HomeMy WebLinkAboutHR18-161 - Original - CIGNA - Basic Group Life Insurance Certificate #FLX-968145 - 01/01/2018 i
Records Management Document
CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to the City Clerk's Office. All portions are to be completed.
If you have questions, please contact the City Clerk's Office at 253-856-5725.
® Blue/Motion Sheet Attached
® Pink Sheet Attached
Vendor Name: Cigna
Vendor Number (]DE):
Contract Number (City Clerk) Ti12�. ...l�lp �� ...
Category:'Contra c..t Agreement
Sub-Category (if applicable) gGhr,
Project Name:
Contract Execution Date: 1/1/18 Termination Date: 12/31/2020
Contract Manager: Laura Horea Department: HR
Contract Amount: $705.000
Approval Authority: ❑ Director ❑ Mayor ® City Council
Other Details:
Group Life
Insurance Certificate
City of Kent
IMPORTANT NOTICES
If you reside in one of the following states, please read the important notices below:
Arizona, Florida and Maryland residents:
The group pohcy is issued in the state and Washington awed w fll be governed by its Navas. If you
reside in a state other than Washington, Uhis aen-taficate of iasnrance nnay not provide Mll of the
beneffits and proteefions provided by fhe lawns of your state, PILEASE READ YOUR
CERTIFICATE CAREFULLY.
Washington Residents:
(In Accordance With WAC 284-23-610, 620, 650, 730)
The accelerated life benefit in this policy does not and is not intended to qualify as long-term care under
Washington state law. Washington state law prevents this accelerated life benefit from being marketed or
sold as long-term care.
If an Insured receives payment of accelerated benefits from a life insurance policy,he or she may lose the
right to receive certain public funds, such as Medicare, Medicaid, Social Security, Supplemental Security,
Supplemental Security Income(SSI),and possibly others. Also,receiving accelerated benefits from a life
insurance policy may have tax consequences for the Insured. We cannot give advice about this. The Insured
may wish to obtain advice from a tax professional or an attorney before he or she decides to receive
accelerated benefits under a life policy.
NOTICE
Benefits paid under the Accelerated Benefits provision will reduce the Death Benefit payable for
life insurance.
Benefits payable under the Accelerated Benefits provision may be taxable. If so, the Employee or
the Employee's beneficiary may incur a tax obligation. As with all tax matters,an Employee should
consult with a personal tax advisor to assess the impact of this benefit. Accelerated Benefits are not
payable if life insurance coverage under the Policy is not in force.
Any accidental death benefits that you may have under the policy will not be affected by the
acceleration of life insurance benefits.
'1'L-004788
FOREWORD
Life insurance provides individuals and their families with financial protection. The Life Insurance
Benefit described in this booklet will help secure your family's financial security in the event of your
death.
The need for life insurance protection depends on individual circumstances and financial situations. This
valuable coverage should add an extra dimension to your personal insurance portfolio.
In an effort to make your benefit program more comprehensive and responsive to your needs, your
Employer is providing this insurance to you at no cost.
LIFE INSURANCE COMPANY OF NORTH AMERICA
1601 CHESTNUT STREET GROUP INSURANCE
PHILADELPHIA, PA 19192-2235 CERTIFICATE
(800) 732-1603 TDD(800) 336-2485
A STOCK INSURANCE COMPANY
We,the LIFE INSURANCE COMPANY OF NORTH AMERICA, certify that we have issued a Group
Policy, FLX-968145,to City of Kent.
We certify that we insure all eligible persons, who are enrolled according to the terms of the Policy. Your
coverage will begin and end according to the terms set forth in this certificate.
This certificate describes the benefits and basic provisions of your coverage. You should read it with care
so you will understand your coverage.
This is not the insurance contract. It does not waive or alter any of the terms of the Policy. If questions
arise,the Policy will govern. You may examine the Policy at the office of the Policyholder or the
Administrator.
This certificate replaces any and all certificates which may have been issued to you in the past under the
Policy.
Matthew G. Manders, President
IL 004704
TABLE OF CONTENTS
SCHEDULE OF BENEFITS,............. ............ .............. ............... ............. ....... .................. i
WHO1S ELIGIBLE................................................................................................................................-- 4
WHENCOVERAGE BEGINS ....................................................................................................................5
WHENCOVERAGE ENDS ........................................................................................................................6
WHEN COVERAGE CONTINUES,,.................. ....... ...... ............ .......... -----------6
LIFEINSURANCE BENEFITS................................................................................................................. 13
CLAIMPROVISIONS............................................................................................................................... 16
ADMINISTRATIVE PROVISIONS..........................................................................................................19
GENERALPROVISIONS -.........--... ....---....... ...... ...... ........................................ ... ...... .... .......20
DEFINITIONS............................................................................................................................................20
DOMESTIC PARTNER/CIVIL UNION PARTNER RIDER....................................................................23
STATE MODIFYING PROVISIONS AMENDMENT RIDER.......................... -...,......„.,..........,.,........25
SCHEDULE OF BENEFITS
Policy Effective Date: January 1, 2018
Policy Anniversary Date: January 1
Policy Number: FLX-968145
Class Definition
You are eligible for insurance if you are a member of the class defined below.
All active, Benefited Employees of the City of Kent regularly working the minimum required weekly
hours for theirjob subject to a minimum of 20 hours per week, and the elected Mayor currently in office.
Your Eligibility Waiting Period
The Eligibility Waiting Period is the period of time you must be in Active Service to be eligible for
coverage. It will be extended by the number of days you are not in Active Service.
If you were hired on or before the Policy Effective Date:
No Waiting Period
If you were hired after the Policy Effective Date:
No Waiting Period
LIFE INSURANCE BENEFITS
Employee Benefits
Amount of Insurance I times your Annual Compensation
Minimum Benefit: $25,000
Guaranteed Issue Amount: the lesser of 1 times Annual Compensation or$50,000
Maximum Benefit: the lesser of 1 times Annual Compensation or$50,000
The Benefit Amount, Guaranteed Issue Amount and Maximum Benefit will be rounded to the next
higher$1,000, if not already a multiple thereof.
