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HomeMy WebLinkAboutES05-336 - Original - Standard Insurance Company - 2005-2007 Group Long Term Disability Insurance Policy - 07/01/2005 STANDARD INSURANCE COMPANY A Stock Life Insurance Company 900 SW Fifth Avenue Portland, Oregon 97204-1282 (503) 321-7000 GROUP LONG TERM DISABILITY INSURANCE POLICY Policyholder City of Kent Policy Number: 339619-B Effective Date July 1, 2005 The consideration for this Group Policy is the application of the Policyholder and the payment by the Policyholder of premiums as provided herein Subject to the Policyholder Provisions and the Incontestability Provisions, this Group Policy (a) is issued for the Initial Rate Guarantee Period shown in the Coverage Features, and (b) may be renewed for successive renewal periods by the payment of the premium set by us on each renewal date The length of each renewal period will be set by us, but will not be less than 12 months For purposes of effective dates and ending dates under this Group Policy, all days begin and end at 12.00 midnight Standard Time at the Policyholder's address. All provisions on this and the following pages are part of this Group Policy "You" and "your" mean the Member. "We", "us", and "our" mean Standard Insurance Company Other defined terms appear with their initial letters capitalized. Section headings, and references to them, appear in boldface type STANDARD INSURANCE COMPANY By President Secretary GP190-LTD/S399 Table of Contents COVERAGE FEATURES ..... ... .................... . .... . . ......... 1 GENERAL POLICY INFORMATION ................. .......... .. 1 SCHEDULE OF INSURANCE............................................. ............................ ..... 1 PREMIUM CONTRIBUTIONS .. .. . ......................... ........................................... 2 PREMIUM AND RENEWALS..... .. . ............................. . ............. .................. 2 INSURING CLAUSE ...... . ....... .. .. .......... . ...... .. . 3 BECOMING INSURED . . ........ . .. . . ...... 3 WHEN YOUR INSURANCE BECOMES EFFECTIVE.............. . ......................... .. ..3 ACTIVE WORK PROVISIONS ................. ....I........................ 4 CONTINUITY OF COVERAGE ......................... ......... . .. ............................ ...........4 WHEN YOUR INSURANCE ENDS ... ... ............. .................. .............................. . 5 WAIVER OF PREMIUM ... . ...I. .... ....... . ................ ......... . ....................5 REINSTATEMENT OF INSURANCE ... ........ .......... . . . . . .................. . ... . 5 DEFINITION OF DISABILITY... . .. . . .. .. ........................... ..... .. .. ...........6 RETURN TO WORK PROVISIONS ........ . ..... .................... ... 7 REASONABLE ACCOMMODATION EXPENSE BENEFIT ............................ . . ... .......8 REHABILITATION PLAN PROVISION. .......... . ........... . .............................. .9 TEMPORARY RECOVERY ...................... .. ..... .. ............. ............................... . 9 WHEN LTD BENEFITS END .................................................. ............................... 9 PREDISABILITY EARNINGS ....... . . .......... . .......... . ................ .. 10 DEDUCTIBLE INCOME . .......... ................. 11 EXCEPTIONS TO DEDUCTIBLE INCOME.............................. . .. .. ................ 12 RULES FOR DEDUCTIBLE INCOME ............ .......................... .. 13 SUBROGATION . ... .... .......... ................... ...................... 13 ASSISTED LIVING BENEFIT .. .. . .. . .................................. ................................ 14 SURVIVORS BENEFIT ..... .. . ........................... .... . . ................................ 16 CONVERSION OF INSURANCE .. ..... . ....................... .. .. . 16 BENEFITS AFTER INSURANCE ENDS OR IS CHANGED . ........ .. . 17 EFFECT OF NEW DISABILITY .. ....... ...... . . ..................... . 17 DISABILITIES EXCLUDED FROM COVERAGE ............... ....... ............ . . 17 DISABILITIES SUBJECT TO LIMITED PAY PERIODS ..... . ....................................... 18 LIMITATIONS .................................. ................ 19 CLAIMS ...................................................................................... .....I. ... .....20 ALLOCATION OF AUTHORITY . . .. .... . .... ..... ........ . ... ...... .. ..................22 TIME LIMITS ON LEGAL ACTIONS ............................................................................22 INCONTESTABILITY PROVISIONS .. ... . ........ ... . .... .. . ..............22 CLERICAL ERROR, AGENCY, AND MISSTATEMENT .. 23 TERMINATION OR AMENDMENT OF THE GROUP POLICY . . ........... ............... .23 DEFINITIONS . . ... . .... . .......... ...............................24 POLICYHOLDER PROVISIONS ....... .......................................................................25 Index of Defined Terms Maximum LTD Benefit, 2 Active Work, Actively At Work, 4 Member, 1, 3 Activities Of Daily Living, 14 Mental Disorder, 18 Allowable Periods, 9 Minimum LTD Benefit, 2 Any Occupation, 7 Minimum Participation Number, 2 Any Occupation Period, 1 Minimum Participation Percentage, 2 Assisted Luang Benefit, 2, 14 Noncontributory, 24 Bathing, 14 Benefit Waiting Period, 2, 24 Other Limited Conditions, 18 Own Occupation, 6 Class Definition, 1 Own Occupation Period, 1 Continence, 14 Contributory, 24 P C Partner, 24 CPI-W, 24 Partially Disabled, 7 Physical Disease, 24 Deductible Income, 11 Physician, 24 Disabled, 6 Policyholder, 1 Dressing, 14 Predisability Earnings, 10 Preexisting Condition, 17 Eating, 14 Pregnancy, 24 Eligibility Waiting Period, 1 Premium Due Dates, 2 Employer, 24 Premium Rates, 2 Employer(s), 1 Prior Plan, 25 Evidence Of Insurability, 4 Reasonable Accommodation Expense Grace Period, 25 Benefit, 8 Group Policy, 24 Rehabilitation Plan, 9 Group Policy Effective Date, 1 Group Policy Number, 1 Severe Cognitive Impairment, 15 Standby Assistance, 14 Hands-on Assistance, 14 Substance Abuse, 18 Hospital, 19 Substantial Supervision, 15 Survivors Benefit, 16 Indexed Predisability Earnings, 24 Initial Rate Guarantee Period, 2 Temporary Recovery, 9 Injury, 24 Toiletmg, 14 Transferring, 14 L.L.C. Owner-Employee, 24 LTD Benefit, 24 War, 17 Work Earnings, 8 Material Duties, 7 Maximum Benefit Period, 2, 24 COVERAGE FEATURES This section contains many of the features of your long term disability (LTD) insurance. Other provisions, including exclusions, limitations, and Deductible Income, appear in other sections Please refer to the text of each section for full details The Table of Contents and the Index of Defined Terms help locate sections and definitions GENERAL POLICY INFORMATION Group Policy Number: 339619-B Policyholder City of Kent Employer(s): City of Kent Group Policy Effective Date: July 1, 2005 Policy Issued in Washington Member means a citizen or resident of the United States or Canada and one of the following 1. An elected Mayor currently in office or a regular full-time or part-time employee of the Employer, other than a Uniformed Officer, Firefighter or Assistant Fire Chief who is Actively At Work at least 21 hours each week, or 2 A regular employee of the Employer working in a lob share position, other than a Uniformed Officer, Firefighter or Assistant Fire Chief who is Actively At Work at least 20 hours each week For purposes of the Member definition, Actively At Work will include regularly scheduled days off, holidays, or vacation days, so long as the person is capable of Active Work on those days Member does not include a temporary or seasonal employee, a full-time member of the armed forces of any country, a leased employee, or an independent contractor Class Definition. None SCHEDULE OF INSURANCE Eligibility Waiting Period. You are eligible on one of the following dates: If you are a Member on the Group Policy Effective Date, you are eligible on that date. If you become a Member after the Group Policy Effective Date, you are eligible on the date you become a Member Eligibility Waiting Period means the period you must be a Member before you become eligible for insurance Own Occupation Period The first 24 months for which LTD Benefits are paid. Any Occupation Period From the end of the Own Occupation Period to the end of the Maximum Benefit Period. Printed 08/03/2005 1 - 339619-B LTD Benefit: 66 2/3% of the first $10,500 of your Predisabihty Earnings, reduced by Deductible Income Maximum: $7,000 before reduction by Deductible Income. Minimum: $100 or 10% of your LTD Benefit before reduction by Deductible Income, whichever is greater Assisted Living Benefit: An additional 13 33% of the first $10,500 of your Predisability Earnings, but not to exceed $1,400 The Assisted Living Benefit is not reduced by Deductible Income Benefit Waiting Period* 90 days Maximum Benefit Period: Determined by your age when Disability begins, as follows- Age Maximum Benefit Period 61 or younger ....... ...... To age 65, or 3 years 6 months, if longer. 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 PREMIUM CONTRIBUTIONS Insurance is: Noncontributory PREMIUM AND RENEWALS Premium Rates LTD Insurance 0 730% of the first $10,500 of each insured Member's insured Predisabdity Earnings. Premium Due Dates: July 1, 2005 and the first day of each calendar month thereafter Initial Rate Guarantee Period: July 1, 2005 to January 1, 2007 Minimum Participation Number. 