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Home My WebLink AboutES05-336 - Extension - Standard Insurance Company - 2012-2013 Merged Volunary Life Insurance & Core Life Insurance Contracts - 11/01/2012 Records M ern KENT Document WASHINGTON CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to City Clerks Office. All portions are to be completed. If you have questions, please contact City Clerk's Office. Vendor Name: i�) (A �o(YLIPI4A-)Lr Vendor Number: JD Edwards Number Contract Number: es05`^- This is assigned by City Clerk's Office Project Name: NOA t N NMRA:P=T Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment Contract ❑ Other: ' Contract Effective Date: Termination Date: Contract Renewal Notice (Days): Number of days required notice for terming ion or renewal or amendment Contract Manager: { epartment: Detail: (i.e. address, location, parcel number, tax id, etc.): S•Public\RecordsManagement\Forms\ContractCover\adcc7832 1 11/08 STANDARD INSURANCE COMPANY A Stock Life Insurance Company 900 SW Fifth Avenue Portland, Oregon 97204-1282 (503) 321-7000 GROUP LIFE INSURANCE POLICY Policyholder: City of Kent Policy Number: 339619-E Effective Date: November 1, 2012 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 Tune at the Policyholder's address. This policy includes an Accelerated Benefit. Death benefits will be reduced if an Accelerated Benefit is paid. The receipt of this benefit may be taxable and may affect your eligibility for Medicaid or other government benefits or entitlements. However, if you meet the definition of "terminally ill individual" according to the Internal Revenue Code Section 101, your Accelerated Benefit may be non-taxable. You should consult your personal tax and/or legal advisor before you apply for an Accelerated Benefit. 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 Prrnxleni Carpar atc cecrritlry GP190-I1FE/S399 Table of Contents COVERAGE FEATURES.............................................................................................. 1 GENERAL POLICY INFORMATION .............................................................. .. ......1 BECOMINGINSURED . ......... .... ........................................................................ 1 PREMIUM CONTRIBUTIONS. ........ . ..... ............. ............... ............................2 SCHEDULE OF INSURANCE ........... ..................................... . .................. .........3 REDUCTIONS IN INSURANCE ........ ................................... . . .............................5 OTHERBENEFITS ................................................................... ................ .......5 OTHER PROVISIONS.............................................................................................6 PREMIUM RATES AND RENEWALS . ....................................................... ............6 LIFE INSURANCE ........ ....... ........... .................... ............... . .................. ..............8 A. Insuring Clause ......... ................... . .. ................................... ...... ...............8 B. Amount Of Life Insurance.............. .. ........................ .................................. .8 C. Changes In Life Insurance............................................ ..................................8 D. Repatriation Benefit............. ..................... .................. ...................... ..........8 E. When Life Insurance Becomes Effective............................................................8 F. When Life Insurance Ends .. .........................................................................9 G Reinstatement Of Life Insurance.............. . ....................... ......................... 10 DEPENDENTS LIFE INSURANCE .......... .................................................................. 10 A. Insuring Clause ................................................. ...................................... 10 B. Amount Of Dependents Life Insurance....................................................... ... 10 C. Changes In Dependents Life Insurance............................................ .............10 D. Definitions For Dependents Life Insurance..... ...... ........................................ 10 E. Becoming Insured For Dependents Life Insurance..... ............................... .. 11 F When Dependents Life Insurance Ends . ..................... .............................. 12 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE.......... ........................... 12 A. Insuring Clause............................... ............................................................. 12 B. Definition Of Loss For AD&D Insurance......................................................... 12 C. Amount Payable............ .. . . ......................................................... ... . 12 D. Changes In AD&D Insurance. ................................................................... .. 12 E. AD&D Insurance Exclusions..................... .... .. . .................................... .. 13 F. Additional AD&D Benefits . ....................... .. .. . ................................ ........ 13 G. Becoming Insured For AD&D Insurance .......................................... .. .......... 14 HWhen AD&D Insurance Ends .. . ........................................ .......................... 15 ACTIVE WORK PROVISIONS..................................................................................... 15 PORTABILITY OF INSURANCE ............................ .................................................. 15 STRIKE CONTINUATION . ..... .. .. ......................... ................................................... 16 WAIVER OF PREMIUM... . ... ..................... ... .. . .......... ....................................... 17 ACCELERATED BENEFIT....... .. .... ......................................................................... 18 RIGHTTO CONVERT ............................................................................................... 19 CLAIMS .. .......... ........................... ... . . .................................... ... ................ .......21 ASSIGNMENT.......... ..... ...................... . . . ....................................... .. . 23 BENEFIT PAYMENT AND BENEFICIARY PROVISIONS............... .. ... 23 ALLOCATION OF AUTHORITY . ... . . .. .......................................... ........... ...........25 TIME LIMITS ON LEGAL ACTIONS ........................................ 26 INCONTESTABILITY PROVISIONS.. . ........................................ ..... ... .. ... . . .26 CLERICAL ERROR AND MISSTATEMENT..................................................................26 TERMINATION OR AMENDMENT OF THE GROUP POLICY......... ..............................27 DEFINITIONS. .. . ......... . . ............................................... ...............................27 POLICYHOLDER PROVISIONS..................... ............. ................................. ...... .. 29 i Index of Defined Terms Life Insurance, 28 Accelerated Benefit, 18 Loss, 12 Active Work, Actively At Work, 15 AD&D Insurance, 27 Maximum Conversion Amount, 6 Annual Earnings, 27 Member, 1 Automobile, 13 Minimum Participation, 7 Minimum Participation Number, 7 Beneficiary, 23 Minimum Participation Percentage(s), 7 Minimum Time Insured, 6 Child, 28 Contributory, 28 Noncontributory, 28 Conversion Period, 20 Notice of Rate Change, 7 Dependent, 10 Physician, 28 Dependents Life Insurance, 28 Policyholder, 1 Disabled, 28 Pregnancy, 28 Domestic Partner, 29 Premium Due Dates, 7 Premium Rates, 6 Eligibility Waiting Period, 28 Prior Plan, 29 Employer(s), 1 Proof Of Loss, 21 Evidence Of Insurability, 28 Qualifying Event, 20 Family Status Change, 2 Qualifying Medical Condition, 18 Grace Period, 7 Recipient, 24 Group Policy, 28 Right To Convert, 19 Group Policy Effective Date, 1 Group Policy Number, 1 Seat Belt System, 13 Guarantee Issue Amount (for Plan 2 Sickness, 29 Dependents Life Insurance), 2 Spouse, 29 Guarantee Issue Amount (for Plan 2), 2 Totally Disabled, 17 Initial Rate Guarantee Period, 7 Injury, 28 Waiting Period (for Waiver Of Premium), Insurance (for Accelerated Benefit), 19 17 Insurance (for Right to Convert), 20 Waiver Of Premium, 17 Insurance (for Waiver Of Premium), 17 War, 13 Leave Of Absence Period, 6 You, Your (for Right To Convert), 20 COVERAGE FEATURES This section contains many of the features of your group life insurance. Other provisions, including exclusions and limitations, 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-E Type of Insurance Provided: Life Insurance Yes Dependents Life Insurance: Yes Accidental Death And Dismemberment (AD&D) Insurance: Yes Policyholder: City of Kent Employer(s): City of Kent Group Policy Effective Date: November 1, 2012 Policy Issued in: Washington BECOMING INSURED To become insured for Life Insurance you must. (a) Be a Member; (b) Complete your Eligibility Waiting Period, and (c) Meet the requirements in Life Insurance and Active Work Provisions. The requirements for becoming insured for coverages other than Life Insurance are set out in the text Definition of Member: You are a Member if you are one of the following: 1. An elected Mayor currently in office or a regular full- time or part-time employee of the Employer who is regularly working at least 21 hours each week; or 2. A regular employee of the Employer working in a job share position who is regularly working at least 20 hours each week. You are not a Member if you are: 1. A temporary or seasonal employee. 