Age Based Reductions When you are age 70 or older,your Life Insurance Benefit will
reduce to the percentage shown below:
65%of the Life Insurance Benefit at age 70
50%of the Life Insurance Benefit at age 75
Benefit reductions will be effective on the January 1st coinciding with or next following the
Employee's attainment of age as specified in schedule above.
Terminal Illness Benefit You can elect up to 75% of Life Insurance Benefits in force on
the date you are determined by the Insurance Company to be
Terminally BI, subject to a Maximum Benefit of$37,500.
1
Spouse or Domestic Partner Benefits
Amount of Insurance $5,000
Guaranteed Issue Amount: $5,000
Maximum Benefit: $5,000
Your Spouse's Life Insurance Benefits cannot exceed 100%of your Life Insurance Benefits.
Terminal Illness Benefit The insured can elect up to 75%of Life Insurance Benefits in
force on the date the Insured is determined by the Insurance
Company to be Terminally III.
Dependent Child Benefits
Amount of Insurance $2,000
Your Dependent Child's Life Insurance Benefits cannot exceed 100% of your Life Insurance Benefits,
All Dependent Child benefits are Guaranteed Issue.
Former Employee Benefits
Amount of Insurance An amount elected subject to the Maximum Benefit amount for
Life Insurance Benefits allowable to you, less any amount of
conversion insurance issued under the Conversion Privilege for
Life Insurance.
Any amount elected in excess of the Life Insurance Benefits in
effect on the date you no longer qualify as an Employee will be
effective on the date the Insurance Company agrees in writing to
insure you.
Terminal Illness Benefit You can elect up to 75%of Life Insurance Benefits in force on
the date you are determined by the Insurance Company to be
Terminally Ill, subject to a Maximum Benefit of$37,500.
Spouse of Former Employee Benefits
Amount of Insurance An amount elected subject to the Maximum Benefit amount for
Life Insurance Benefits available to a Spouse.
Any amount elected in excess of the Life Insurance Benefits in
effect on the date your employment with the Employer ends will
be effective on the date we agree in writing to insure him or her.
Terminal Illness Benefit The insured can elect up to 75% of Life Insurance Benefits in
force on the date the Insured is determined by the Insurance
Company to be Terminally III.
2
Former Spouse Benefits
Amount of Insurance An amount elected subject to the Maximum Benefit amount for
Life Insurance Benefits available to a Spouse.
Any amount elected in excess of the Life Insurance Benefits in
effect on the date he or she no longer qualifies as a Spouse will
be effective on the date we agree in writing to insure him or her.
Tenninal Illness Benefit The insured can elect up to 75%of Life Insurance Benefits in
force on the date the Insured is determined by the Insurance
Company to be Terminally III.
Former Dependent Child Benefits
Amount of Insurance Units of$25,000
Guaranteed Issue Amount: $25,000
Maximum Benefit: $50,000
Maximum Benefit Period To Age 70
1 L-004774(MIA)
3
WHO IS ELIGIBLE
Classes of Eligible Persons
A person may be insured only once under the Policy as an Employee, Spouse or Dependent Child, even
though he or she may be eligible under more than one class.
Employee
If you qualify under the Class Definition shown in the Schedule of Benefits,you are eligible to be insured
under the Policy on the Policy Effective Date, or the day after you complete the applicable Eligibility
Waiting Period, if later.
If you have previously converted your insurance under the Policy, you will not become eligible until your
converted policy is surrendered. This does not apply to any amount of insurance that was previously
converted under the Policy due to a reduction in your Life Insurance Benefits based on age or a change in
class unless those conditions no longer affect the amount of insurance available to you.
Except as noted in the Reinstatement Provision, if you terminate coverage and later wish to reapply, or if
you are a former Employee who is rehired, a new Eligibility Waiting Period must be satisfied. You are
not required to satisfy a new Eligibility Waiting Period, if insurance ends because you are no longer in a
Class of Eligible Employees,but continue to be employed by the Employer, and within one year you
become a member of an eligible class.
Spouse
Your Spouse is eligible to be insured on the date you are eligible or the date he or she becomes your
Spouse, if later. You must be insured in order to elect spouse coverage.
For eligibility purposes,your Spouse must be a lawful Spouse and not legally separated from, divorced
from, or widowed by you.
Dependent Child
Your Dependent Child is eligible to be insured on the date you are eligible or the date the child becomes a
Dependent Child, if later.
In no event will a Dependent Child be eligible to be insured more than once under the Policy.
4
WHEN COVERAGE BEGINS
You,your Spouse and Dependent Children will be insured for an amount not to exceed the Guaranteed
Issue Amount on the date you become eligible, if you are not required to contribute to the cost of this
insurance.
If coverage for a Dependent Child is in force and another Dependent Child becomes eligible, coverage for
that child is effective on the date he or she qualifies as a Dependent Child.
If you are not in Active Service on the date insurance would otherwise go into effect, it will be effective
on the date you return to Active Service.
If an eligible Spouse or Dependent Child is:
1. an inpatient in a hospital, hospice, rehabilitation or convalescence center, or custodial care
facility; or
2. confined to his or her home under the care of a Physician
on the date insurance would otherwise be effective, it will be effective on the date he or she is no longer
an inpatient in these facilities or confined at home. If such Spouse or Dependent Child was covered by
the Prior Plan immediately prior to the Policy Effective Date,this provision will not apply to the amount
of coverage in effect as of the Policy Effective Date, but will apply to any increase in coverage. This does
not apply to a Dependent Child who is age 6 months or less.