10 insured Members Minimum Participation Percentage: 100% of eligible Members Printed 08/03/2005 - 2 - 339619-B INSURING CLAUSE If you become Disabled while insured under the Group Policy, we will pay LTD Benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us Mic OT.1 BECOMING INSURED To become insured you must be a Member, complete your Eligibility Waiting Period, and meet the requirements in Active Work Provisions and When Your Insurance Becomes Effective You are a Member if you are a citizen or resident of the United States or Canada and one of the following 1. An elected Mayor currently in office or a regular full-time or part-time employee of the Employer, other than a Uniformed Officer, Firefighter or Assistant Fire Chief who is Actively At Work at least 21 hours each week, or 2 A regular employee of the Employer working in a job share position, other than a Uniformed Officer, Firefighter or Assistant Fire Chief who is Actively At Work at least 20 hours each week. For purposes of the Member definition, Actively At Work will include regularly scheduled days off, holidays, or vacation days, so long as you are capable of Active Work on those days You are not a Member if you are a temporary or seasonal employee, a full-time member of the armed forces of any country, a leased employee, or an independent contractor. Eligibility Waiting Period means the period you must be a Member before you become eligible for insurance Your Eligibility Waiting Period is shown in the Coverage Features. (VAR MBR DEF) LT.BI OT.1 WHEN YOUR INSURANCE BECOMES EFFECTIVE A When Insurance Becomes Effective Subject to the Active Work Provisions, your insurance becomes effective as follows: 1. Insurance Subject To Evidence Of Insurability Insurance subject to Evidence Of Insurability becomes effective on the date we approve your Evidence Of Insurability 2 Insurance Not Subject To Evidence of Insurability The Coverage Features states whether insurance is Contributory or Noncontributory. a. Noncontributory Insurance Noncontnbutory insurance not subject to Evidence Of Insurability becomes effective on the date you become eligible. b. Contributory Insurance You must apply in writing for Contributory insurance and agree to pay premiums. Contributory insurance not subject to Evidence Of Insurability becomes effective on I. The date you become eligible if you apply on or before that date, or ii. The date you apply if you apply within 31 days after you become eligible. Late application Evidence Of Insurability is required if you apply more than 31 days after you become eligible Printed 08/03/2005 - 3 - 339619-B B Takeover Provisions 1. If you were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy, your Eligibility Waiting Period is waived on the effective date of your Employer's coverage under the Group Policy 2. You must submit satisfactory Evidence Of Insurability to become insured if you were eligible for insurance under the Prior Plan for more than 31 days but were not insured C Evidence Of Insurability Requirement Evidence Of Insurability satisfactory to us is required: a. For late application for Contributory insurance. b. For Members eligible but not insured under the Prior Plan. c. For reinstatements if required. Providing Evidence Of Insurability means you must: 1. Complete and sign our medical history statement; 2. Sign our form authorizing us to obtain information about your health; 3 Undergo a physical examination, if required by us, which may include blood testing; and 4. Provide any additional information about your insurability that we may reasonably require (VAR E01) LT EF.OT.1 ACTIVE WORK PROVISIONS A Active Work Requirement You must be capable of Active Work on the day before the scheduled effective date of your insurance or your insurance will not become effective as scheduled If you are incapable of Active Work because of Physical Disease, Injury, Pregnancy or Mental Disorder on the day before the scheduled effective date of your insurance, your insurance will not become effective until the day after you complete one full day of Active Work as an eligible Member Active Work and Actively At Work mean performing with reasonable continuity the Material Duties of your Own Occupation at your Employer's usual place of business. B. Changes In Insurance This Active Work requirement also applies to any increase in your insurance. LT AW Or.IL CONTINUITY OF COVERAGE If your Disability is subject to the Preexisting Condition Exclusion, LTD Benefits will be payable if: 1 You were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy; 2 You became insured under the Group Policy when your insurance under the Prior Plan ceased, 3 You were continuously insured under the Group Policy from the effective date of your insurance under the Group Policy through the date you became Disabled from the Preexisting Condition, and 4 Benefits would have been payable under the terms of the Prior Plan if it had remained in force, taking into account the preexisting condition exclusion, if any, of the Prior Plan Printed 08/03/2005 - 4 - 339619-B For such a Disability, the amount of your LTD Benefit will be the lesser of: a The monthly benefit that would have been payable under the terms of the Prior Plan if it had remained in force, or b. The LTD Benefit payable under the terms of the Group Policy, but without application of the Preexisting Condition Exclusion. Your LTD Benefits for such a Disability will end on the earlier of the following dates: a. The date benefits would have ended under the terms of the Prior Plan if it had remained in force, or b. The date LTD Benefits end under the terms of the Group Policy. aw LT CC OT 1 WHEN YOUR INSURANCE ENDS Your insurance ends automatically on the earliest of 1 The date the last period ends for which a premium contribution was made for your insurance. 2. The date the Group Policy terminates 3. The date your employment terminates. 4 The date you cease to be a Member However, your insurance will be continued during the following periods when you are absent from Active Work, unless it ends under any of the above a During the first 90 days of a temporary or indefinite administrative or involuntary leave of absence or sick leave, provided your Employer is paying you at least the same Predisabihty Earnings paid to you immediately before you ceased to be a Member A period when you are absent from Active Work as part of a severance or other employment termination agreement is not a leave of absence, even if you are receiving the same Predisability Earnings b. During a medical leave of absence approved in writing by your Employer, and requiring a physician's certification, which will not exceed 180 days c. During a leave of absence if continuation of your insurance under the Group Policy is required by a state-mandated family or medical leave act or law Such leave may run concurrent with the medical leave of absence in b above d. During any other temporary leave of absence approved by your Employer in advance and in writing and scheduled to last 30 days or less A period of Disability is not a leave of absence LT EN OT.1X WAIVER OF PREMIUM We will waive payment of premium for your insurance while LTD Benefits are payable. LT.WP OT.1 REINSTATEMENT OF INSURANCE If your insurance ends, you may become insured again as a new Member. However, the following will apply: 1 If you cease to be a Member because of a covered Disability, your insurance will end; however, if you become a Member again immediately after LTD Benefits end, the Eligibility Waiting Period will be waived and, with respect to the condition(s) for which LTD Benefits were payable, the Printed 08/03/2005 - 5 - 339619-B Preexisting Condition Exclusion will be applied as if your insurance had remained in effect during that period of Disability 2 If your insurance ends because you cease to be a Member for any reason other than a covered Disability, and if you become a Member again within 90 days, the Eligibility Waiting Period will be waived. 