2. A leased employee. 3. An independent contractor. 4. A full time member of the armed forces of any country. 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. Your Eligibility Waiting Period will be reduced by any continuous period as an employee of the Employer immediately prior to the date you become a Member. Printed 10/31/2012 - 1 - 339619-E Evidence Of Insurability: Required: a. For late application for Contributory insurance. b. For reinstatements if required. c. For Members and Dependents eligible but not insured under the Prior Plan. d. For any Plan 2 Life Insurance Benefit in excess of the Guarantee Issue Amount of $50,000 However, this requirement will be waived on the Group Policy Effective Date for an amount equal to the amount of additional life msuiance under the Prior Plan on the day before the Group Policy Effective Date, if you apply on or before the Group Policy Effective Date. e. For any Plan 2 Dependents Life Insurance Benefit for your Spouse in excess of the Guarantee Issue Amount of$10,000. However, this requirement will be waived on the Group Policy Effective Date for an amount equal to the amount of additional dependents life insurance under the Prior Plan on the day before the Group Policy Effective Date, if you apply on or before the Group Policy Effective Date. f. For any increase resulting from a plan or option change you elect. g. For becoming insured for any amount greater than the amount for which you or your Spouse were insured under the Prior Plan, if your or your Spouse's Evidence Of Insurability was not approved by us. Evidence Of Insurability is not required for a Child to become insured for Dependents Life Insurance. Certain Evidence Of Insurability Requirements Will Be Waived. Your insurance is subject to all other terms of the Group Policy. For a Family Status Change In the event of a Family Status Change certain Evidence Of Insurability requirements will be waived with respect to Plan 2 Dependents Life Insurance Benefits for your Spouse. However, we will not waive the Evidence Of Insurability requirements if your Spouse previously submitted Evidence Of Insurability that was not approved by us under any group policy issued by us to the Policyholder or covering your Employer. If your Spouse is eligible but not insured for Plan 2 Dependents Life Insurance, requirements a., c. and d. above will be waived if you apply for $10,000 of Plan 2 Dependents Life Insurance for your Spouse within 31 days of a Family Status Change. Family Status Change means a Change of Status as defined under your Employer's IRC Section 125 Cafeteria Plan. The change must be allowed by your Employer's IRC Section 125 Cafeteria Plan. PREMIUM CONTRIBUTIONS Life Insurance: Plan 1: Noncontributory Plan 2: Contributory Printed 10/31/2012 - 2 - 339619-E AD&D Insurance: Noncontributory Dependents Life Insurance: Spouse: Plan 1: Noncontributory Plan 2: Contributory Child: Plan 1: Noncontributory Plan 2: Contributory SCHEDULE OF INSURANCE SCHEDULE OF LIFE INSURANCE For you: Life Insurance Benefit: You will become insured under Plan 1 if you meet the requirements to become insured under the Group Policy. If you are insured under Plan 1, you may also become insured under Plan 2 if you meet the requirements to become insured under Plan 2 Life Insurance under the Group Policy. Plan 2 is a Contributory plan requiring premium contributions from Members. Plan 1 (basic): 1 times your Annual Earnings, rounded to the next higher multiple of $1, if not already a multiple of $1. The maximum amount is $50,000 and the minimum amount is $25,000. Plan 2 (additional): You may apply for Plan 2 Life Insurance in multiples of $10,000, from $10,000 to $300,000 However, the amount of your Plan 2 Life Insurance may not exceed 600%of your Annual Earnings. The Repatriation Benefit: The expenses incurred to transport your body to a mortuary near your primary place of residence, but not to exceed $5,000 or 10% of the Life Insurance Benefit, whichever is less. Dependents Life Insurance Benefit: For your Spouse: Plan 1 (basic): $5,000 Plan 2 (additional): You may apply for Dependents Life Insurance in multiples of$10,000 from 810,000 to $300,000. The amount of Dependents Life Insurance for your Spouse may not exceed 100% of the amount of your Life Insurance For your Child: Plan 1 (basic): $2,000 Plan 2 (additional)- You may elect one of the following options- Option 1• $2,000 Option 2 $5,000 Option 3: $10,000 Printed 10/31/2012 - 3 - 339619-E The amount of Dependents Life Insurance for your Child may not exceed 100% of the amount of V your Life Insurance. SCHEDULE OF AD&D INSURANCE For you: AD&D Insurance Benefit: The amount of your AD&D Insurance Benefit is equal to the amount of your Plan 1 Life Insurance Benefit The amount payable for certain Losses is less than 100% of the AD&D Insurance Benefit. See AD&D Table Of Losses. Seat Belt Benefit: The amount of the Seat Belt Benefit is the lesser of (1) $50,000 or (2) the amount of AD&D Insurance Benefit payable for loss of life. Career Adjustment Benefit: The tuition expenses for traimng incurred by your Spouse ,mthm 36 months after the date of your death, exclusive of board and room, books, fees, supplies and other expenses, but not to exceed $5,000 per year, or the cumulative total of $10,000 or 25% of the AD&D Insurance Benefit, whichever is less. Child Care Benefit: The total child care expense incurred by your Spouse within 36 months after the date of your death for all Children under age 13, but not to exceed $5,000 per year, or the cumulative total of S10,000 or 25% of the AD&D Insurance Benefit, whichever is less. Higher Education Benefit: The tuition expenses incurred per Child within 4 years after the date of your death at an accredited institution of higher education, exclusive of board and room, books, fees, supplies and other expenses, but not to exceed $5,000 per year, or the cumulative total of $20,000 or 25% of the AD&D Insurance Benefit, whichever is less. Public Transportation Benefit: The lesser of (1) $200,000; or (2) 100% of the amount of the AD&D Insurance Benefit otherwise payable for the Loss of your life. AD&D TABLE OF LOSSES The amount payable is a percentage of the AD&D Insurance Benefit in effect on the date of the accident and is determined by the Loss suffered as shown in the following table: Loss: Percentage Payable: a. Life 100% b. One hand, one foot or sight of one 50% eye c. Two or more of the Losses listed 100% in b. above No more than 100% of your AD&D Insurance will be paid for all Losses resulting from one accident. Printed 10/31/2012 - 4 - 339619-E REDUCTIONS IN INSURANCE Plan 1 (basic) Life and AD&D Insurance: If you reach an age shown below, the amount of insurance will be the amount determined from the Schedule Of Insurance, multiplied by the appropriate percentage below: Age Of Member Percentage 70 through 74 65% 75 or over 50% Plan 2 (additional) Life Insurance and Plan 2 (additional) Dependent Life Insurance for your Spouse: If you or your Spouse reaches an age shown below, the amount of insurance will be the amount in effect on the day before reaching age 70 multiplied by the appropriate percentage below: Age of Member/Spouse Percentage 70 through 74 65% 75 or over 50% OTHER BENEFITS Waiver Of Premium: Yes Accelerated Benefit: Yes Insurance Eligible For Portability Of Insurance: Life Insurance. Yes. The maximum amount of Life Insurance you may continue is the lesser of (1) the amount in effect on the date your employment terminates; or (2) $300,000. The minimum amount of Life Insurance you may continue is $25,000. Portability Premium Age-graded Rates Per Multiple Of$1,000 Per Month Age of Insured On Last January 1 Rate Under 30 $ .118 30 through 34 .125 35 through 39 164 40 through 44 266 45 through 49 .468 50 through 54 721 55 through 59 1.233 60 through 64 1.471 65 through 69 2 827 70 through 74 5.089 75 through 79 7.624 80 through 89 14.088 90 or above 35 584 Printed 10/31/2012 - 5 - 339619-E OTHER PROVISIONS Limits on Right To Convert if Group Policy terminates or is amended: Minimum Time Insured: 5 years Maximum Conversion Amount: $2,000 Leave Of Absence Period: 6 months Strike Continuation: Yes.The Strike Continuation premium percentage is 100% of the Premium Rate. Annual Earnings based on: Earnings in effect on your last full day of Active Work. PREMIUM RATES AND RENEWALS Premium Rates: Life Insurance: Plan 1: $0.210 monthly per$1,000 of Life Insurance Plan 2: Age of Insured On Monthly per$1,000 of Last January 1 Life Insurance Under 30 $ .086 30 through 34 .091 35 through 39 .119 40 through 44 .194 45 through 49 .340 50 through 54 .524 55 through 59 .897 60 through 64 1.070 65 through 69 2.056 70 through 74 3.701 75 through 79 5.545 80 or above 10.246 Dependents Life Insurance: Plan 1: $1 000 monthly per Member with one or more Dependents Printed 10/31/2012 - 6- 339619-E Plan 2. Spouse: Age of Insured On Monthly per$1,000 of Last January 1 Life Insurance Under 30 $ .086 30 through 34 .091 35 through 39 .119 40 through 44 .194 45 through 49 .340 50 through 54 .524 55 through 59 .897 60through 64 1.070 65 through 69 2.056 70 through 74 3.701 75 through 79 5 545 80 or above 10 246 Child- $0 200 monthly per$1,000 of Dependents Life Insurance AD&D Insurance: $0 040 monthly per $1,000 of AD&D Insurance Premium Due Dates: November 1, 2012 and the first day of each calendar month thereafter. Grace Period: 45 days Initial Rate Guarantee Period: November 1, 2012 to January 1, 2013 Notice of Rate Change- 60 days Minimum Participation: Life Insurance: Number: 10 insured Members Percentage: Plan 1 (basic): 100%of Members eligible for Plan 1 Plan 2 (additional): The greater of 10 insured Members or 20% of Members eligible for Plan 2 Dependents Life Insurance: Plan 1 (basic)- 100% Plan 2 (additional): 75% of insured Members with Dependents eligible for Plan 2 must elect to insure those Dependents Printed 10/31/2012 - 7 - 339619-E LIFE INSURANCE A. Insuring Clause If you die while insured for Life Insurance, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us. B. Amount Of Life Insurance See the Coverage Features for the Life Insurance schedule. C. Changes In Life Insurance 1. Increases You must apply in writing for any elective increase in your Life Insurance. Subject to the Active Work Provisions, an increase in your Life Insurance becomes effective as follows: a. Increases Subject To Evidence Of Insurability An increase in your Life Insurance subject to Evidence Of Insurability becomes effective on the date we approve your Evidence Of Insurability. b. Increases Not Subject To Evidence Of Insurability An increase in your Life Insurance not subject to Evidence Of Insurability becomes effective on: (i) The first day of the calendar month coinciding with or next following the date you apply for an elective increase or the date of change in your classification, age or Annual Earmngs. 3 (ii) The later of the date you apply or the date of the Family Status Change, if you apply within 31 days of a Family Status Change. 2. Decreases A decrease in your We Insurance because of a change in your classification, age or Annual Earnings becomes effective on the first day of the calendar month coinciding with or next following the date of the change Any other decrease in your Life Insurance becomes effective on the first day of the calendar month coinciding with or next following the date the Policyholder or your Employer receives your written request for the decrease. D. Repatriation Benefit The amount of the Repatriation Benefit is shown in the Coverage Features. We will pay a Repatriation Benefit if all of the following requirements are met. 1. A Ufe Insurance Benefit is payable because of your death. 2. You die more than 200 miles from your primary place of residence. 3. Expenses are incurred to transport your body to a mortuary near your primary place of residence. E. When Life Insurance Becomes Effective The Coverage Features states whether your Life Insurance is Contributory or Noncontributory. Printed 10/31/2012 - 8 - 339619-E Subject to the Active Work Provisions, your Life Insurance becomes effective as follows: 1. Life Insurance subject to Evidence Of Insurability Life Insurance subject to Evidence Of Insurability becomes effective on the date we approve your Evidence Of Insurability. 2. Life Insurance not subject to Evidence Of Insurability a. Noncontributory Life Insurance Noncontributory Life Insurance not subject to Evidence Of Insurability becomes effective on the date you become eligible b. Contributory Life Insurance You must apply in writing for Contributory Life Insurance and agree to pay premiums. Contributory Life Insurance not subject to Evidence Of Insurability becomes effective on (1) The date you become eligible if you apply on or before that date. (ii) The date you apply if you apply within 31 days after you become eligible. (in)The later of the date you apply or the date of the Family Status Change, if you apply within 31 days of a Family Status Change. Late application: Evidence Of Insurability is required if you apply more than 31 days after you become eligible 3. Takeover Provision a. 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 b. You must submit satisfactory Evidence Of Insurability to become insured for Life Insurance if you were eligible under the Prior Plan for more than 31 days but were not insured. F. When Life Insurance Ends Life Insurance ends automatically on the earliest of: 1. The date the last period ends for which a premium was paid for your Life Insurance; 2. The date the Group Policy terminates; 3. The date your employment terminates; and 4. The last day of the calendar month in which you cease to be a Member. However, if you cease to be a Member because you are working less than the required minimum number of hours, your Life Insurance will be continued with premium payment during the following periods, unless it ends under 1 through 3 above. a. While your Employer is paying you at least the same Annual Earnings paid to you immediately before you ceased to be a Member. b. While your ability to work is limited because of Sickness, Injury, or Pregnancy. c. During the first 60 days of a temporary layoff d. 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 e. During any other scheduled leave of absence approved by your Employer in advance and in writing and lasting not more than the period shown in the Coverage Features. Printed 10/31/2012 - 9 - 339619-E G. Reinstatement Of Life Insurance If your Life Insurance ends, you may become insured again as a new Member. However, 1 through 4 below will apply. 1. If your Life Insurance ends because you cease to be a Member, and if you become a Member again within 90 days, the Eligibility Waiting Period will be waived. 2. If your Life Insurance ends because you fail to make a required premium contribution, you must provide Evidence Of Insurability to become insured again. 3. If you exercised your Right To Convert, you must provide Evidence Of Insurability to become insured again. 4. If your Life 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. DWPAT_FAM STAT) LI LF.WA.3X DEPENDENTS LIFE INSURANCE A. Insuring Clause If your Dependent dies while insured for Dependents Life Insurance, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us. B. Amount Of Dependents Life Insurance See the Coverage Features for the amount of your Dependents Life Insurance. C. Changes In Dependents Life Insurance 1. Increases You must apply in writing for any elective increase in your Dependents Life Insurance. Subject to the Active Work Provisions, an increase in your Dependents Life Insurance becomes effective as follows: a. Increases Subject To Evidence Of Insurability An increase in your Dependents Life Insurance subject to Evidence Of Insurability becomes effective on the date we approve that Dependent's Evidence Of Insurability b. Increases Not Subject To Evidence Of Insurability An increase in your Dependents Life Insurance not subject to Evidence Of Insurability becomes effective on the first day of the calendar month coinciding with or next following the date you apply for an elective increase An increase in your Dependents Life Insurance because of an increase in your Life Insurance becomes effective on the date your Life Insurance increases. 2. Decreases A decrease in your Dependents Life Insurance because of a decrease in your Life Insurance becomes effective on the date your Life Insurance decreases. D. Definitions For Dependents Life Insurance Dependent means your Spouse or Child. Dependent does not include a person who is a full-time member of the armed forces of any country. Printed 10/31/2012 - 10 - 339619-E E Becoming Insured For Dependents Life Insurance 1. Eligibility You become eligible to insure your Dependents on the later of: a. The date you become eligible for Life Insurance; and b. The date you first acquire a Dependent. A Member may not be insured as both a Member and a Dependent. A Child may not be insured by more than one Member. 