11,004712
Takeover Provision
Special Terms Applicable to Previously Insured Employees Not in fictive Service and Their Dependents
Coverage will not go into effect for you, or your Spouse and Dependent Children unless you are in Active
Service on the date you would have first become eligible to be insured under this Policy.
However:
I. if you, and your Spouse or Dependent Children were insured under a Prior Plan on the date
immediately prior to the date you would have first become eligible to be insured under this Policy
and had satisfied the Active Service requirement, and
2. if you,your Spouse or Dependent Child die,
we agree to provide a Death Benefit only equal to the lesser of:
a. the amount due under this Policy(had you satisfied the Active Service requirement),or
b. the amount that world have been due under the Prior Plan had it remained in force.
The benefit amount will be reduced by any amount paid by the Prior Plan, or that would have been paid
had this Policy not been issued and had timely filing of the claim been made under the Prior Plan.
These special terns will end on the earliest of the following dates:
1. the date you meet the Active Service requirements;
2. the date insurance terminates for one of the reasons stated in the Termination of Insurance
provision;
3. 12 months after the date you first become eligible under this Policy; or
4. the last day you,your Spouse or Dependent Children would have been covered under the Prior
Plan if coverage under that plan for you,your Spouse or Dependent Children was still in force.
rl�aoeozu-1
5
WHEN COVERAGE ENDS
Coverage will end on the earliest of the following dates:
1. the date you are eligible for coverage under a plan intended to replace this coverage;
2. the date we terminate the Policy;
3. the date you,your Spouse or Dependent Children are no longer in an eligible class;
4. the date coinciding with the end of the last period for which required premiums are paid;
5. the date you are no longer in Active Service;
6. for an Employee, Spouse or Dependent Child,the date the Employer cancels participation under
the Policy; and
7. the date your coverage ends, for any insured Spouse or Dependent Child.
'CLA0411 I
WHEN COVERAGE CONTINUES
Continuation for Temporary Leave of Absence,Layoff or Family Medical Leave
If you are an Employee and your Active Service ends due to an Employer approved unpaid leave of
absence, layoff or family medical leave, your insurance will continue if the required premium is paid.
In these circumstances,your insurance may continue as follows.
L For an Employer approved unpaid leave of absence, up to 12 months.
2. For layoff, up to the end of the month in which the layoff begins.
3. For an Employer approved family medical leave, up to the later of the period of the approved
FMLA leave or the leave period required by the laws of the state in which the Employee is
employed.
Continuation of Life Coverage During Labor Disputes
If your Active Service ends because of a Labor Dispute and your premium for Life Insurance Benefits
under the Policy is paid either by the Employer, in whole or in part, or by you through payroll deductions,
then you may continue your Life Insurance Benefits. The Employer will send you written notice of the
right to continue coverage at your most recent address as on file with the Employer.
To continue coverage, you must pay premiums directly to the Employer, who will remit the premiums to
us. Premiums must be paid by the date they are due, subject to the 31 day grace period. Policy coverages
and premiums will stay the same during a Labor Dispute; however,we may make normal changes in
premium rates when the Policy is renewed, under the terms set forth in the Policy.
Coverage continued in this manner will end on the earliest of the following dates.
1. The date the Labor Dispute has ended.
2. The date coverage has been continued for 6 months.
If the Labor Dispute continues beyond 6 months,you may apply for an individual insurance policy, as set
forth in detail under"Conversion Privilege for Life Insurance."
"Labor Dispute," as used here, means a strike, lockout,or other labor dispute between the Employer and
its Employees, during which time the Employee is not paid by the Employer.
6
Continuation for Disability for Employees over Age 60
If you become Disabled and are age 60 or over, the Life Insurance Benefits shown in the Schedule of
Benefits will be continued, provided premiums are paid, until the earlier of the following dates:
1. The date you are no longer Disabled.
2. The date you are Disabled for 12 consecutive months.
3. The date coinciding with the end of the last period for which premiums are paid.
4. The date the Policy is terminated by us.
Amount g1Insurance
If you die while you are Disabled and coverage is continued under this provision, we will pay a Death
Benefit equal to the amount in effect on the date you became Disabled. However,the Life Insurance
Benefit will be subject to the provisions of the Policy that reduce the coverage amount because of age,
retirement, payment of an Accelerated Benefit or a change in class. Automatic increases in Life
Insurance Benefits will end while coverage is continued under this provision. We will pay benefits only
if due proof of your continuous Disability is received within one year of the date of the loss.
"Disability"P'Disabled" means because of Injury or Sickness you are unable to perform all the material
duties of your Regular Occupation; or are receiving disability benefits under the Employer's plan.
"Regular Occupation"means the occupation you routinely perform at the time the Disability begins. We
will consider the duties of the occupation as it is normally performed in the general labor market in the
national economy.
Extended Death Benefit with Waiver of Premium
Extended Death Benefit
If you become Disabled and are less than age 60, the Life Insurance Benefits shown in the Schedule of
Benefits will be extended without premium payment until the earlier of the following dates:
1. The date you are no longer Disabled; or
2. 12 months after the end of your Active Service.
Amount of Insurance
If you die while you are Disabled and coverage is extended under this provision, we will pay a Death
Benefit equal to the amount in effect on the date you became Disabled. However, the Life Insurance
Benefit will be subject to the provisions of the Policy that reduce the coverage amount because of age,
retirement,payment of an Accelerated Benefit or a change in class. Automatic increases in Life
Insurance Benefits will end while premiums are waived. We will pay benefits only if due proof of your
continuous Disability is received within one year of the date of the loss.
"Disability"PUsabled"means because of Injury or Sickness you are unable to perform the material
duties of your Regular Occupation; or are receiving disability benefits under the Employer's plan.
"Regular Occupation"means the occupation you routinely perform at the time the Disability begins. We
will consider the duties of the occupation as it is normally performed in the general labor market in the
national economy.