3 If your insurance ends because you fail to make a required premium contribution, you must provide Evidence Of Insurability to become insured again 4. If your insurance ends because you are on a federal or 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 federal or state-mandated family or medical leave act or law. 5 The Preexisting Conditions Exclusion will be applied as if insurance had remained in effect in the following instances a If you become insured again within 90 days. b. If required by federal or 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 6. In no event will insurance be retroactive LT RE.OT.1 DEFINITION OF DISABILITY You are Disabled if you meet one of the following definitions during the periods they apply: A Own Occupation Definition Of Disability; B. Any Occupation Definition Of Disability; or C Partial Disability Definition. A. Own Occupation Definition Of Disability During the Benefit Waiting Period and the Own Occupation Period you are required to be Disabled only from your Own Occupation. You are Disabled from your Own Occupation if, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to perform with reasonable continiuty the Material Duties of your Own Occupation Note- You are not Disabled merely because your right to perform your Own Occupation is restricted, including a restriction or loss of license During the Own Occupation Period you may work in another occupation while you meet the Own Occupation Definition Of Disability However, you will no longer be Disabled when your Work Earnings from another occupation meet or exceed 80% of your Indexed Predisability Earnings Your Work Earnings may be Deductible Income See Return To Work Provisions and Deductible Income Own Occupation means any employment, business, trade, profession, calling or vocation that involves Material Duties of the same general character as the occupation you are regularly performing for your Employer when Disability begins In determining your Own Occupation, we are not limited to looking at the way you perform your job for your Employer, but we may also look at the way the occupation is generally performed in the national economy If your Own Occupation involves the rendering of professional services and you are required to have a professional or Printed 08/03/2005 - 6 - 339619-B occupational license in order to work, your Own Occupation is as broad as the scope of your license Material Duties means the essential tasks, functions and operations, and the skills, abilities, knowledge, training and experience, generally required by employers from those engaged in a particular occupation that cannot be reasonably modified or omitted In no event will we consider working an average of more than 40 hours per week to be a Material Duty B. Any Occupation Definition Of Disability During the Any Occupation Period you are required to be Disabled from all occupations. You are Disabled from all occupations if, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to perform with reasonable continuity the Material Duties of Any Occupation Any Occupation means any occupation or employment which you are able to perform, whether due to education, training, or experience, which is available at one or more locations in the national economy and in which you can be expected to earn at least 60% of your Indexed Predisability Earnings within twelve months following your return to work, regardless of whether you are working in that or any other occupation Material Duties means the essential tasks, functions and operations, and the skills, abilities, knowledge, training and experience, generally required by employers from those engaged in a particular occupation that cannot be reasonably modified or omitted In no event will we consider working an average of more than 40 hours per week to be a Material Duty. C Partial Disability Definition During the Benefit Waiting Period and the Own Occupation Period, you are Partially Disabled when you work in your Own Occupation but, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to earn 80% or more of your Indexed Predisability Earnings, in that occupation Your Work Earnings may be Deductible Income. See Return To Work Provisions and Deductible Income. Your Owen Occupation Period and Any Occupation Period are shown in the Coverage Features LT2 DD 33 RETURN TO WORK PROVISIONS A. Return To Work Responsibility During the Own Occupation Period no LTD Benefits will be paid for any period when you are able to work in your Own Occupation and able to earn at least 20% of your Indexed Predisability Earnings, but you elect not to work During the Any Occupation Period no LTD Benefits will be paid for any period when you are able to work in Any Occupation and able to earn at least 20% of your Indexed Predisability Earnings, but you elect not to work B. Return To Work Incentive You may serve your Benefit Waiting Period while working if you meet the Own Occupation Definition Of Disability Printed 08/03/2005 - 7 - 339619-B You are eligible for the Return To Work Incentive on the first day you work after the Benefit Waiting Period if LTD Benefits are payable on that date The Return To Work Incentive changes 12 months after that date, as follows 1. During the first 12 months, your Work Earnings will be Deductible Income as determined in a., b and c a. Determine the amount of your LTD Benefit as if there were no Deductible Income, and add your Work Earnings to that amount b Determine 100% of your Indexed Predisability Earnings. c. If a is greater than b , the difference will be Deductible Income. 2. After those first 12 months, 50%of your Work Earnings will be Deductible Income. C Work Earnings Definition Work Earnings means your gross monthly earnings from work you perform while Disabled, plus the earnings you could receive if you worked as much as you are able to, considering your Disability, in work that is reasonably available a In your Own Occupation during the Own Occupation Period, and b. In Any Occupation during the Any Occupation Period. Work Earnings includes earnings from your Employer, any other employer, or self-employment, and any sick pay, vacation pay, annual or personal leave pay or other salary continuation earned or accrued while working. Earnings from work you perform will be included in Work Earnings when you have the right to receive them If you are paid in a lump sum or on a basis other than monthly, we will prorate your Work Earnings over the period of time to which they apply If no period of time is stated, we will use a reasonable one In determining your Work Earnings we: 1. Will use the financial accounting method you use for income tax purposes, if you use that method on a consistent basis 2. Will not be limited to the taxable income you report to the Internal Revenue Service. 3. May ignore expenses under section 179 of the IRC as a deduction from your gross earnings. 4. May ignore depreciation as a deduction from your gross earnings 5 May adjust the financial information you give us in order to clearly reflect your Work Earnings. If we determine that your earnings vary substantially from month to month, we may determine your Work Earnings by averaging your earnings over the most recent three-month period During the Own Occupation Period you will no longer be Disabled when your average Work Earnings over the last three months exceed 80% of your Indexed Predisabihty Earnings During the Any Occupation Period you will no longer be Disabled when your average Work Earnings over the last three months exceed 60% of your Indexed Predisabhty Earnings LT.RW OT 1 REASONABLE ACCOMMODATION EXPENSE BENEFIT If you return to work in any occupation for any employer, not including self-employment, as a result of a reasonable accommodation made by such employer, we will pay that employer a Reasonable Accommodation Expense Benefit of up to $25,000, but not to exceed the expenses incurred. Printed 08/03/2005 - 8 - 339619-B The Reasonable Accommodation Expense Benefit is payable only if the reasonable accommodation is approved by us in writing prior to its implementation LT RAMA REHABILITATION PLAN PROVISION While you are Disabled you may qualify to participate in a Rehabilitation Plan Rehabilitation Plan means a written plan, program or course of vocational training or education that is intended to prepare you to return to work To participate in a Rehabilitation Plan you must apply on our forms or in a letter to us The terms, conditions and objectives of the plan must be accepted by you and approved by us in advance. We have the sole discretion to approve your Rehabilitation Plan An approved Rehabilitation Plan may include our payment of some or all of the expenses you incur in connection with the plan, including• a Training and education expenses. b. Family care expenses. c. Job-related expenses. d. Job search expenses LT RH OT.1 TEMPORARY RECOVERY You may temporanly recover from your Disability and then become Disabled again from the same cause or causes without having to serve a new Benefit Waiting Period Temporary Recovery means you cease to be Disabled for no longer than the applicable Allowable Period See Definition Of Disability A Allowable Periods 1 During the Benefit Waiting Period- a total of 30 days of recovery. 2. During the Maximum Benefit Period 180 days for each period of recovery B. Effect Of Temporary Recovery If your Temporary Recovery does not exceed the Allowable Periods, the following will apply. 1 The Predisability Earnings used to determine your LTD Benefit will not change 2 The period of Temporary Recovery will not count toward your Benefit Waiting Period, your Maximum Benefit Period or your Own Occupation Period 3 No LTD Benefits will be payable for the period of Temporary Recovery. 4. No LTD Benefits will be payable after benefits become payable to you under any other disability insurance plan under which you become insured during your period of Temporary Recovery. 