2. Effective Date The Coverage Features states whether your Dependents Life Insurance is Contributory or Noncontributory. Subject to the Active Work Provisions, your Dependents Life Insurance becomes effective as follows: a. Dependents Life Insurance Subject To Evidence Of Insurability Dependents Life Insurance subject to Evidence Of Insurability becomes effective on the later of: 1. The date your Life Insurance becomes effective; and 2. The first day of the calendar month coinciding with or next following the date we approve the Dependent's Evidence Of Insurability. b. Dependents Life Insurance Not Subject To Evidence Of Insurability 1. Noncontributory Dependents Life Insurance Noncontributory Dependents Life Insurance not subject to Evidence Of Insurability becomes effective on the later of: i The date your Life Insurance becomes effective; and ii. The date you first acquire a Dependent. 2. Contributory Dependents Life Insurance You must apply in writing for Contributory Dependents Life Insurance and agree to pay premiums. Contributory Dependents Life Insurance not subject to Evidence Of Insurability becomes effective on the latest of: i. The date your Life Insurance becomes effective if you apply on or before that date; ii. The date you become eligible to insure your Dependents if you apply on or before that date, and iii. The date you apply if you apply within 31 days after you become eligible. Late Application: Evidence Of Insurability is required for each Dependent if you apply more than 31 days after you become eligible. c. While your Dependents Life Insurance is in effect, each new Child becomes insured immediately d. Takeover Provision Each Dependent who was eligible under the Prior Plan for more than 31 days but Nvas not insured must submit satisfactory Evidence Of Insurability to become insured for Dependents Life Insurance Printed 10/31/2012 - 11 - 339619-E F. When Dependents Life Insurance Ends Dependents Life Insurance ends automatically on the earliest of: 1. Five months after you die (no premiums will be charged for your Dependents Life Insurance during this time); 2. The date your Life Insurance ends, 3. The date the Group Policy terminates, or the date Dependents Life Insurance terminates under the Group Policy, 4. The date the last period ends for which you made a premium contribution, if your Dependents Life Insurance is Contributory; 5. For your Spouse, the date of your divorce or termination of your Domestic Partner relationship; 6. For any Dependent, the date the Dependent ceases to be a Dependent; and 7. For a Child who is Disabled, 90 days after we mad you a request for proof of Disability, if proof is not given. [SP&CH_DOW U.DL.OT.4 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE A. Insuring Clause If you have an accident, while insured for AD&D Insurance, and the accident results in a Loss, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us. B. Definition Of Loss For AD&D Insurance Loss means loss of life, hand, foot, sight which meets all of the following requirements: 1. Is caused solely and directly by an accident. 2. Occurs independently of all other causes. 3. Occurs within 365 days after the accident. 4. With respect to Loss of life, is evidenced by a certified copy of the death certificate. 5. With respect to all other Losses, is certified by a Physician in the appropriate specialty as determined by us. With respect to a hand or foot, Loss means actual and permanent severance from the body at or above the wrist or ankle joint With respect to sight, Loss means entire, uncorrectable, and irrecoverable loss of sight. C. Amount Payable See Coverage Features for the AD&D Insurance schedule. The amount payable is a percentage of the AD&D Insurance Benefit in effect on the date of the accident and is determined by the Loss suffered. See AD&D Table Of Losses in the Coverage Features. D. Changes In AD&D Insurance Changes in your AD&D Insurance will become effective on the date your Life Insurance changes. Printed 10/31/2012 - 12 - 339619-E E. AD&D Insurance Exclusions No AD&D Insurance benefit is payable if the accident or Loss is caused or contributed to by any of the following: 1. War or 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. Suicide or other intentionally self-inflicted Injury, while sane or insane. 3 Committing or attempting to commit an assault or felony, or actively participating in a violent disorder or riot. Actively participating does not include being at the scene of a violent disorder or riot while performing your official duties 4. The voluntary use or consumption of any poison, chemical compound, alcohol or drug, unless used or consumed according to the directions of a Physician. 5. Sickness or Pregnancy but not including complications of pregnancy, existing at the time of the accident. 6. Heart attack or stroke. 7. Medical or surgical treatment for any of the above. F. Additional AD&D Benefits Seat Belt Benefit The amount of the Seat Belt Benefit is shown in the Coverage Features. We will pay a Seat Belt Benefit if all of the following requirements are met: 1. You die as a result of an Automobile accident for which an AD&D Insurance Benefit is payable for Loss of your Life, and 2. You are wearing and properly utilizing a Seat Belt System at the time of the accident, as evidenced by a police accident report Seat Belt System means a properly installed combination lap and shoulder restraint system that meets the Federal Vehicle Safety Standards of the National Highway Traffic Safety Administration Seat Belt System will include a lap belt alone, but only if the Automobile did not have a combination lap and shoulder restraint system when manufactured. Seat Belt System does not include a shoulder restraint alone. Automobile means a motor vehicle licensed for use on public highways Career Adjustment Benefit The amount of the Career Adjustment Benefit is shown in the Coverage Features. We will pay a Career Adjustment Benefit to your Spouse if all of the following requirements are met: 1. You are insured for AD&D Insurance under the Group Policy. 2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss of your life. 3. Your Spouse is, within 36 months after the date of your death, registered and in attendance at an accredited institution of higher education or trades training program for the purpose of obtaining employment or increasing earnings No Career Adjustment Benefit will be paid if you have no surviving Spouse. Printed 10/31/2012 - 13 - 339619-E Child Care Benefit The amount of the Child Care Benefit is shown in the Coverage Features. We will pay a Child Care Benefit to your Spouse if all of the following requirements are met: 1. You are insured for AD&D Insurance under the Group Policy. 2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss of your life. 3. Your Spouse pays a licensed child care provider who is not a member of your family for child care provided to your Child(ren) under age 13 within 36 months of your death 4. The child care is necessary in order for your Spouse to work or to obtain training for work or to increase earnings. No Child Care Benefit will be paid if you have no surviving Spouse. Higher Education Benefit The amount of the Higher Education Benefit is shown in the Coverage Features. We will pay a Higher Education Benefit to your Child if all of the following requirements are met: 1. You are insured for AD&D Insurance under the Group Policy. 2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss of your life. 3. Your Child is, within 12 months after the date of your death, registered and in full-time attendance at an accredited institution of higher education beyond high school. The Higher Education Benefit will be paid to each Child who meets the requirements of item 3 above, for a maidmum of 4 consecutive years beginning on the date of your death No Higher Education Benefit will be paid if there is no Child eligible to receive it Public Transportation Benefit The amount of the Public Transportation Benefit is shown in the Coverage Features. We will pay a Public Transportation Benefit if all of the following requirements are met: 1. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss of your life. 2. The accident occurs while you are riding as a fare-paying passenger on Public Transportation. Public Transportation means a public passenger conveyance operated by a licensed common carrier for the transportation of the general public for a fare and operating on regular passenger routes with a definite schedule of departures and arrivals. G. Becoming Insured For AD&D Insurance 1. Eligibility You become eligible for AD&D Insurance on the date your Life Insurance is effective. 