7
Waiver of Premium
If you submit satisfactory proof that you have been continuously Disabled for 9 months, your coverage
will be extended.
Such proof must be submitted to us no later than 3 months after the date the Waiver Waiting Period ends.
Premiums will be waived from the date we agree in writing to waive premiums for you.
After premiums have been waived for 12 months, they will be waived for future periods of 12 months, if
you remain Disabled and submit satisfactory proof that Disability continues. Satisfactory proof must be
submitted to us 3 months before the end of the 12-month period.
Amount of Insurance
If you die while you are Disabled and coverage is continued under this provision, we will pay a Death
Benefit equal to the amount in effect on the date you became Disabled. However,the Life Insurance
Benefit will be subject to the provisions of the Policy that reduce the coverage amount because of age,
retirement, payment of an Accelerated Benefit or a change in class. Automatic increases in Life
Insurance Benefits will end while premiums are waived. We will pay benefits only if due proof of your
continuous Disability is received within one year of the date of the loss.
Termination of I'aiver
Your insurance will end on the earliest of the following dates.
1. The date you are no longer Disabled;
2. The date you refuse to submit to any physical examination required by us;
3. The date you refuse to participate in a Rehabilitation Plan for which the Insurance Company
determines you to be eligible;
4. The last day of the 12-month period of Disability during which you fail to submit satisfactory
proof of continued Disability.
"Disability/Disabled" means because of Injury or Sickness you are unable to perform the material duties
of your Regular Occupation, or are receiving disability benefits under the Employer's plan, during the
initial 9 months of Disability. Thereafter,you must be unable to perform all of the material duties of any
occupation which you may reasonably become qualified based on education,training or experience, or are
subject to the terms of a Rehabilitation Plan approved by the Insurance Company.
"Regular Occupation"means the occupation the Employee routinely performs at the time the Disability
begins. The Insurance Company will consider the duties of the occupation as it is normally performed in
the general labor market in the national economy.
13
Rehahilitation During a Period of Disability
If the Insurance Company determines that you are a suitable candidate for rehabilitation, the Insurance
Company may require you to participate in an assessment and Rehabilitation Plan, not to exceed 18
months, at our expense. The Insurance Company has the sole discretion to approve your participation in a
Rehabilitation Plan and to approve a program as a Rehabilitation Plan. If you fail to fully cooperate in all
required phases of the Rehabilitation Plan and assessment without Good Cause, your insurance under the
Policy will end.
"Good Cause"means a medical reason preventing participation, in whole or in part, in the Rehabilitation
Plan. Satisfactory proof of Good Cause must be provided to the Insurance Company.
"Rehabilitation Plan" means a written plan designed to enable the Employee to return to work. The
Rehabilitation Plan will consist of one or more of the following phases:
1. Rehabilitation, under which the Insurance Company may provide, arrange or authorize
educational, vocational or physical rehabilitation or other appropriate services;
2. Work,which may include modified work and work on a Part-time basis.
"Part-time" means regularly working less than the number of full time hours set by the Employer as a
regular work day for Employees in an Eligible Class of Employees in the Policy.
TL009J4.9 x,.odrtlod by [L 009745 1
9
Portability Options
For Employees
You must apply to the Insurance Company and pay the required premium. If you continue coverage,
coverage for youir Spouse or Dependent Child may also be continued by you. Your Spouse or Dependent
Child must be covered under the Policy on the date coverage would otherwise end. The application must
be submitted:
a. within 31 days of your termination of employment or membership in an eligible class under the
Policy; or
b. during the time that you have to exercise the Conversion Privilege.
Coverage under this option may not be elected at a later date.
When applying for this option, you must name a beneficiary. Any beneficiary named previously under
the Policy is no longer in effect. If there is no named or surviving beneficiary, Death Benefits will be
paid to the first surviving class of the following living relatives:
a. spouse;
b. child or children;
C. mother or father;
d. brothers or sisters; or
e. the executors or administrators of your estate.
When coverage is continued under this option,you become a Former Employee. Your Spouse becomes a
Spouse of a Former Employee. Your Dependent Child becomes a Dependent Child of a Former
Employee.
If you, as a Former Employee, later acquire a Spouse or Dependent Child, you may elect coverage for
them. You must apply to the Insurance Company and pay the required premium. Coverage for your
Spouse or Dependent Child will be effective on the date we agree in writing to insure them. We may
require that your Spouse or Dependent Child satisfy the Insurability Requirement before we agree to
insure them.
Coverage will end on the earliest of the following dates.
a. The date we cancel coverage for all Former Employees.
b. The end of the period for which premiums are paid.
C. The date an Insured reaches age 70.
d. The date the Maximum Benefit Period shown in the Schedule of Benefits for this option ends.
Also, coverage for any Dependent Child will end on any of the dates listed above or when he or she no
longer qualifies as a Dependent Child, if earlier.
10
For Spouses
A Spouse who continues coverage may also continue coverage for a Dependent Child. The Dependent
Child must be covered under the Policy on the date coverage would otherwise end. A Spouse must elect
to continue insurance under this option within 31 days after coverage ends. Coverage may not be elected
at a later date.
When applying for this option, a Spouse must name a beneficiary. Any beneficiary named previously
under the Policy is no longer in effect. If there is no named or surviving beneficiary, Death Benefits will
be paid to the first surviving class of the following living relatives:
a. spouse;
b. child or children;
C. mother or father;
d. brothers or sisters; or
e. the executors or administrators of the Spouse's estate.
When coverage is continued under this option, the Spouse becomes a Former Spouse. A separate
certificate of insurance will be issued to the Former Spouse. Coverage will be effective on the date after
coverage as a Spouse ends if the required premium is paid.
Coverage will end on the earliest of the following dates.
a. The date we cancel coverage for all Former Spouses.
b. The end of the period for which premiums are paid.
c. The date the Maximum Benefit Period shown in the Schedule of Benefits for this option ends.