5. Except as stated above, the provisions of the Group Policy will be applied as if there had been no interruption of your Disability LT TROT 1 WHEN LTD BENEFITS END Your LTD Benefits end automatically on the earliest of 1 The date you are no longer Disabled. Printed 08/03/2005 - 9 - 339619-B 2 The date your Maximum Benefit Period ends 3. The date you die. 4 The date benefits become payable under any other LTD plan under which you become insured through employment during a period of Temporary Recovery 5. The date you fail to provide proof of continued Disability and entitlement to LTD Benefits LT BE OT.1 PREDISABILITY EARNINGS Your Predisability Earnings will be based on your earnings in effect on your last full day of Active Work However, if you are a Partner, L L C Owner-Employee, Sole Proprietor or S-Corporation Shareholder, your Predisability Earnings will be based on your Employer's prior tax year or the Policyholder's prior tax year if you are a P C Partner Any subsequent change in your earnings after that last day of Active Work will not affect your Predisability Earnings A. Partners, P C Partners, L.L.C. Owner-Employees, Sole Proprietors and S-Corporation Shareholders If you are a Partner, L L C Owner-Employee, Sole Proprietor or S-Corporation Shareholder, Predisability Earnings means your average monthly compensation from your Employer during the Employer's prior tax year If you are a P C Partner, Predisability Earnings means the average monthly compensation received by your professional corporation from the Policyholder during the Policyholder's prior tax year Your average monthly compensation is determined by adding the following amounts as reported on the applicable Schedule K-1, Schedule C, Form W-2 or S-Corporation federal income tax return, and dividing by 12 (or by the number of months you were a Partner, PC Partner, L L C Owner-Employee, Sole Proprietor or S-Corporation Shareholder if less than 12) 1. Your ordinary income from trade or business activity(ies). 2. Your guaranteed payments, if you are a Partner. 3. Your net profit from business. 4. Your compensation (as an officer), salary, or wages, if you are an S-Corporation Shareholder. If you were not a Partner, P C Partner, L L C Owner-Employee, Sole Proprietor or S-Corporation Shareholder during the entire prior tax year, your Predisability Earnings will be your average monthly compensation for your period as a Partner, P.C. Partner, L.L.0 Owner-Employee, Sole Proprietor or S-Corporation Shareholder. B All Other Members Predisability Earnings means your monthly rate of earnings from your Employer, including- 1. Commissions averaged over the preceding 12 months or over the period of your employment if less than 12 months 2. Shift differential pay. Predisability Earnings does not include: 1 Bonuses 2. Overtime pay 3. Any other extra compensation. If you are paid on an annual contract basis, your monthly rate of earnings is one-twelfth (1/12th) of your annual contract salary Printed 08/03/2005 - 10 - 339619-B If you are paid hourly, your monthly rate of earnings is based on your hourly pay rate multiplied by the number of hours you are regularly scheduled to work per month, but not more than 173 hours If you do not have regular work hours, your monthly rate of earnings is based on the average number of hours you worked per month during the preceding 12 calendar months (or during your period of employment if less than 12 months), but not more than 173 hours C. All Members Predisability Earnings includes: 1. Contributions you make through a salary reduction agreement with your Employer to- a. An Internal Revenue Code (IRC) Section 401(k), 403(b), 408(k), 408(p), or 457 deferred compensation arrangement; or b. An executive nonqualified deferred compensation arrangement. 2 Amounts contributed to your fringe benefits according to a salary reduction agreement under an IRC Section 125 plan. Predisability Earnings does not include your Employer's contributions on your behalf to any deferred compensation arrangement or pension plan (KIREG WITH COW LT PD OT 1 DEDUCTIBLE INCOME Subject to Exceptions To Deductible Income, Deductible Income means: 1. Sick pay, annual or personal leave pay, severance pay, or other salary continuation, including donated amounts, (but not vacation pay) paid to you by your Employer, if it exceeds the amount found in a , b , and c a. Determine the amount of your LTD Benefit as if there were no Deductible Income, and add your sick pay or other salary continuation to that amount. b. Determine 100% of your Indexed Predisability Earnings. c If a is greater than b., the difference will be Deductible Income. 2. Your Work Earnings, as described in the Return To Work Provisions. 3 Any amount you receive or are eligible to receive because of your disability, including amounts for partial or total disability, whether permanent, temporary, or vocational, under any of the following- a. A workers' compensation law, b. The Jones Act, c. Maritime Doctrine of Maintenance, Wages, or Cure; d Longshoremen's and Harbor Worker's Act; or e Any similar act or law 4 Any amount you, your spouse, or your child under age 18 receive or are eligible to receive because of your disability or retirement under a. The Federal Social Security Act, b The Canada Pension Plan; c. The Quebec Pension Plan, d The Railroad Retirement Act; or Printed 08/03/2005 - 11 - 339619-B e. Any similar plan or act. Full offset Both the primary benefit (the benefit awarded to you) and dependents benefit are Deductible Income Benefits your spouse or a child receives or are eligible to receive because of your disability are Deductible Income regardless of marital status, custody, or place of residence The term "child" has the meaning given in the applicable plan or act. 5 Any amount you receive or are eligible to receive because of your disability under any state disability income benefit law or similar law 6. Any amount you receive or are eligible to receive because of your disability under another group insurance coverage. 7 Any disability or retirement benefits you receive or are eligible to receive under your Employer's retirement plan, including a public employee retirement system, a state teacher retirement system, and a plan arranged and maintained by a union or employee association for the benefit of Its members You and your Employer's contributions will be considered as distributed simultaneously throughout your lifetime, regardless of how funds are distributed from the retirement plan. You are not required to apply for disability or early retirement benefits under your Employer's retirement plan if the receipt of such benefit would reduce the benefit you would be eligible to receive at normal retirement age However, disability or early retirement benefits you do receive will be Deductible Income 8 Any earnings or compensation included in Predisabillty Earnings which you receive or are eligible to receive while LTD Benefits are payable 9. Any amount you receive or are eligible to receive under any unemployment compensation law or similar act or law 10 Any amount you receive or are eligible to receive from or on behalf of a third party because of your disability, whether by judgement, settlement or other method If you notify us before filing suit or settling your claim against such third party, the amount used as Deductible Income will be reduced by a pro rata share of your costs of recovery, including reasonable attorney fees 11 Any amount you receive by compromise, settlement, or other method as a result of a claim for any of the above, whether disputed or undisputed (CHOICE NO OTHR OFFST_PUH_WITH 9RD) IT DI.OT la EXCEPTIONS TO DEDUCTIBLE INCOME Deductible Income does not include: 1 Any cost of living increase in any Deductible Income other than Work Earnings, if the increase becomes effective while you are Disabled and while you are eligible for the Deductible Income. 2. Reimbursement for hospital, medical, or surgical expense 3. Reasonable attorneys fees incurred in connection with a claim for Deductible Income. 4 Benefits from any individual disability insurance policy 5 Early retirement benefits under the Federal Social Security Act which are not actually received. 6 Group credit or mortgage disability insurance benefits 7. Accelerated death benefits paid under a life insurance policy 8. Benefits from the following Printed 08/03/2005 - 12 - 339619-B a Profit sharing plan. b. Thrift or savings plan. c. Deferred compensation plan d Plan under IRC Section 401(k), 408(k), 408(p), or 457 e Individual Retirement Account (IRA) f. Tax Sheltered Annuity (TSA) under IRC Section 403(b) g Stock ownership plan h. Keogh (HR-10) plan. (PUB_NO OTHR OFFST) LT.ED OT.1 RULES FOR DEDUCTIBLE INCOME A. Monthly Equivalents Each month we will determine your LTD Benefit using the Deductible Income for the same monthly period, even if you actually receive the Deductible Income in another month. If you are paid Deductible Income in a lump sum or by a method other than monthly, we will determine your LTD Benefit using a prorated amount We will use the period of time to which the Deductible Income applies If no period of time is stated, we will use a reasonable one B. Your Duty To Pursue Deductible Income You must pursue Deductible Income for which you may be eligible We may ask for written documentation of your pursuit of Deductible Income You must provide it within 60 days after we mail you our request Otherwise, we may reduce your LTD Benefits by the amount we estimate you would be eligible to receive upon proper pursuit of the Deductible Income C. Pending Deductible Income We will not deduct pending Deductible Income until it becomes payable. You must notify us of the amount of the Deductible Income when it is approved You must repay us for the resulting overpayment of your claim. D. Overpayment Of Claim We will notify you of the amount of any overpayment of your claim under any group disability insurance policy issued by us You