N0 , 8 Attached to and made a part of Group Policy 339619 issued to City of Kent as Policyowner . It is agreed that this policy is amended as follows : 1 . The Group Policy is amended to provide Additional Insurance for Members who are insured on December Saf9 under the Employer' s by ecO, subject the group life insurance policy issued by following provisions : a . The Member must be insured under the Group Policy on January 1 , 1990 . b . The Member must apply in writing to become insured for Additional Insurance and agree to make the required contributions to the Policyowner . The Policyowner determines the amount of the Member' s contribution towards the cost of his Additional Insurance . c . The Face Amount of Additional Life Insurance and the Principal Sum of Additional Accident Insurance for a Member under age 70 shall equal the amount of the Member ' s supplemental life insurance in effect on December 31 , 1989 and shall become effective on January 1 , 1990 . The Face Amount of Additional Life Insurance and the Principal Sum of Additional Accident Insurance for a Member age 70 through 74 shall each be equal to 65% of the amount which would be applicable if the Member were under age 70 . The Face Amount of Additional Life Insurance and the Principal Sum of Additional Accident Insurance for a Member age 75 or over shall each be equal to 50% of the amount which would be applicable if the Member were under age 70 . d . A Member cannot change the amount of his Additional Insurance . e . The amount of Additional Insurance shall end on the last day of the last period for which the Member made the required premium contribution for his Additional Insurance . f . Once the Additional Insurance ends, the Member may not become insured again for Additional Insurance . Page 1 of Amendment 8 Group Policy No . 339619 2 . The Group Policy is amended to add Dependents Life Insurance in accordance with the provisions of the attached DEPENDENTS LIFE INSURANCE SUPPLEMENT . 3 . The premium rates for Life Insurance and Accidental Death and i Dismemberment Insurance shall be as follows, nuary 1990 and continuing until changed as provided in the group policy : Additional per $1 , 000 Face Amount Life Insurance . 35 monthly Suffix 01 Additional Accidental Death and s . 06 monthly per s1 , 000 Principal Sum Dismemberment Insurance Suffix 01 Dependents Life Insurance �1 . 65 monthly per Member with one or more dependents This amendment is effective as of January 1 , 1990 . STANDARD INSURANCE COMPANY By President Secretary Page 2 of Amendment 8 Group Policy No . 339619 DEPENDENTS LIFE INSURANCE SUPPLEMENT is Dependents Life Insurance dentsrLife Insurance lisesgoverned of aMbybethe Dependents . A Member 's Depen following provisions : DL5200 A . Definition of Dependent Dependent means : ( 1 ) Spouse Dependent : A Member' s spouse; and ( 2) Child Dependent : A Member ' s unmarried child under 21 years of age . The Member' s stepchild residing in the Member' s home is considered a child of the Member; and (3) Student Dependent : A Member' s unmarried child 21 years of age or over, but under 23 years of age, who is a registered student in regular full time attendance at an accredited educational institution . D5203A B . Effective Date of Dependents Life Insurance A Member 's Dependents Life Insurance becomes effective on the latest of the following dates : ( 1 ) The date the Member ' s Life Insurance becomes effective . (2) The date the Member first acquires a Dependent . (3 ) January 1 , 1990 . A person who becomes a Dependent while the Member' s Dependents Life Insurance is in effect is automatically insured on the date the person becomes a Dependent . D5201B 1 _ 339619 Printed ( 01 /05/90 ) DEP LIFE SUPP C . Insuring Clause Standard will pay , subject to the terms of the group policy , the amount determined from the Schedule of DependeTtOefLife thatinsurance Dependentimmediately of the upon receipt of satisfactory written p Members Dependents Life Insurance is in Member has died while the effect . D5201C D . Schedule of Dependents Life Insurance The amount of life insurance for each Dependent shall be equal to the lesser of : ( 1 ) One-half the Face Amount of the Member' s Life Insurance ; and ( 2) The appropriate amount shown below : . . . . . . . . . . $5, 000 Spouse Dependent . . . . . . . . . . . . . . . . . . . . . . . . . . . 21000 Child Dependent while under 6 months . . . . . . . . . . . . 