Also, coverage for a Dependent Child will end on any of the dates listed above or when he or she no
longer qualifies as a Dependent Child, if earlier.
11
For Dependent Children
If a Dependent Child is insured under the Policy and is at least 19 years of age, Life Insurance Benefits
may be continued under this option. Coverage may be continued up to the Maximum Benefit shown in
the Schedule of Benefits for this option.
The Dependent Child must apply to the Insurance Company and pay the required premium. If a
Dependent Child does not elect to continue insurance within 31 days after reaching age 19; or the date he
or she no longer qualifies as a Dependent Child, if later, coverage under this option may not be elected at
a later date.
When applying for this option, a Dependent Child must name a beneficiary. Any beneficiary named
previously under the Policy is no longer in effect. If there is no named or surviving beneficiary, Death
Benefits will be paid to the first surviving class of the following living relatives:
a. spouse;
b. child or children;
C. mother or father;
d. brothers or sisters; or
e. the executors or administrators of the Dependent Child's estate.
When a Dependent Child continues coverage Linder this option, he or she becomes a Former Dependent
Child. A separate certificate of insurance will be issued to the Former Dependent Child. Coverage for a
Former Dependent Child will be effective on the following dates.
a. For any Guaranteed Issue Amount, immediately following the date his or her coverage as a
Dependent Child ends, provided the Insurance Company receives the required premium.
b. For any amount of insurance that exceeds the Guaranteed Issue Amount,the date the Insurance
Company agrees in writing to insure him or her. The Insurance Company will require the Former
Dependent Child to satisfy the Insurability Requirement before it agrees to insure him or her.
Coverage will end on the earliest of the following dates.
a. The date we cancel coverage for all Former Dependent Children.
b. The end of the period for which premiums are paid.
G. The date the Former Dependent Child is age 70.
d. The date the Maximum Benefit Period shown in the Schedule of Benefits for this option ends.
'I LAO471 b-modi fled by H,001MO
12
WHAT IS COVERED
LIFE INSURANCE BENEFITS
Death Benefit
If an Insured dies, we will pay the Life Insurance Benefit in force for that Insured on the date of his or her
death.
'I L 004710
Accelerated Benefits
Any benefits payable under this and under any similar Accelerated Benefits provision accelerated under a
Prior Plan will reduce the Death Benefit payable for Life Insurance. We will deduct from any Death
Benefit payable under this Policy, the amount of any similar accelerated benefit paid under a Prior Plan.
Any automatic increases in Life Insurance Benefits will end when benefits are payable under this
provision, unless the Insured is determined by us not to be eligible for Accelerated Benefits.
Terminal Illness Benefit
We will pay a Terminal Illness Benefit to an Insured who has incurred a Terminal Illness while insured
under this provision.
The Terminal Illness Benefit is shown on the Schedule of Benefits.
A claim for a similar terminal illness benefit under a Prior Plan or group policy intended to replace this
Policy shall be deemed payable until such time as it is finally determined not to be payable.
Determination of Terminal Illness
For the propose of determining the existence of a Terminal Illness, we will require the Insured submit the
following proof:
I. A written diagnosis and prognosis by a licensed Physician; and
2. Supportive evidence satisfactory to us, including but not limited to, radiological,histological or
laboratory reports documenting the Terminal Illness.
We may require, at our expense, an examination of the Insured and a review of the documented evidence
by a Physician of our choice.
Such proofs must be submitted to us within the period of time provided in the Proof of Loss section of the
Policy. For purposes of this Benefit, the date of loss shall be the date of first prognosis of Terminal
Illness.
"Terminal Illness" means that, due to an Injury or Sickness,the Insured has a prognosis of no less than
twenty-four months without reasonable prospect of recovery, as determined by its.
Payment of Terminal Illness Benefit
The Terminal Illness Benefit will be payable in accordance with the provisions of the To Whom Payable
section of the Policy.
The Terminal Illness Benefit is payable only once under the Policy in an Insured's lifetime.
13
Conditions Applicable to Coverage
Unless the Insured qualifies for waiver of premium, premium payments must continue to be paid on the
full amount of group life insurance, including during any Continuation of Insurance under the Policy, in
accordance with the Premium section in the Administrative Provisions.
The amount of Life Insurance which may be converted under the Conversion Privilege cannot exceed the
amount of the reduced death benefit payable under the Policy.
Before a Terminal Illness Benefit is paid in a Community Property state, we may require the written
consent of the Insured's Spouse.
Exclusions Applicable to Terminal Illness Benefit
A Terminal Illness Benefit will not be payable:
I. when the Insured has irrevocably assigned group life insurance under this Policy;
2. when all or a portion of group life insurance benefits under this Policy are to be paid to a former
spouse as part of a qualified domestic relations order;
3. for any intentionally self-inflicted Injury or Sickness, or suicide attempt;
4. if the Insured's coverage ends under the When Coverage Ends provision prior to the prognosis of
Terminal Illness;
5. if the required premium is due and unpaid;
6. if this Policy terminates prior to the prognosis of Terminal Illness;
7. if you or the Insured is only provided coverage under the Takeover provision of the Policy
(Employees Not in Active Service on the Policy Effective Date); or
8. if the date of first prognosis of Terminal Illness occurs more than 12 months before the
submission of the Terminal Illness claim.
11,004748a WA
14
Conversion Privilege for Life Insurance
Each Insured may convert all or any portion of his or her Life Insurance that would end under the Policy
due to:
1. termination of employment;
2. termination of membership in an eligible class under the Policy;
3. termination of the Policy.