must immediately repay us You will not receive any LTD Benefits until we have been repaid in full. In the meantime, any LTD Benefits paid, including the Minimum LTD Benefit, will be applied to reduce the amount of the overpayment We may charge you interest at the legal rate for any overpayment which is not repaid within 30 days after we first mail you notice of the amount of the overpayment LT RU.OT.1 SUBROGATION If LTD Benefits are paid or payable to you under the Group Policy as the result of any act or omission of a third party, we will be subrogated to all rights of recovery you may have in respect to such act or omission You must execute and deliver to us such instruments and papers as may be required and do whatever else is needed to secure such rights You must avoid doing anything that would prejudice our rights of subrogation. If you notify us before filing suit or settling your claim against such third party, the amount to which we are subrogated will be reduced by a pro rata share of your costs of recovery, including reasonable Printed 08/03/2005 - 13 - 339619-B attorney fees If suit or action is filed, we may record a notice of payments of LTD Benefits, and such notice shall constitute a lien on any judgement recovered If you or your legal representative fail to bring suit or action promptly against such third party, we may institute such suit or action in our name or in your name We are entitled to retain from any judgement recovered the amount of LTD Benefits paid or to be paid to you or on your behalf, together with our costs of recovery, including attorney fees The remainder of such recovery, if any, shall be paid to you or as the court may direct. LT.SQATJ ASSISTED LIVING BENEFIT A. Assisted Living Benefit If you meet the requirements in 1 through 3 below, we will pay Assisted Living Benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us Assisted Living Benefit Requirements 1. You are Disabled and LTD Benefits are payable to you 2. While you are Disabled a You, due to loss of functional capacity as a result of Physical Disease or Injury, become unable to safely and completely perform two or more Activities Of Daily Living without Hands-on Assistance or Standby Assistance, or b. You require Substantial Supervision for your health or safety due to Severe Cognitive Impairment as a result of Physical Disease or Injury. 3. The condition in 2 a or 2 b above is expected to last 90 days or more as certified by a Physician in the appropriate specialty as determined by us B. Definitions For Assisted Living Benefit Activities Of Daily Living means Bathing, Continence, Dressing, Eating, Toiletmg, or Transferring. Bathing means washing oneself, whether in the tub or shower or by sponge bath, with or without the help of adaptive devices Continence means voluntarily controlling bowel and bladder function, or, if incontinent, maintaining a reasonable level of personal hygiene Dressing means putting on and removing all items of clothing, footwear, and medically necessary braces and artificial limbs Eating means getting food and fluid into the body, whether manually, intravenously, or by feeding tube Toileting means getting to and from and on and off the toilet, and performing related personal hygiene Transferring means moving into or out of a bed, chair or wheelchair, with or without adaptive devices. Hands-on Assistance means the physical assistance of another person without which the insured would be unable to perform the Activity Of Daily Living Standby Assistance means the presence of another person within arm's reach of the insured that is necessary to prevent, by physical intervention, injury to the insured while the insured is performing the Activity Of Daily Living (such as being ready to catch the insured if the insured falls while getting into or out of the bathtub or shower as part of Bathing, or being ready to remove food from the insured throat if the insured chokes while Eating) Printed 08/03/2005 - 14- 339619-B Severe Cognitive Impairment means a loss or deterioration in intellectual capacity that is (a) comparable to (and includes) Alzheimer's disease and similar forms of irreversible dementia, and (b) is measured by clinical evidence and standardized tests approved by us that reliably measure impairment in (i) short-term or long-term memory, (ii) orientation as to people, places, or time, and (m) deductive or abstract reasoning Severe Cognitive Impairment does not include loss or deterioration as a result of a Mental Disorder. Substantial Supervision means continual supervision (which may include cueing by verbal prompting, gestures, or other demonstrations) by another person that is necessary to protect you from threats to your health or safety(such as may result from wandering). C Amount Of The Assisted Living Benefit The amount of the Assisted Living Benefit is shown in the Coverage Features. D. Becoming Insured For Assisted Living Benefits You are eligible for Assisted Living Benefit coverage if you are insured for LTD insurance Subject to the Active Work Provision, your Assisted Living Benefit coverage becomes effective on the date your LTD insurance becomes effective. E. Payment Of Assisted Living Benefits We will pay Assisted Living Benefits within 60 days after Proof Of Loss is satisfied. Your Assisted Living Benefits will be paid to you at the same time LTD Benefits are payable F. Time Limits On Filing Proof Of Loss Proof Of Loss must be provided witlun 90 days after the date of the loss. If that is not possible, it must be provided as soon as reasonably possible, but not later than one year after that 90-day period If Proof Of Loss is filed outside these tune limits, the claim will be denied. These limits will not apply while the claimant lacks legal capacity G When Assisted Living Benefits End Assisted Living Benefits end automatically on the earliest of- 1 The date you no longer meet the requirements in item A above. 2. The date your LTD Benefits end H. No Conversion Assisted Living Benefit coverage may not be converted under the Conversion Of Insurance provision I Assisted Living Benefit Exclusions No Assisted Living Benefit is payable if your inability to perform Activities Of Daily Living or your Severe Cognitive Impairment is caused or contributed to by 1. Use of alcohol, alcoholism, use of any drug, including hallucinogens, or drug addiction 2. A Mental Disorder. J. When Assisted Living Benefits Coverage Ends Assisted Living Benefit coverage ends automatically on the earliest of 1. The date your LTD insurance ends 2. The date Assisted Living Benefit coverage terminates under the Group Policy. K. Assisted Living Benefits After Insurance Ends Or Is Changed Printed 08/03/2005 - 15 - 339619-B Your right to receive Assisted Living Benefits will not be affected by the occurrence of the events described in 1 or 2 below that become effective after you become Disabled. 1 Termination or amendment of the Group Policy or your Employer's coverage under the Group Policy 2. Termination of Assisted Living Benefit coverage while the Group Policy or your Employer's coverage under the Group Policy remains in force (CONY) LT LB OT.1 SURVIVORS BENEFIT If you die while LTD Benefits are payable, and on the date you die you have been continuously Disabled for at least 180 days, we will pay a Survivors Benefit according to 1 through 4 below 1. The Survivors Benefit is a lump sum equal to 3 times your LTD Benefit without reduction by Deductible Income 2 The Survivors Benefit will first be applied to reduce any overpayment of your claim 3. The Survivors Benefit will be paid at our option to any one or more of the following. a. Your surviving spouse; b. Your surviving unmarried children, including adopted children, under age 25; c. Your surviving spouse's unmarried children, including adopted children, under age 25; or d. Any person providing the care and support of any person listed in a., b , or c above 4 No Survivors Benefit will be paid if you are not survived by any person listed in a., b., or c. above. (MULTPL) LT SB OT 1 CONVERSION OF INSURANCE Conversion Of Insurance Benefit When your insurance ends, you may buy LTD conversion insurance if you meet 1 through 5 below 1. Your insurance ends for a reason other than a. Termination or amendment of the Group Policy; b. Your failure to make a required premium contribution, or c Your retirement. 2 You were continuously insured under your Employer's long term disability insurance plan for at least one year as of the date your insurance ended 3. You are not Disabled on the date your insurance ends. 4 You are a citizen or resident of the United States or Canada. 5. You must apply in writing and pay the first premium to us within 31 days after your insurance ends. Your LTD conversion insurance becomes effective on the day after your insurance ends. The maximum LTD conversion insurance benefit you may select is the smallest of 1. $4,000 (however, if you provide satisfactory Evidence Of Insurability, this upper limit is $8,000), 2 60% of your insured Predisability Earnings on the date your insurance ended, and Printed 08/03/2005 - 16 - 339619-B 3 The LTD Benefit payable if you had become Disabled on the day before your insurance ended and you had no Deductible Income. The maximum LTD conversion insurance benefit is reduced by deductible income The certificate we will issue to you when your LTD conversion msurance becomes effective will contain other provisions which will also differ from the Group Policy. LT MOT.1 BENEFITS AFTER INSURANCE ENDS OR IS CHANGED During each period of continuous Disability, we will pay LTD Benefits according to the terms of the Group Policy in effect on the date you become Disabled Your right to receive LTD Benefits will not be affected by 1. Any amendment to the Group Policy that is effective after you become Disabled. 