2. Effective Date Printed 10/31/2012 - 14 - 339619-E The Coverage Features states whether AD&D Insurance is Contributory or Noncontributory. Subject to the Active Work Provisions, AD&D Insurance becomes effective as follows: a. Noncontributory AD&D Insurance Noncontributory AD&D Insurance becomes effective on the date you become eligible. b. Contributory AD&D Insurance You must apply in writing for Contributory AD&D Insurance and agree to pay premiums. Contributory AD&D Insurance becomes effective on the later of. (i) The date you become eligible if you apply on or before that date (ii) The first day of the calendar month coinciding with or next following the date you apply, if you apply after you become eligible. H. When AD&D Insurance Ends AD&D Insurance ends automatically on the earlier of: 1. The date your Life Insurance ends. 2. The date your Waiver Of Premium begins. 3. The date AD&D Insurance terminates under the Group Policy. 4. The date the last period ends for which a prenuum was paid for your AD&D Insurance. (FB NO DEP REQD_PART XP BEN PKG-ALCOHL EXCL-SEAT AIR COMBO) LLAD WA 5 ACTIVE WORK PROVISIONS If you are incapable of Active Work because of Sickness, Injury or Pregnancy on the day before the scheduled effective date of your insurance or an increase in your insurance, your insurance or increase 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 the material duties of your own occupation at your Employer's usual place of business. You will also meet the Active Work requirement if: 1. You were absent from Active Work because of a regularly scheduled day off, holiday, or vacation day; 2. You were Actively At Work on your last scheduled work day before the date of your absence; and 3. You were capable of Active Work on the day before the scheduled effective date of your insurance or increase in your insurance. LLAw.OT.I PORTABILITY OF INSURANCE A. Portability Of Insurance You may continue your Insurance if your employment with your Employer terminates, subject to the following: 1. The amount of any Insurance to be continued must have been continuously in effect for at least 12 consecutive months on the date your employment terminates In computing the 12 consecutive month period, we will include tune insured under the Prior Plan. 2 You must be able to perform with reasonable continuity the material duties of at least one gainful occupation for which you are reasonably fitted by education, training and experience on the date your employment terminates. Printed 10/31/2012 - 15 - 339619-E 3. Termination of your employment is not due to retirement. If you do not continue your Life Insurance, you may not continue any other Insurance. Insurance continued under Waiver Of Premium may not be continued under this provision. Insurance means your Life Insurance and if you continue your Lire Insurance, includes the other insurance eligible for portability under the provision as shown in the Coverage Features. B. Application And Premium Payment To continue Insurance under this provision you must apply in writing and pay the first Portability Premium to us within 31 days after the date your employment terminates The Portability Premium Rate is shown in the Coverage Features. C. Amount Of Insurance The minimum and maximum amounts of Insurance eligible for portability are shown in the Coverage Features. The amount of Insurance you continue under this provision cannot be increased. The amount of your Insurance will be reduced or terminated according to the terms of the Group Policy in effect on the date your employment terminates, D. When Insurance Ends Insurance continued under this provision ends automatically on the earlier of: 1. The date it would otherwise end under the Group Policy. 2. The date you become insured under any other group life insurance plan. E. Group Policy Provisions Except as provided above, Insurance continued under this provision is subject to all other terms of the Group Policy With respect to any notice you are required to provide to the Policyholder or your Employer under other provisions of the Group Policy, such notice must be provided to us while your Insurance is continued. LL PY OT 2X STRIKE CONTINUATION Insurance may be continued for up to 6 months while you are absent from Active Work because of a strike, lockout or other general work stoppage caused by a labor dispute. Rules 1 through 4 below will apply. 1. When your compensation is suspended or terminated because of a work stoppage, your Employer will immediately notify you in writing of your rights under this provision Your Employer will mail the notice to you at your last address on record with the Employer. 2. You must pay the entire premium for your insurance, including the Employer's share, if any, to your Employer on or before each Premium Due Date. 3. The premiums for your insurance during the work stoppage will equal a percentage of the premium rate in effect on the date the work stoppage began (see Coverage Features). We may change premium rates during the work stoppage according to the terms of the Group Policy. 4. Insurance continued under this provision will end on the earliest of. a. Any Premium Due Date if you fail to make the required premium contribution to your Employer on or before that date. b. The date you have been absent from Active Work for 6 months. Printed 10/31/2012 - 16 - 339619-E c. On the date you begin full-tune employment with another employer. d. At our option, on any Premium Due Date if less than 75% of the Members eligible to continue insurance under this provision make the required premium payment to the Employer u sx ar.i WAIVER OF PREMIUM A. Waiver Of Premium Benefit Insurance will be continued without payment of premiums while you are Totally Disabled if: 1. You become Totally Disabled while insured under the Group Policy and under age 60; 2. You complete your Waiting Period, and 3. You give us satisfactory Proof Of Loss. We may have you examined at our expense at reasonable intervals. Any such examination will be conducted by specialists of our choice. B. Definitions For Waiver Of Premium 1. Insurance means all your insurance under the Group Policy, except AD&D Insurance. 2. Totally Disabled means that, as a result of Sickness, accidental Injury, or Pregnancy, you are unable to perform with reasonable continuity the material duties of any gainful occupation for which you are reasonably fitted by education, training and experience. 3. Waiting Period means the 180 consecutive day period beginning on the date you become Totally Disabled. Waiver Of Premium begins when you complete the Waiting Period. C. Premium Payment Premium payment must continue until the later of: 1. The date you complete your Waiting Period; and 2. The date we approve your claim for Waiver Of Premium. D. Refund Of Premiums We will refund up to 12 months of the premiums that were paid for Insurance after the date you become Totally Disabled. E. Amount Of Insurance The amount of Insurance eligible for Waiver Of Premium is the amount in effect on the day before you become Totally Disabled. However, the following will apply. 1. If you become insured under a group life insurance plan that replaces the Group Policy while you are eligible for Waiver Of Premium, any death benefit payable under the Group Policy will be reduced by the amount payable under the replacement group life insurance plan 2. If you receive an Accelerated Benefit, Insurance will be reduced according to the Accelerated Benefit provision F. Effect Of Death During The Waiting Period If you die during the Waiting Period and are otherwise eligible for Waiver Of Premium, the Waiting Period will be waived. Printed 10/31/2012 - 17 - 339619-E G. Termination Or Amendment Of The Group Policy Insurance will not be affected by termination or amendment of the Group Policy after you become Totally Disabled. H. When Waiver Of Premium Ends Waiver Of Premium ends on the earliest of: 1. The date you cease to be Totally Disabled; 2. 