The Insured may apply for any type of life insurance we offer to persons of the same age in the amount
applied for, except you may not:
1. choose term insurance;
2. apply for an amount of insurance greater than the coverage amount terminating under the Policy
(also, the conversion policy will not provide accident, disability or other benefits); or
3. apply for more than$10,000 of insurance if the Policy is terminated or amended to terminate the
insurance for any class of Insureds, or the Employer cancels participation under the Policy.
Conversion in these cases is only permitted if you have been covered by the Policy or, any group
life insurance policy issued to the Employer which the Policy replaced,for at least 3 years.
If the Insured becomes eligible for coverage under any group life policy within 31 days of termination of
coverage under this Policy, the Insured may not convert an amount of insurance greater than the amount
of coverage terminating under the Policy less the amount for which he or she may be covered under the
other policy.
To apply for conversion insurance, the Insured must, within 31 days after coverage under the Policy ends:
1. submit an application to us; and
2, pay the required premium.
Evidence of insurability is not required.
Premium for the conversion insurance will be based on the age and class of risk of the Insured and the
type and amount of coverage issued.
If the Insured has assigned ownership of his group coverage,the owner/assignee must apply for the
individual policy.
Conversion insurance will become effective on the 31st day after the date coverage under the Policy ends
provided the application is received by us and the required premium has been paid.
If the Insured dies during the 31-day conversion period, the Life Insurance benefits will be paid under the
Policy regardless of whether he or she applied for conversion insurance. If a conversion policy is issued,
it will be in exchange for any further benefits for that type and amount of insurance from this Policy.
15
F.xlension of Conversion Period
If an Insured is eligible for conversion insurance and is not notified of this right at least 15 days prior to
the end of the 31-day conversion period, the conversion period will be extended. The Insured will have
15 days from the date notice is given to apply for conversion insurance. In no event will the conversion
period be extended beyond 90 days. Notice, for the purpose of this section, means written notice
presented to the Insured by the Employer or mailed to the Insured's last known address as reported by the
Employer.
If the Insured dies during the extended conversion period, but more than 31 days after his or her coverage
under the Policy terminates, Life Insurance benefits:
1. will not be paid under the Policy; and
2. will be payable under the conversion insurance;provided:
a. the Insured's application for conversion insurance has been received by us; and
b. the required premium has been paid.
Prior Conversion Limitation
If an Insured is covered under a life insurance conversion policy previously issued by us, he or she will
not be eligible for this Conversion Privilege unless the prior coverage has ended.
PLp99940
CLAIM PROVISIONS
Notice of Claim
Written notice of claim, or notice by any other electronic/telephonic means authorized by us, must be
given to us within 31 days after a covered loss occurs or begins or as soon as reasonably possible. If
written notice, or notice by any other electronic/telephonic means authorized by us, is not given in that
time,the claim will not be invalidated or reduced if it is shown that notice was given as soon as was
reasonably possible. Notice can be given at our home office in Philadelphia, Pennsylvania or to our
agent. Notice should include the Employer's name, the Policy Number and the claimant's name and
address.
Written notice, or any other electronic/telephonic means authorized by us,of a diagnosis of a Terminal
Illness on which claim is based must be given to Lis within 60 days after the diagnosis. If notice is not
given in that time, the claim will not be invalidated or reduced if it is shown that written notice, or any
other electronic/telephonic means authorized by us, was given as soon as reasonably possible.
Claim Forms
When we receive notice of claim, we will send claim forms for filing proof of loss. If we do not send
claim forms within 15 days after notice is received by us,the proof requirements will be met by
submitting, within the time required under the"Proof of Loss" section,written proof, or proof by any
other electronic/telephonic means authorized by us, of the nature and extent of the loss.
Claimant Cooperation Provision
If you fail to cooperate with us in our administration of your claim,we may terminate the claim. Such
cooperation includes, but is not limited to, providing any information or documents needed to determine
whether benefits are payable or the actual benefit amount due.
16
Insurance Data
The Employer is required to cooperate with us in the review of claims and applications for coverage. Any
information we provide to the Employer in these areas is confidential and may not be used or released by
the Employer if not permitted by applicable privacy laws.
Proof of Loss
You must provide written proof of loss to us,or proof by any other electronic/telephonic means
authorized by us, within 90 days after the date of the loss for which a claim is made. If written proof of
loss, or proof by any other electronic/telephonic means authorized by its, is not given in that 90 day
period,the claim will not be invalidated nor reduced if it is shown that it was given as soon as was
reasonably possible. In any case,written proof of loss, or proof by any other electronic/telephonic means
authorized by us, must be given not more than one year after the 90 day period. If written proof of loss,
or proof by any other electronic/telephonic means authorized by us, is provided outside of these time
limits,the claim will be denied. These time limits will not apply due to lack of legal capacity.
Written proof, or any other electronic/telephonic means authorized by us, of loss for Accelerated Benefits
must be furnished 90 days after the date of diagnosis. This proof must describe the occurrence, character
and diagnosis for which claim is made.
In case of claim for any other loss, proof must be furnished within 90 days after the date of such loss.
If it is not reasonably possible to submit proof of loss within these time periods, we will not deny or
reduce any claim if proof is furnished as soon as reasonably possible. Proof must, in any case, be
furnished not more than a year later, except for lack of legal capacity.
Time of Payment
Benefits due under the Policy for a loss, other than a loss for which the Policy provides installment
payments, will be paid immediately upon receipt of due written proof of such loss.
Subject to the receipt of satisfactory written proof of loss, all accrued benefits for loss for which the
Policy provides installment payments will be paid monthly; any balance remaining unpaid upon the
termination of liability will be paid immediately upon receipt of due written proof, unless otherwise stated
in the Description of Benefits.
Manner of Payment of Claims
The Policyholder authorizes that any benefit payment due as a lump sum of$5,000 or more shall be
credited to a draft account with the Insurance Company, in the name of the beneficiary. The beneficiary
may withdraw the entire proceeds at any time by issuing one or more drafts, or may withdraw lesser
amounts, subject to a minimum account balance set by the Insurance Company from time to time.