2 Termination of the Group Policy after you become Disabled. LT.BAOT.1 EFFECT OF NEW DISABILITY If a period of Disability is extended by a new cause while LTD Benefits are payable, LTD Benefits will continue while you remain Disabled However, 1 and 2 apply. 1. LTD Benefits will not continue bevond the end of the original Maximum Benefit Period 2 The Disabilities Excluded From Coverage, Disabilities Subject To Limited Pay Periods, and Limitations sections will apply to the new cause of Disability LT ND OT.1 DISABILITIES EXCLUDED FROM COVERAGE A 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 B. Intentionally Self-Inflicted Injury You are not covered for a Disability caused or contributed to by an intentionally self-inflicted Injury, while sane or insane C. Preexisting Condition 1. Definition Preexisting Condition means a mental or physical condition whether or not diagnosed or misdiagnosed: a. For which you have done or for which a reasonably prudent person would have done any of the following• L Consulted a physician or other licensed medical professional; ii. Received medical treatment, services or advice, iii Undergone diagnostic procedures, including self-administered procedures; iv. Taken prescribed drugs or medications; Printed 08/03/2005 - 17- 339619-B b. Which, as a result of any medical examination, including routine examination, was discovered or suspected, at any time during the 90-day period just before your insurance becomes effective. 2. 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, on the date you become Disabled, you a Have been continuously insured under the Group Policy for 12 months; and b. Have been Actively At Work for at least one full day after the end of that 12 months D. Loss Of License Or Certification You are not covered for a Disability caused or contributed to by the loss of your professional license, occupational license or certification. E. Violent Or Criminal Conduct You are not covered for a Disability caused or contributed to by your committing or attempting to commit an assault or felony, or actively participating ui a violent disorder or not Actively participating does not include being at the scene of a violent disorder or riot while performing your official duties. (WITH PRUDNT) LT XD OT.1 DISABILITIES SUBJECT TO LIMITED PAY PERIODS A Mental Disorders, Substance Abuse and Other Limited Conditions Payment of LTD Benefits is limited to 24 months during your entire lifetime for a Disability caused or contributed to by any one or more of the following, or medical or surgical treatment of one or more of the following 1. Mental Disorders; 2. Substance Abuse, or 3. Other Limited Conditions. However, if you are confined in a Hospital solely because of a Mental Disorder at the end of the 24 months, this limitation will not apply while you are continuously confined Mental Disorder means any mental, emotional, behavioral, psychological, personality, cognitive, mood or stress-related abnormality, disorder, disturbance, dysfunction or syndrome, regardless of cause (including any biological or biochemical disorder or imbalance of the brain) or the presence of physical symptoms Mental Disorder includes, but is not limited to, bipolar affective disorder, organic brain syndrome, schizophrenia, psychotic illness, manic depressive illness, depression and depressive disorders, anxiety and anxiety disorders Substance Abuse means use of alcohol, alcoholism, use of any drug, including hallucinogens, or drug addiction Other Limited Conditions means chronic fatigue conditions (such as chronic fatigue syndrome, chronic fatigue immunodeficiency syndrome, post viral syndrome, limbic encephalopathy, Epstem- Barr virus infection, herpes virus type 6 infection, or myalgic encephalomyelitis), any allergy or sensitivity to chemicals or the environment (such as environmental allergies, sick building syndrome, multiple chemical sensitivity syndrome or chronic toxic encephalopathy), chronic pain conditions (such as fibromyalgia, reflex sympathetic dystrophy or myofascial pain), carpal tunnel or repetitive motion syndrome, temporomandibular joint disorder, cramomandibular joint disorder, Printed 08/03/2005 - 18 - 339619-B arthritis, diseases or disorders of the cervical, thoracic, or lumbosacral back and its surrounding soft tissue, and sprains or strains of joints or muscles. However, Other Limited Conditions does not include neoplastic diseases, neurologic diseases, endocrine diseases, hematologic diseases, asthma, allergy-induced reactive lung disease, tumors, malignancies, or vascular malformations, demyelmatmg diseases, lupus, rheumatoid or psonatic arthritis, herniated discs with neurological abnormalities that are documented by electromyogram and computerized tomography or magnetic resonance imaging, scollosis, radiculopathies that are documented by electromyogram, spondylolisthesis, grade II or higher, myelopathies and myelitis, traumatic spinal cord necrosis, osteoporosis, discitis, Paget's disease Hospital means a legally operated hospital providing full-time medical care and treatment under the direction of a full-time staff of licensed physicians Rest homes, nursing homes, convalescent homes, homes for the aged, and facilities primarily affording custodial, educational, or rehabilitative care are not Hospitals B Rules For Disabilities Subject To Limited Pay Periods 1 If you are Disabled as a result of a Mental Disorder or any Physical Disease or Injury for which payment of LTD Benefits is subject to a limited pay period, and at the same time are Disabled as a result of a Physical Disease, Injury, or Pregnancy that is not subject to such limitation, LTD Benefits will be payable first for conditions that are subject to the limitation 2. No LTD Benefits will be payable after the end of the limited pay period, unless on that date you continue to be Disabled as a result of a Physical Disease, Injury, or Pregnancy for which payment of LTD Benefits is not limited (WITH MUSQ MMOT.1 LIMITATIONS A Care Of A Physician You must be under the ongoing care of a Physician in the appropriate specialty as determined by us during the Benefit Waiting Period No LTD Benefits will be paid for any period of Disability when you are not under the ongoing care of a Physician in the appropriate specialty as determined by us B. Return To Work Responsibility During the Own Occupation Period no LTD Benefits will be paid for any period of Disability when you are able to work in your Own Occupation and able to earn at least 20% of your Indexed Predisability Earnings, but you elect not to work. During the Any Occupation Period, no LTD Benefits will be paid for any period of Disability when you are able to work in Any Occupation and able to earn at least 20% of your Indexed Predisability Earnings, but elect not to work C. Rehabilitation Program No LTD Benefits will be paid for any period of Disability when you are not participating in good faith in a plan, program or course of medical treatment or vocational training or education approved by us unless your Disability prevents you from participating D Foreign Residency Payment of LTD Benefits is limited to 12 months for each period of continuous Disability while you reside outside of the United States or Canada E. Imprisonment Printed 08/03/2005 - 19 - 339619-B No LTD Benefits will be paid for any period of Disability when you are confined for any reason in a penal or correctional institution LT LM.OT.1 CLAIMS A Filing A Claim Claims should be filed on our forms. If we do not provide our forms within 15 days after they are requested, you may submit your claim in a letter to us The letter should include the date disability began, and the cause and nature of the disability. B Time Linits On Filing Proof Of Loss You must give us Proof Of Loss within 90 days after the end of the Benefit Waiting Period If you cannot do so, you must give it to us as soon as reasonably possible, but not later than one year after that 90-day period If Proof Of Loss is filed outside these time limits, your claim will be denied These limits will not apply while you lack legal capacity C Proof Of Loss Proof Of Loss means written proof that you are Disabled and entitled to LTD Benefits. Proof Of Loss must be provided at your expense For claims of Disability due to conditions other than Mental Disorders, we may require proof of physical impairment that results from anatomical or physiological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques. D. Documentation Completed claims statements, a signed authorization for us to obtain information, and any other items we may reasonably require in support of a claim must be submitted at your expense If the required documentation is not provided within 45 days after we mail our request, your claim may be denied E Investigation Of Clain We may