90 days after the date we mall you a request for additional Proof Of Loss, if it is not given; 3. The date you fall to attend an examination or cooperate with the examiner; 4. With respect to the amount of Insurance which an insuied has converted, the effective date of the individual life insurance policy issued to the insured. (ELIG 60_NO RED) LI WP.ar2 ACCELERATED BENEFIT A. Accelerated Benefit If you qualify for Waiver Of Premium and give us satisfactory proof of having a Qualifying Medical Condition while you are 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 eligible. If your Insurance is scheduled to end within 24 months following the date you apply for the Accelerated Benefit, you will not be eligible for the Accelerated Benefit Qualifying Medical Condition means you are terminally ill as a result of an illness or physical condition which is reasonably expected to result in death within 24 months. We may have you examined at our expense in connection with your 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 75% of your Insurance. The maximum Accelerated Benefit is 8500,000. The minimum Accelerated Benefit is $5,000 or 10% of your Insurance whichever is greater. If the amount of your Insurance is scheduled to reduce within 24 months following the date you apply for the Accelerated Benefit, your Accelerated Benefit will be based on the reduced amount. The Accelerated Benefit will be paid to you once in your lifetime in a lump sum. If you recover from your Qualifying Medical Condition after receiving an Accelerated Benefit, we will not ask you for a refund. D. Effect On Insurance And Other Benefits For any purpose other than premium payment, the amount of your Insurance after payment of the Accelerated Benefit will be the greater of the amounts in (1) and (2) below, however, if you assign your rights under the Group Policy, the amount of your Insurance will be the amount in (2) below. (1) 10% of the amount of your Insurance as if no Accelerated Benefit had been paid; or Printed 10/31/2012 - 18 - 339619-E (2) The amount of your Insurance as if no Accelerated Benefit had been paid; minus The amount of the Accelerated Benefit; minus 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 The amount of your AD&D Insurance, if any, is not affected by payment of the Accelerated Benefit. AD&D is not continued under Waiver Of Premium. Note: If you assign your rights under the Group Policy, the amount of your Insurance after payment of the Accelerated Benefit will be the amount in (2) above. E. Exclusions No Accelerated Benefit will be paid if: 1. All or part of your Insurance must be paid to your Child(ren), or your Spouse or former Spouse as part of a court approved divorce decree, separate maintenance agreement, or property settlement agreement. 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 Benefit 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 Benefit under the Group Policy. G. Resolution Of Disputes Over A Qualifying Medical Condition Pursuant to "The Washington Regulation on Accelerated Life Insurance Benefits" (WAC 284-26-600 through WAC 284-23-730), you may have the right to mediation or binding arbitration of any dispute over whether you have incurred a Qualifying Medical Condition LI.ABMA.5 RIGHT TO CONVERT A. Right To Convert You may buy an individual policy of life insurance without Evidence Of Insurability ifi: 1. Your Insurance ends or is reduced due to a Qualifying Event, and 2. You apply in wnting and pay us the first premium during the Conversion Period. Printed 10/31/2012 - 19 - 339619-E Except as limited under C. Limits On Right To Convert, the maximum amount you have a Right To Convert is the amount of your Insurance which ended. B. Definitions For Right To Convert 1. Conversion Period means the 31-day period after the date of any Qualifying Event. 2. Insurance means all your insurance under the Group Policy, including insurance continued under Waiver Of Premium, but excluding AD&D Insurance. 3. Qualifying Event means termination or reduction of your Insurance for any reason except: a. The Member's failure to make a required premium contribution. b. Payment of an Accelerated Benefit. 4. You and your mean any person insured under the Group Policy. C. Limits On Right To Convert If your Insurance ends or is reduced because of termination or amendment of the Group Policy, 1 and 2 below will apply 1. You may not convert Insurance which has been in effect for less than the Minimum Time Insured. See Coverage Features. 2. The maximum amount you have a Right To Convert is the lesser of: a. The amount of your Insurance which ended, minus any other group life insurance for which you become eligible during the Conversion Period, and b. The Maximum Conversion Amount See Coverage Features. D. The Individual Policy You may select any form of individual life insurance policy we issue to persons of your age, except: 1. A term insurance policy; 2. A universal life policy; 3. A policy with disability, accidental death, or other additional benefits; or 4. A policy in an amount less than the minimum amount we issue for the form of life insurance you select. The individual policy of life insurance will become effective on the day after the end of the Conversion Period. We will use our published rates for standard risks to determine the premium. The time periods contained in the incontestability provision of the individual policy of life insurance will be credited with the last continuous period you were insured under the Group Policy. y E. Death During The Conversion Period If you die during the Conversion Period, we will pay a death benefit equal to the maximum amount you had a Right To Convert, whether or not you applied for an individual policy. The benefit will be paid according to the Benefit Payment And Beneficiary Provisions u ac wA.1 Printed 10/31/2012 - 20 - 339619-E CLAIMS A. Filing A Clain Claims should be filed on our forms. If we do not provide our forms within 15 days after they are requested, the claim may be submitted in a letter to us B. Time Limits On Filing Proof Of Loss Proof Of Loss must be provided within 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. Proof Of Loss for Waiver Of Premium must be provided within 12 months after the end of the Waiting Period We will require further Proof Of Loss at reasonable intervals, but not more often than once a year after you have been continuously Totally Disabled for two years. If Proof Of Loss is filed outside these time limits, the claim will be denied. These limits will not apply while the Member or Beneficiary lacks legal capacity. C. Proof Of Loss Proof Of Loss means written proof that a loss occurred: 1. For which the Group Policy provides benefits, 2. Which is not subject to any exclusions; and 3. Which meets all other conditions for benefits. Proof Of Loss includes any other information we may reasonably require in support of a claim. Proof Of Loss must be m writing and must be provided at the expense of the claimant No benefits will be provided until we receive Proof Of Loss satisfactory to us. D. Investigation Of Claim We may have you examined at our expense at reasonable intervals. Any such examination will be conducted by specialists of our choice. We may have an autopsy performed at our expense, except where prohibited by law. E. Time Of Payment We will pay benefits within 60 days after Proof Of Loss is satisfied. F. Notice Of Decision On Claim We will evaluate a claim for benefits promptly after we receive it. With respect to all claims except Waiver Of Premium claims (or other benefits based on disability), within 90 days after we receive the claim we will send the claimant. (a) a written decision on the claim; or (b) a notice that we are extending the period to decide the claim for an additional 90 days With respect to Waiver Of Premium claims (or other benefits based on disability), within 45 days after we receive the claim we will send the claimant (a) a written decision on the claim; or (b) a notice that we are extending the period to decide the claim for 30 days Before the end of this extension period we will send the claimant. (a) a written decision on the Waiver Of Prenuum claim (or other benefits based on disability), or (b) a notice that we are extending the period to decide the claim for an additional 30 days. If an extension is due to the claimant's failure to provide information necessary to decide the Waiver Of Premium claim (or other benefits based on disability), the extended time period for deciding the claim will not begin until the claimant provides the information or otherwise responds. If we extend the period to decide the claim, we will notify the claimant of the following- (a) the reasons for the extension, (b) when we expect to decide the claim (c) an explanation of the Printed 10/31/2012 - 21 - 339619-E standards on 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, the claimant will have 45 days to provide the information. If the claimant does not provide the requested information within 45 days, we may decide the claim based on the information we have received. If we deny any part of the claim,we will send the claimant a written notice of denial containing: 1. The reasons for our decision. 2. Reference to the parts of the Group Policy on which our decision is based. 3. A description of any additional information needed to support the claim. 