2, 000 Child Dependent age 6 months and over . . . • • • • • • 2, 000 Student Dependent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D5212D E . Beneficiary Death benefits under this Supplement will be paid to the Member if the Member is living . If the Member is not living, the death benefits will be paid in equal shares to the first surviving class of the following classes : ( 1 ) The Member' s spouse; (2 ) The Member' s children; or a the Member ' s parents . If there is no surviving spouse, child or parent , death benefits will be paid to the Member' s estate . However, if aideath benefit is payable to the Members estate or to any who to any not competent to give a valid release, Standard may pay P to $Soo person related to the Member by blood or marriage who Standard believes is equitably entitled to such payment . D5201E F . Continued Coverage Without Payment of Premiums A Member' s Dependents Life Insurance will be continued in force without payment of premiums as follows : ( 1 ) For five months after the death of a Member . Printed ( 01 /05/90 ) - 2 339619 - DEP LIFE SUPP he ce is (2) For the same period that t mMofbpremiumsfwhilesthenMember continued in force without payment is totally disabled . Note : Dependents Life Insurance on the life of any Dependent will terminate on the date determined under G . 2 . Termination of Dependents Life Insurance . D5201F G . Termination of Dependents Life Insurance 1 . A Member ' s Dependents Life 2Insurance owing terminates automatically on the earliest of the a . Five months after the date of death of the Member . b . The date the Member' s life insurance terminates for any reason other than the death of the Member . C . The date the group policy is discontinued, unless the Member ' s Dependents Life Insurance is continued in force under F . above . 2 . Dependents Life Insurance on the life of any Dependent terminates automatically on the earliest of the following dates : a . The date the Member ' s Dependents Life Insurance terminates . b . The date the Dependent becomes a full time member of the armed forces of any country . C . The date the Child Dependent becomes 21 years of age , except when coverage continues beyond that date for a Student Dependent or a Handicapped Child . d . With respect to a Student Dependent age 21 or over , the earlier of the following dates : ( 1 ) The date the Student Dependent becomes 25 years of age except when coverage continues beyond that date for a Handicapped Child; and ( 2) The date the Student Dependent ceases to be a registered student in regular full time attendance at 3 _ 339619 Printed ( 01 /05/90 ) DEP LIFE SUPP an accredited educational institution . e . The date the Child Dependent or Student Dependent marries . f . The date the Spouse Dependent becomes legally separated or divorced from the Member . D5207G H . Continued Coverage For a Handicapped Child se Dependents Life insurance shall or°a Studentte solely DependenteifutheaMember ceases to be a Child Depend written proof that the child is provides Standard with satisfactory both : ( 1 ) Incapable of self-sustaining employment by reason of mental retardation or physical handicap incurred prior to the date the child ceases to be a Child Dependent or Student Dependent ; and (2) Chiefly dependent upon the Member for support and maintenance . Such proof must be furnished to Standard on Standard' s forms within 31 days of the date the child ceases to be a Child Dependent or Student Dependent , and thereafter as required by Standard, but ote often than once a year . Standard shall have the right to obtain, at its own expense, one or more independent examinatons of the child . No coverage shall be continued under this provision unless the required proof is approved by Standard . An individual 's coverage which is continued under this provision terminates on the earliest of the following dates : ( 1 ) The date the child becomes capable of self-sustaining employment . (2) The date the child ceases to be chiefly dependent upon the Member for support and maintenance . (3) The date the Member fails to provide satisfactory written proof that the child continues to qualify for coverage under this provision . (4) The date insurance would terminate under G . Termination of Dependents Life Insurance any areason Studentother Dependentthe child a Child De ceasing to be Pendent or 4 _ 339619 Printed ( 01 /05/90 ) DEP LIFE SUPP D5206B I . Right To Convert To An Individual Policy A Dependent has the right to buy an individual life insurance policy , ife without submitting evidence of rQasonuotherltY, if than thethe discontinuancesoflthe insurance terminates for any group policy before the Member ' s Life Insurance has been force for five years . The individual life insurance policy may be on any form, other than term Standard . The individual policy will not insurance, then