Interest shall be credited to such account at rates as determined from time to time by the Insurance
Company.
17
To Whom Payable
Death Benefits will be paid to the Insured's named beneficiary, if any, on file at the time of payment. If
there is no named beneficiary or surviving beneficiary, Death Benefits will be paid to the first surviving
class of the following living relatives: spouse or Registered Domestic Partner;child or children; mother or
father; brothers or sisters; or to the executors or administrators of the Insured's estate. The Insurance
Company may reduce the amount payable by any indebtedness due. ("Registered Domestic Partner"
means a person who has entered into a Domestic Partnership with the Employee or Former Employee
registered under any state which legally recognizes Domestic Partnerships or Civil Unions, and which
confers on the Employee and Domestic Partner legal rights and obligations substantially similar to lawful
marriage. Such person will continue to be recognized as a Registered Domestic Partner unless and until:
(1)the Domestic Partnership is dissolved under applicable law; or(2)either the Employee or Former
Employee or the Domestic Partner marries another person.)
All benefits payable under the Accelerated Benefits section are payable to the Insured, if living. if the
Insured dies prior to the payment of an eligible claim for an Accelerated Benefit,benefits will be paid in
accordance with the provisions applicable to the payment of Life Insurance proceeds, unless the Insured
has directed us otherwise in writing. However, any payment made by us prior to notice of the Insured's
death shall discharge us of any benefit that was paid.
All other benefits unless otherwise stated in the Policy, will be payable to the Insured or the certificate
owner if other than the Insured.
Any other accrued benefits which are unpaid at your death will, at our option, be paid either to your
beneficiary or to the executor or administrator of your estate.
If we pay benefits to the executor or administrator of your estate or to a person who is incapable of giving
a valid release, we may pay up to$1,000 to a relative by blood or marriage whom we believe is equitably
entitled. This good faith payment satisfies our legal duty to the extent of that payment.
Change of Beneficiary
You may change your beneficiary at any time by giving written notice to the Employer or to us. The
beneficiary's consent is not required for this or any other change which you may make unless your
designation of beneficiary is irrevocable.
No change in beneficiary will take effect until the form is received by the Employer or us. When this form
is received, it will take effect as of the date of the form. If you die before the form is received, we will
not be liable for any payment that was made before receipt of the form.
Physical Examination and Autopsy
We may, at our expense, exercise the right to examine any person for whom a claim is pending as often as
we may reasonably require. Also, we may, at our expense,require an autopsy unless prohibited by law.
Legal Actions
No action at law or in equity may be brought to recover benefits under the Policy less than 60 days after
written proof of loss, or proof by any other electronic/telephonic means authorized by us, has been
furnished as required by the Policy. No such action shall be brought more than 3 years after the time
satisfactory proof of loss is required to be furnished.
is
Time Limitations
If any time limit stated in the Policy for giving notice of claim or proof of loss, or for bringing any action
at law or in equity, is less than that permitted by the law of the state in which you live when the Policy is
issued,then the time limit provided in the Policy is extended to agree with the minimum permitted by the
law of that state.
Physician/Patient Relationship
You have the right to choose any Physician who is practicing legally. We will in no way disturb the
Physician/patient relationship.
rL004724
ADMINISTRATIVE PROVISIONS
Premiums
The premiums for this Policy will be based on the rates currently in force, the plan and the amount of
insurance in effect.
If an Insured's coverage amount is reduced due to acceleration of a Death Benefit,premium will be based
on the amount of coverage in force on the day before the reduction took place. If the Insured's coverage
amount is reduced due to his or her attained age, premium will be based on the amount of coverage in
Force on the day after the reduction took place.
Draft Accounts
The Insurance Company shall be entitled to retain, as part of its compensation, any earnings on draft
accounts created in connection with benefit claims, in excess of interest credited under the terms of the
policy.
Reinstatement of Insurance
Your coverage may be reinstated without satisfying the Insurability Requirement, if your insurance ends
because you are on an unpaid leave of absence and you apply for Reinstatement within 31 days of your
return to Active Service.
After your insurance ends, it may be reinstated at any date prior to five years after the date of termination
if the following conditions are met.
1. The Policy is still in force.
2. You are eligible under the Policy.
3. You send us a written request for reinstatement and a new enrollment form.
4. The required premium is paid.
5. The Insurability Requirement, if applicable,is satisfied.
LAW4nz
19
GENERAL PROVISIONS
Incontestability
All statements made by the Employer or by an Insured are representations not warranties. No statement
will be used to deny or reduce benefits or as a defense to a claim, unless a copy of the instrument
containing the statement has been furnished to the claimant. In the event of death or legal incapacity, the
beneficiary or representative must receive the copy.
After two years from an Insured's effective date of insurance, or from the effective date of any added or
increased benefits, no such statement will cause insurance to be contested.
Misstatement of Age
If an Insured's age has been misstated, we will adjust all benefits to the amounts that would have been
purchased for the correct age.
Workers' Compensation Insurance
The Policy is not in lieu of and does not affect any requirements for insurance under any Workers'
Compensation Insurance Law.
Assignment of Benefits
We will not be affected by the assignment of your certificate until the original assignment or a certified
copy of the assignment is filed with us. We will not be responsible for the validity or sufficiency of an
assignment. An assignment of benefits will operate so long as the assignment remains in force provided
insurance under the Policy is in effect. This insurance may not be levied on, attached, garnisheed, or
otherwise taken for a person's debts. This prohibition does not apply where contrary to law.
Clerical Error
A person's insurance will not be affected by error or delay in keeping records of insurance under the
Policy. If such an error is found, the premium will be adjusted fairly.
Ownership of Records
All records maintained by the Insurance Company are, and shall remain,the property of the Insurance
Company.