investigate your claim at any time. At our expense, we may have you examined at reasonable intervals by specialists of our choice We may deny or suspend LTD Benefits if you fail to attend an examination or cooperate with the examiner F. Time Of Payment We will pay LTD Benefits within 60 days after you satisfy Proof Of Loss. LTD Benefits will be paid to you at the end of each month you qualify for them. LTD Benefits remaining unpaid at your death will be paid to the person(s) receiving the Survivors Benefit If no Survivors Benefit is paid, the unpaid LTD Benefits will be paid to your estate G. Notice Of Decision On Claim We will evaluate your claim promptly after you file it. Within 45 days after we receive your claim we will send you (a) a written decision on your claim, or (b) a notice that we are extending the period to decide your claim for 30 days Before the end of this extension period we will send you (a) a written decision on your claim, or (b) a notice that we are extending the period to decide your claim for an additional 30 days If an extension is due to your failure to provide information necessary to decide the claim, the extended time period for deciding your claim will not begin until you provide the information or otherwise respond If we extend the period to decide your claim, we will notify you of the following (a) the reasons for the extension; (b) when we expect to decide your claim, (c) an explanation of the standards on Printed 08/03/2005 - 20- 339619-B which entitlement to benefits is based, (d) the unresolved issues preventing a decision; and (e) any additional information we need to resolve those issues If we request additional information, you will have 45 days to provide the information If you do not provide the requested information within 45 days, we may decide your claim based on the information we have received If we deny any part of your claim, you will receive a written notice of denial containing a The reasons for our decision b Reference to the parts of the Group Policy on which our decision is based. c A description of any additional information needed to support your claim. d. Information concerning your right to a review of our decision H. Review Procedure If all or part of a claim is denied, you may request a review You must request a review in writing within 180 days after receiving notice of the denial. You may send us written comments or other items to support your claim You may review and receive copies of any non-privileged information that is relevant to your request for review. There will be no charge for such copies You may request the names of medical or vocational experts who provided advice to us about your claim The person conducting the review will be someone other than the person who denied the claim and will not be subordinate to that person The person conducting the review will not give deference to the initial denial decision If the denial was based on a medical judgement, the person conducting the review will consult with a qualified health care professional This health care professional will be someone other than the person who made the original medical judgement and will not be subordinate to that person Our review will include any written comments or other items you submit to support your claim We will review your claim promptly after we receive your request. Within 45 days after we receive your request for review we will send you (a) a written decision on review, or (b) a notice that we are extending the review period for 45 days If the extension is due to your failure to provide information necessary to decide the claim on review, the extended time period for review of your claim will not begin until you provide the information or otherwise respond. If we extend the review period, we will notify you of the following (a) the reasons for the extension; (b) when we expect to decide your claim on review, and (c) any additional information we need to decide your claim If we request additional information, you will have 45 days to provide the information. If you do not provide the requested information within 45 days, we may conclude our review of your claim based on the information we have received. If we deny any part of your claim on review, you will receive a written notice of denial containing a. The reasons for our decision. b. Reference to the parts of the Group Policy on which our decision is based. c. Information concerning your right to receive, free of charge, copies of non-privileged documents and records relevant to your claim I Assignment The rights and benefits under the Group Policy are not assignable (REV PUB WRDG) LT.CLAT.2 Printed 08/03/2005 - 21 - 339619-B ALLOCATION OF AUTHORITY Except for those functions which the Group Policy specifically reserves to the Policyholder or Employer, we have full and exclusive authority to control and manage the Group Policy, to administer claims, and to interpret the Group Policy and resolve all questions arising in the administration, interpretation, and application of the Group Policy. Our authority includes, but is not limited to ' 1. The right to resolve all matters when a review has been requested; 2. The right to establish and enforce rules and procedures for the administration of the Group Policy and any claim under it, 3 The right to determine: a. Eligibility for insurance; b. Entitlement to benefits; c. The amount of benefits payable, and d. The sufficiency and the amount of information we may reasonably require to determine a., b , or c , above Subject to the review procedures of the Group Policy, any decision we make in the exercise of our authority is conclusive and binding LT.AL.OT.1 TIME LIMITS ON LEGAL ACTIONS No action at law or in equity may be brought until 60 days after you have given us Proof Of Loss. No such action may be brought more than three years after the earlier of - 1 The date we receive Proof Of Loss, and 2. The time within which Proof Of Loss is required to be given LT TL OT 1 INCONTESTABILITY PROVISIONS A. Incontestability Of Insurance Any statement made to obtain insurance or to increase insurance is a representation and not a warranty No misrepresentation will be used to reduce or deny a claim or contest the validity of insurance unless 1. The insurance would not have been approved if we had known the truth: and 2 We have given you or any other person claiming benefits a copy of the signed written instrument which contains the misrepresentation After insurance has been in effect for two years during the lifetime of the insured, we will not use a misrepresentation to reduce or deny the claim, unless it was a fraudulent misrepresentation B Incontestability Of The Group Policy Any statement made by the Policyholder or Employer to obtain the Group Policy is a representation and not a warranty Printed 08/03/2005 - 22 - 339619-B No misrepresentation by the Policyholder or your Employer will be used to deny a claim or to deny the validity of the Group Policy unless- 1 The Group Policy would not have been issued if we had known the truth; and 2 We have given the Policyholder or Employer a copy of a written instrument signed by the Policyholder or Employer which contains the misrepresentation The validity of the Group Policy will not be contested after it has been in force for two years, except for nonpayment of premiums or fraudulent misrepresentations. LT IN OT.1 CLERICAL ERROR, AGENCY, AND MISSTATEMENT A. Clerical Error Clerical error by the Policyholder, your Employer, or their respective employees or representatives will not 1. Cause a person to become insured. 2. Invalidate insurance under the Group Policy otherwise validly in force. 3 Continue insurance under the Group Policy otherwise validly terminated B. Agency The Policyholder and your Employer act on their own behalf as your agent, and not as our agent. The Policyholder and your Employer have no authority to alter, expand or extend our liability or to waive, modify or compromise any defense or right we may have under the Group Policy C Misstatement Of Age If a person's age has been misstated, we will make an equitable adjustment of premiums, benefits, or both The adjustment will be based on. 1 The amount of insurance based on the correct age, and 2. The difference between the premiums paid and the premiums which would have been paid if the age had been correctly stated LT.CE.OT.1 TERMINATION OR AMENDMENT OF THE GROUP POLICY The Group Policy may be terminated by us or the Policyholder according to its terms It will terminate automatically for nonpayment of premium The Policyholder may terminate the Group Policy in whole, and may terminate insurance for any class or group of Members, at any time by giving us written notice Benefits under the Group Policy are limited to its terms, including any valid amendment. No change or amendment will be valid unless it is approved in writing by one of our executive officers and given to the Policyholder for attachment to the Group Policy If the terms of the certificate differ from the Group Policy, the terms stated in the Group Policy will govern The Policyholder, your Employer, and their respective employees or representatives have no right or authority to change or amend the Group Policy or to waive any of its terms or provisions without our signed written approval. We may change