issued by contain disability or double indemnity benefits . The Dependent must apply 1 in writing for the individual policy and must pay the applicable premium to Standard within 31 days after the date o termination of the Dependent ' s riod, t dies Standard ewill upay cthe e . lmaximum f the Damount nof life during this 31 day period, insurance for which anaanaividedlfor policy individualhave Policylssued, whether or not the Dependent h pp If a Child Dependent does not have the legal capacity to enter into a contract of insurance which is binding on both Standard and the Child Dependent , the Dependent ' s ofrent or the Dependardian must apply for the individual policy on the life The Dependent ' s individual policy , if issued, shall become effective on life the 32nd day after the date of termination of the Dependent's life insurance under this Supplement . Such individual Policy Of that insurance shall be subject to all may be°issuedntoaadMember under the apply to the individual policy which may provision entitled "Conversion of Life life insurance benefit Insurance . " A Dependent who has exercised the right to convert to an individual policy shall not be eligible for coverage again under the Member' s Dependents Life Insurance . D5202I 5 _ 339619 Printed ( 01 /05/90 ) DEP LIFE SUPP STANDARD INSURANCE COMPANY Seattle Group Office 2101 4th Avenue, Suite 1850 July 5, 1995 Seattle, Washington 98121 (206) 448-5562 Fax (206) 448-6923 ANH HOANG - HUMAN RESOURCES ANALYST CITY OF KENT 220 - 4TH AVE S KENT WA 98032-5895 Re: Group Life and A D & D Insurance Group Policy #339619 Dear Anh: I'm writing regarding your recent amendment request to change the Life/AD&D contract to provide a minimum$25,000 benefit. Enclosed is your group policy Amendment copy; please attach this copy to your policy. The Important Notices will soon be printed and mailed to you to be distributed to all insured employees. If you have any questions, please call me or Laura Turner. Sincerely, f Luke Gordon Group Service Coordinator Enclosures DEDICATED TO EXCELLENCE GROUP POLICY AMENDMENT NO. 9 Attached to and made a part of Group Policy 339619 issued to City of Kent as Policyowner. It is agreed that Section 1 . SCHEDULE OF INSURANCE is amended to read as follows : The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member under age 70 shall each be equal to the Member' s Basic Annual Earnings, rounded to the next higher $1 . 00 , if not already an even dollar amount . The minimum Face Amount and minimum Principal Sum shall each be $25 , 000 . The maximum Face Amount and maximum Principal Sum shall each be $50, 000 . The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member age 70 through 74 shall each be equal to 6511 of the amount which would be applicable if the Member were under age 70 . The Face Amount of Life Insurance and the Principal Sum of Accident Insurance for a Member age 75 or over shall each be equal to 50% of the amount which would be applicable if the Member were under age 70 . Changes in amounts of insurance because of changes in age shall be effective on the first day of the calendar month next following the date of change in age . This amendment is effective June 1, 1995 . STANDARD INSURANCE COMPANY By President Secretary C , 1995 Request For Group Insurance Amendment QEPJ. RECEIVED� Standard Insurance Company JUN 13 IM 900 SW 5TH AVE GROUP UNDERWRITING PORTLAND OR 97204-1282 Employee Benefit Representative/Group Office: Tammy Bucy / Seattle Group Office Service Contact: Luke Gordon / Laura Turner Policyowner Name: City of Kent Group Policy Number: 339619 As an authorized representative of the Policyowner, I request Standard amend the above Group Policy as follows, subject to Standard's usual underwriting requirements: Change Life / AD&D schedule to include a $25,000 minimum benefit. I request the amendment, if approved by Standard, become effective on June 1, 1995, and be issued in the policy language customarily used by Standard. I understand the amendment will be subject to the terms and conditions of the Group Policy including, if applicable, Evidence Of Insurability or a Preexisting Condition limitation. I understand any increase in Insurance for a Member who is not Actively At Work on the day before the scheduled effective date of the amendment will be deferred until the Member meets the Group Policy's Active Work requirement. I request the amendment, if approved by Standard, become effective by its terms without any further acceptance by the Policyowner, and a copy of this Request For Group Insurance Amendment form be attached to and made part of the amendment. Signed By. Title: Date: 6 _J .77