4. Information concerning the claimant's right to a review of our decision. G. Review Procedure If all or part of a claim is denied, the claimant may request a review. The claimant must request a review in writing: 1. Within 180 days after receiving notice of the denial of a claim for Waiver Of Premium (or other benefits based on disability); 2. Within 60 days after receiving notice of the denial of any other claim. The claimant may send us written comments or other items to support the claim. The claimant may review and receive copies of any non-privileged information that is relevant to the request for review. There will be no charge for such copies. Our review will include any written comments or other items the claimant submits to support the claim. We will review the claim promptly after use receive the request With respect to all claims except Waiver Of Premium claims (or other benefits based on disability), within 60 days after we receive the request for review we will send the claimant- (a) a written decision on review; or (b) a notice that we are extending the review period for 60 days. With respect to Waiver Of Premium claims (or other benefits based on disability), within 45 days after we receive the request for review we will send the claimant: (a) a written decision on review, or (b) a notice that we are extending the review period for 45 days. If an extension is due to the claimant's failure to provide information necessary to decide the claim on review, the extended time period for review of the claim will not begin until the claimant provides the information or otherwise responds. If ive extend the review period, we will notify the claimant of the following: (a) the reasons for the extension, (b) when we expect to decide the claim on review, and (c) any additional information we need to decide the claim. If we request additional information, the claimant will have 45 days to provide the information. If the claimant does not provide the requested information within 45 days, we may conclude our review of the claim based on the information we have received. With respect to Waiver Of Premium claims (or other benefits based on disability), 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 demal 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. The claimant may request the names of medical or vocational experts -%vho provided advice to us about a claim for Waiver Of Premium (or other benefits based on disability). If we deny any part of the claim on review, the claimant will receive a written notice of denial containing: Printed 10/31/2012 - 22 - 339619-E 1. The reasons for our decision. 2. Reference to the parts of the Group Policy on which our decision is based. 3. Information concerning the claimant's right to receive, free of charge, copies of non-privileged documents and records relevant to the claim. (2ND REV PUB WRDG_NEW WOP WRDG) LI.CL OT.B ASSIGNMENT The rights and benefits under the Group Policy cannot be assigned. LI.A9.OT.1 BENEFIT PAYMENT AND BENEFICIARY PROVISIONS A. Payment Of Benefits 1. Except as provided in item 5 below, benefits payable because of your death will be paid to the Beneficiary you name. See B through E of this section. 2. AD&D Insurance benefits payable for Losses other than Loss of Life will be paid to the person who suffers the Loss for which benefits are payable. Any such benefits remaining unpaid at that person's death will be paid according to the provisions for payment of a death benefit. 3. The benefits below will be paid to you if you are living a. AD&D Insurance benefits payable because of the death of your Dependent. b. Dependents Life Insurance benefits. c. Accelerated Benefits. 4. Dependents Life Insurance benefits and AD&D Insurance benefits payable because of the death of your Dependent which are unpaid at your death will be paid in equal shares to the first surviving class of the classes below. a. The children of the Dependent. b. The parents of the Dependent c. The brothers and sisters of the Dependent. d. Your estate. 5. Additional Benefits will be paid as follows. The Child Care Benefit will be paid to your surviving Spouse. No Child Care Benefit will be paid if you have no Spouse. The Career Adjustment Benefit will be paid to your Spouse. No Career Adjustment Benefit will be paid if you have no Spouse. The Higher Education Benefit will be paid to each eligible Child. No Higher Education Benefit will be paid if there is no Child eligible to receive it The Repatriation Benefit will be paid to the person who incurs the transportation expenses. B. Naming A Beneficiary Beneficiary means a person you name to receive death benefits. You may name one or more Beneficiaries. If you name two or more Beneficiaries in a class: Printed 10/31/2012 - 23 - 339619-E 1. Two or more surviving Beneficiaries will share equally, unless you provide for unequal shares. 2. If you provide for unequal shares in a class, and two or more Beneficiaries in that class survive, we will pay each surviving Beneficiary his or her designated share. Unless you provide otherwise, we will then pay the share(s) otherwise due to any deceased Beneficiary(ies) to the surviving Beneficiaries pro rata based on the relationship that the designated percentage or fractional share of each surviving Beneficiary bears to the total shares of all surviving Beneficiaries. 3. If only one Beneficiary in a class survives, we will pay the total death benefits to that Beneficiary. You may name or change Beneficiaries at any time without the consent of a Beneficiary. Your Beneficiary designation must be the same for Life Insurance and AD&D Insurance death benefits. You may name or change Beneficiaries in writing. Writing includes a form signed by you; or a verification from'us, or our designated agent, the Policyholder, the Policyholders designated agent, the Employer, or the Employer's designated agent of an electronic or telephonic designation made by you Your designation: 1. Must be dated; 2. Must be delivered to us, our designated agent, the Policyholder, the Policyholder's designated agent, the Employer, or the Employer's designated agent; during your lifetime. 3. Must relate to the insurance provided under the Group Policy; and 4. Will take effect on the date it is delivered or, if a telephonic or electronic designation, verified by us, our designated agent, the Policyholder, the Policyholder's designated agent, the Employer, or the Employer's designated agent. If we approve it, a designation, which meets the requirements of a Prior Plan, will be accepted as your Beneficiary designation under the Group Policy. C. Simultaneous Death Provision If a Beneficiary or a person in one of the classes listed in item D. No Surviving Beneficiary dies on the same day you die, or -within 15 days thereafter, benefits will be paid as if that Beneficiary or person had died before you, unless Proof Of Loss -with respect to your death is delivered to us before the date of the Beneficiary's death. D. No Surviving Beneficiary If you do not name a Beneficiary, or if you are not survived by one, benefits will be paid in equal shares to the first surviving class of the classes below. 1. Your Spouse (See Definitions) 2. Your children. 3. Your parents. 4. Your brothers and sisters. 5. Your estate. E Methods Of Payment Recipient means a person who is entitled to benefits under this Benefit Payment and Beneficiary Provisions section. Printed 10/31/2012 - 24 - 339619-E 1. Lump Sum If the amount payable to a Recipient is less than $25,000, we will pay it in a lump sum. 2. Standard Secure Access Checking Account If the amount payable to a Recipient is $25,000, or more, we will deposit it into a Standard Secure Access checking account which: a. Bears interest at a rate equal to the 13-week Treasury Bill (T-Bill) auction rate, but not to exceed 5%; b. Is owned by the Recipient; c. Is subject to the terms and conditions of a confirmation certificate which will be given to the Recipient; and d. Is fully guaranteed by us. 3. Installments Payment to a Recipient may be made in installments if: a. The amount payable is$25,000 or more; b. The Recipient chooses; and c. We agree. To the extent permitted by law, the amount payable to the Recipient will not be subject to any legal process or to the claims of any creditor or creditor's representative. (FB-REPAT_ELECT/TEL DESIG_Wrf H DEP SP-WITH REV SSA-SPOUSE DEF TERM-THIRD PARTY DESIG) U.M.0T.6 ALLOCATION OF AUTHORITY Except for those functions which the Group Policy specifically reserves to the Policyholder,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. Amount of benefits payable; d 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. LI.AL.OTA Printed 10/31/2012 - 25 - 339619-E TIME LIMITS ON LEGAL ACTIONS No action at law or in equity may be brought until 60 days after we have been given 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. u.TL.OT.i INCONTESTABILITY PROVISIONS A. Incontestability Of Insurance Any statement made to obtain or to increase insurance is a representation and not a warranty. No misrepresentation will be used to reduce or deny a claim 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 We will not use a misrepresentation to reduce or deny a claim after the insured's insurance has been in effect for two years during the lifetime of the insured. B. Incontestability Of Group Policy Any statement made by the Policyholder or Employer to obtain the Group Policy is a representation and not a warranty. No misrepresentation by the Policyholder or 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. LI IN OT.2 CLERICAL ERROR 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; or 3. Continue insurance under the Group Policy otherwise validly terminated. B. The Policyholder and your Employer act on their own behalf as your agent, and not as our agent. 