the Group Policy in whole or In part when any change or clarification in law or governmental regulation affects our obligations under the Group Policy, or with the Policyholder's consent. Printed 08/03/2005 - 23 - 339619-B Any such change or amendment of the Group Policy may apply to current or future Members or to any separate classes or groups of Members. LT.TAOT.1 DEFIIVITIONS Benefit Waiting Period means the period you must be continuously Disabled before LTD Benefits become payable No LTD Benefits are payable for the Benefit Waiting Period See Coverage Features Contributory means insurance is elective and Members pay all or part of the premium for insurance CPI-W means the Consumer Price Index for Urban Wage Earners and Clerical Workers published by the United States Department of Labor. If the CPI-W is discontinued or changed, we may use a comparable index Where required, we will obtain prior state approval of the new index Employer means an employer (including approved affiliates and subsidiaries) for which coverage under the Group Policy is approved in writing by us. Group Policy means the group LTD insurance policy issued by us to the Policyholder and identified by the Group Policy Number Indexed Predisability Earnings means your Predisability Earmngs adjusted by the rate of increase in the CPI-W During your first year of Disability, your Indexed Predisability Earnings are the same as your Predisability Earnings Thereafter, your Indexed Predisability Earnings are determined on each anniversary of your Disability by increasing the previous year's Indexed Predisability Earnings by the rate of increase in the CPI-W for the prior calendar year The maximum adjustment in any year is 10% Your Indexed Predisability Earnings will not decrease, even if the CPI-W decreases. Injury means an injury to the body. L.L.0 Owner-Employee means an individual who owns an equity interest in an Employer and is actively employed in the conduct of the Employer's business LTD Benefit means the monthly benefit payable to you under the terms of the Group Policy. Maximum Benefit Period means the longest period for which LTD Benefits are payable for any one period of continuous Disability, whether from one or more causes It begins at the end of the Benefit Waiting Period No LTD Benefits are payable after the end of the Maximum Benefit Period, even if you are still Disabled See Coverage Features Noncontributory means (a) insurance is nonelective and the Policyholder or Employer pay the entire premium for insurance; or (b) the Policyholder or Employer require all eligible Members to have insurance and to pay all or part of the premium for insurance P C. Partner means the sole active employee and majority shareholder of a professional corporation in partnership with the Policyholder Physical Disease means a physical disease entity or process that produces structural or functional changes in the body as diagnosed by a Physician Physician means a licensed M D or D.O , acting within the scope of the license Physician does not include you or your spouse, or the brother, sister, parent, or child of either you or your spouse Pregnancy means your pregnancy, childbirth, or related medical conditions, including complications of pregnancy. Printed 08/03/2005 - 24- 339619-B Prior Plan means your Employer's group long term disability insurance plan in effect on the day before the effective date of your Employer's participation under the Group Policy and which is replaced by coverage under the Group Policy LT DF OT1 POLICYHOLDER PROVISIONS A Premiums The premium due on each Premium Due Date is the sum of the premiums for all persons then insured Premium Rates are shown in Coverage Features B. Contributions From Members The Policyholder determines the amount, if any, of each Member's contribution toward the cost of insurance C Changes In Premium Rates We may change Premium Rates whenever: 1 A change or clarification in law or governmental regulation affects the amount payable under the Group Policy Any such change in Premium Rates will reflect only the change in our obligations 2. Factors material to underwriting the risk we assumed under the Group Policy with respect to an Employer, including, but not limited to, number of persons insured, age, Predisability Earnings, gender, and occupational classification, changes by 25% or more 3 The premium contribution arrangement for Members is changed or vanes from that stated in the Group Policy when issued or last renewed 4. We and the Policyholder or the Employer mutually agree to change Premium Rates. Except as provided above, Premium Rates will not be changed during the Initial Rate Guarantee Period shown in Coverage Features Thereafter, except as provided above, we may change Premium Rates upon 45 days advance written notice to the Policyholder Any such change in Premium Rates may be made effective on any Premium Due Date, but no such change will be made more than once in any contract year Contract years are successive 12 month periods computed from the end of the Initial Rate Guarantee Period D. Payment Of Premiums All premiums are due on the Premium Due Dates shown in Coverage Features. Each premium is payable on or before its Premium Due Date directly to us at our home office The payment of each premium by the Policyholder as it becomes due will maintain the Group Policy in force until the next Premium Due Date. E. Grace Period And Termination For Nonpayment If a premium is not paid on or before its Premium Due Date, it may be paid during the following Grace Period of 45 days The Group Policy or an Employer's coverage under the Group Policy will remain in force during the Grace Period If the premium is not paid during the Grace Penod, the Group Policy will terminate automatically at the end of the Grace Period The Policyholder is liable for premium for coverage during the Grace Period We may charge interest at the legal rate for any premium which is not paid during the Grace Period, beginning with the first day after the Grace Period F. Termination For Other Reasons Printed 08/03/2005 - 25 - 339619-B a The Policyholder may terminate the Group Policy by giving us written notice. The effective date of termination will be the later of: 1. The date stated in the notice, and 2. The date we receive the notice We may terminate the Group Policy as follows: 1 On any Premium Due Date if the number of persons insured is less than the Minimum Participation shown in Coverage Features 2. On any Premium Due Date if we determine that the Policyholder has failed to promptly furnish any necessary information requested by us, or has failed to perform any other obligations relating to the Group Policy The minimum advance notice of termination by us is 45 days G. Premium Adjustments Premium adjustments involving a return of unearned premiums to the Policyholder will be limited to the 12 months just before the date we receive a request for premium adjustment H Certificates We will issue certificates to the Policyholder showing the coverage under the Group Policy The Policyholder will distribute a certificate to each insured Member If the terms of the certificate differ from the Group Policy, the terms stated in the Group Policy will govern I. Records And Reports The Policyholder will furnish on our forms all information reasonably necessary to administer the Group Policy We have the right at all reasonable times to inspect the payroll and other records of the Policyholder which relate to insurance under the Group Policy J. Agency And Release Individuals selected by the Policyholder or by any Employer to secure coverage under the Group Policy or to perform their administrative function under it, represent and act on behalf of the person selecting them, and do not represent or act on behalf of Standard The Policyholder, Employer and such individuals have no authority to alter, expand or extend our liability or to waive, modify or compromise any defense or right we may have under the Group Policy The Policyholder and each Employer hereby release, hold harmless and indemnify Standard from any liability arising from or related to any negligence, error, omission, misrepresentation or dishonesty of any of them or their representatives, agents or employees. K. Notice Of Suit The Policyholder or Employer shall promptly give us written notice of any lawsuit or other legal proceedings arising under the Group Policy L. Entire Contract, Changes The Group Policy and the applications of the Policyholder constitute the entire contract between the parties A copy of the Policyholder's application is attached to the Group Policy when issued The Group Policy may be changed in whole or in part No change in the Group Policy will be valid unless it is approved in writing by one of our executive officers and given to the Policyholder for attachment to the Group Policy. No agent has authority to change the Group Policy, or to waive any of their provisions M Effect On Workers' Compensation, State Disability Insurance Printed 08/03/2005 - 26- 339619-B The coverage provided under the Group Policy is not a substitute for coverage under a workers' compensation or state disability income benefit law and does not relieve the Employer of any obligation to provide such coverage (NO DM LT PH OT 1 WA/LTDP2000% Printed 08/03/2005 - 27 - 339619-B