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: Printed 10/31/2012 - 26 - 339619-E 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. LLCE.OT.2 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. Any such change or amendment of the Group Policy may apply to current or future Members or to any, separate classes or groups thereof. LI.TAOT.I DEFINITIONS AD&D Insurance means accidental death and dismemberment insurance, if any, under the Group Policy. Annual Earnings means your annual rate of earnings from your Employer. Your Annual Earnings will be based on your earnings in effect on your last full day of Active Work unless a different date applies (see the Coverage Features). Annual 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), or 457 deferred compensation arrangement; or b. An executive nonqualified deferred compensation arrangement. 2. Shift differential pay 3. Amounts contributed to your fringe benefits according to a salary reduction agreement under an IRC Section 125 plan. Annual Earnings does not include: 1. Bonuses. 2. Commissions. 3. Overtime pay. 4. Stock options or stock bonuses. 5. Your Employer's contributions on your behalf to any deferred compensation arrangement or pension plan Printed 10/31/2012 - 27 - 339619-E 6. Any other extra compensation. Child means: 1. Your unmarried child from live birth through age 20 (through age 24 if a registered student in full time attendance at an accredited educational institution); or 2. Your unmarried child who meets either of the following requirements: a. The child is insured under the Group Policy and, on and after the date on which insurance would otherwise end because of the Child's age, is continuously Disabled. b. The child was insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy and was Disabled on that day, and is continuously Disabled thereafter. Child includes any of the following, if they otherwise meet the definition of Child: 1. Your adopted child; or ii. Your stepchild and the child of your Spouse, if living in your home, Your child is Disabled if your cluld is: 1. Continuously incapable of self-sustaining employment because of mental retardation or physical handicap; and 2. Chiefly dependent upon you for support and maintenance, or institutionalized because of mental retardation or physical handicap. You must give us proof your Child is Disabled on our forms within 31 days after a) the date on which insurance would otherwise end because of the Child's age or b) the effective date of your Employer's coverage under the Group Policy if your child is Disabled on that date. At reasonable intervals thereafter, we may require further proof, and have your Child examined at our expense. Contributory means you pay all or part of the prenuum for insurance. Dependents Life Insurance means dependents life insurance, if any, under the Group Policy. Eligibility Waiting Period means the period you must be a Member before you become eligible for insurance. See Coverage Features. Evidence Of Insurability means an applicant must: 1. Complete and sign our medical history statement; 2. Sign our form authorizing us to obtain information about the applicant's health; 3. Undergo a physical examination, if required by us,which may include blood testing; and 4. Provide any additional information about the applicant's msurabihty that we may reasonably require. Group Policy means the group life insurance policy issued by us to the Policyholder and identified by the Group Policy Number. Injury means an injury to your body. Life Insurance means life insurance under the Group Policy. Noncontributory means the Policyholder or Employer pays the entire premium for insurance. 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 10/31/2012 - 28 - 339619-E Prior Plan means your Employer's group life insurance plan in effect on the day before the effective date of your Employer's coverage under the Group Policy and which is replaced by the Group Policy. Sickness means your sickness, illness, or disease Spouse means: 1. A person to whom you are legally married; or 2. Your Domestic Partner. Your Domestic Partner means an individual recognized as such under applicable law. For purposes of insurance under the Group Policy, Spouse does not include a person-%vho is a full- time member of the armed forces of any country or a person from whom you are divorced or from whom you have terminated a Domestic Partner relationship (REG NO COM_NO STOCK-DOM STAT) LI DF.WA.5X 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 the Coverage Features. B. Contributions From Members The Policyholder determines the amount, if any, of each Members contribution toward the cost of insurance under the Group Policy. C. Changes In Premium Rates We may change Premium Rates when 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; or 2. Factors material to underwriting the risk we assumed under the Group Policy, including, but not limited to, number of persons insured, age, Annual Earnings, gender and occupational classification, change by 25% or more; or 3. We and the Policyholder mutually agree to change Premium Rates. Except as provided above, Premium Rates will not be changed during the Initial Rate Guarantee Period shown in the Coverage Features Thereafter, except as provided above, we may change Premium Rates upon advance written notice to the Policyholder. The minimum advance notice is shown in the Coverage Features as Notice of Rate Change 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 the 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 as it becomes due will maintain the Group Policy in force until the next Premium Due Date. Printed 10/31/2012 - 29 - 339619-E 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 The length of the Grace Period is shown in the Coverage Features. The Group Policy will remain in force during the Grace Period. If the premium is not paid during the Grace Period, the Group Policy will terminate automatically at the end of the Grace Period. The Policyholder is liable for premium for insurance under the Group Policy 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 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 Number or less than the Minimum Participation Percentage shown in the 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 such termination by us is 60 days. G. Premium Adjustments Premium adjustments involving a return of unearned premiums to the Policyholder will be linuted 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 or Employer will furnish on our forms all information reasonably necessary to administer the Group Policy. We have the right at all reasonable tunes to inspect the payroll and other records of the Policyholder or Employer 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 Insurance Company. 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 Insurance Company 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. Printed 10/31/2012 - 30 - 339619-E 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 application 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,,vull 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 its provisions. M. Effect On Workers' Compensation, State Disability Insurance 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 U.PH.OT 4% ALI99X Printed 10/31/2012 - 31 - 339619-E GROUP POLICY AMENDMENT NO. 1 Attached to and made a part of Group Policy 339619-C issued to City of Kent as Policyholder Effective November 1, 2012, and subject to the Active Work Provisions, the Group Policy is amended as follows: 1. Group Policy 339619-C is replaced by Group Policy 339619-E. 2. The Active Work Provisions will not be construed to terminate insurance for any Member who was insured under Group Policy 339619-C as of October.31, 2012. 3. For purposes of the Incontestability Provisions, Group Policy 339619-E will be deemed to be in effect since July 1, 2005. Any increase in amounts of coverage for a Member who is incapable of Active Work on October 31, 2012, will be deferred until the next day after the Member completes one full day of Active Work STANDARD INSURANCE COMPANY By L/ President Corporate Secretary (10/31/2012) 4 f 3