"fl.004729(WA)
DEFINITIONS
Please note, certain words used in this document have specific meanings. These terms will be capitalized
throughout this document. The definition of any word, if not defined in the text where it is used,may be
found either in this Definitions section or in the Schedule of Benefits.
Active Service
If you are an Employee,you are in Active Service with the Employer on a day which is one of the
Employer's scheduled work days if either of the following conditions are met.
I. You are actively at work. This means you are performing your regular occupation for the
Employer on a Full-time basis,either at one of the Employer's usual places of business or at some
location to which the Employer's business requires you to travel.
2. The day is a scheduled holiday, vacation day or period of Employer approved paid leave of
absence, other than disability or sick leave after 7 days.
You are considered in Active Service on a day which is not one of the Employer's scheduled work days
only if you were in Active Service on the preceding scheduled work day.
20
Annual Compensation
Annual Compensation means your annual wage or salary as reported by the Employer for work
performed for the Employer as of the date the covered loss occurs. It does not include amounts received
as bonuses, commissions, overtime pay or other extra compensation. Annual Compensation is
determined initially on the date you apply for coverage. A change in the amount of Annual
Compensation is effective on the first of the month following the change, if the Employer gives its written
notice of the change and the required premium is paid.
Dependent Child
A child who meets the following requirements.
I. A child from live birth but less than 26 years old;
2. A child who is 26 or more years old, primarily supported by you and incapable of self-sustaining
employment by reason of mental or physical incapacity.
The term "child" means:
a. a stepchild bonito your Spouse and who is living with and financially dependent upon you;
b. a child for whom you are the court-appointed legal guardian and who resides with, and is
financially dependent upon you.
Employee
For eligibility purposes,you are an Employee if you work for the Employer and are in one of the "Classes
of Eligible Employees." Otherwise, you are an Employee if you are an employee of the Employer who is
insured under the Policy.
Employer
The Policyholder and any affiliates or subsidiaries covered under the Policy. The Employer is acting as
your agent for transactions relating to this insurance. You shall not consider any actions of the Employer
as actions of the Insurance Company.
Full-time
Full-time means the number of hours set by the Employer as a regular work day for Employees in your
eligibility class.
Injury
Any accidental loss or bodily harm that results directly and independently from all other causes from an
Accident.
Insurability Requirement
An eligible person satisfies the Insurability Requirement for an amount of coverage on the day we agree
in writing to accept you as insured for that amount. To determine a person's acceptability for coverage,
we will require you to provide evidence of good health and may require it be provided at your expense.
Insurance Company
The Insurance Company underwriting the Policy is named on your certificate cover page. References to
the Insurance Company have been changed to "we", "our", "ours", and "us" throughout the certificate.
Insured
You are an Insured if you are eligible for insurance under the Policy, insurance is elected for you, the
required premium is paid and your coverage is in force under the Policy.
21
Physician
Physician means a licensed doctor practicing within the scope of his or her license and rendering care and
treatment to an Insured that is appropriate for the condition and locality. The term does not include you,
your spouse, the immediate family(including parents, children, siblings, or spouses of any of the
foregoing,whether the relationship derives from blood or marriage), of you or your spouse, or a person
living in your household.
Policy Anniversary
A Policy Anniversary is the date stated on the policy cover and the same date that follows every 12
months for as long the Policy is in effect.
Policy Effective Date
The Policy Effective Date is the date stated on the policy cover,
Policyholder
A Policyholder is an Employer who has applied for coverage under the policy for his eligible Employees
and their Dependents.
Prior Plan
The Prior Plan refers to the plan of insurance providing similar benefits to you, sponsored by the
Employer and in effect directly prior to the Policy Effective Date. A Prior Plan will include the plan of an
employer in effect on the day prior to that employer's addition to this policy.
To be covered under the Policy, required premium must be paid for all covered Employees.
Sickness
The term Sickness means a physical or mental illness.
Spouse
Your current lawful spouse.
TL.n04708 1
22
AMENDATORY RIDER
DOMESTIC PARTNER/CIVIL UNION PARTNER COVERAGE
Policy No. FLX-968145
Effective Date: January 1, 2018
This rider amends the Policy and Certificate to which it is attached. It is effective on the Effective Date
shown above, and expires when the Policy expires.
Domestic Partner/Civil Union Partner means any of the following:
1. A person with whom the Employee or Former Employee has a registered civil union or domestic
partnership under state law which imposes legal obligations on the parties substantially similar to
marriage. Such person will continue to be recognized as a Domestic Partner or Civil Union Partner
unless and until: (1)the civil union or domestic partnership is dissolved under applicable law; or(2)
either the Employee or Former Employee or the Domestic Partner/Civil Union Partner marries
another person.
All references in the policy to "Spouse"shall be changed to read "Spouse, Domestic Partner, and Civil
Union Partner except as follows:
1. The definition of"Spouse"remains unchanged.
2. For purposes of any provision of the policy providing for payment of benefits to relatives of the
Employee or Former Employee, a Domestic Partner/Civil Union Partner shall be included only if:
a. the Domestic Partner/Civil Union Partner meets the requirements of the definition of Domestic
Partner/Civil Union Partner referenced in item 1 or 2, or;
b. the Employee or Former Employee and Domestic Partner have furnished the Employer or the
Insurance Company with a signed statement affirming that the requirements referenced in item 3
within the definition of Domestic Partner are met.
3. A Domestic Partner/Civil Union Partner shall be deemed eligible to be enrolled for insurance on the
latest of:
a. the date of registration under Item 1 of the definition of Domestic Partner/Civil Union Partner;
b. the date that the Employee or Former Employee is eligible for insurance under the Policy; or;
c. the effective date of this Amendment to the Policy.
4. A child of a Domestic Partner/Civil Union Partner may only be eligible to be insured if:
a. the child is primarily dependent on the Employee for financial support;
b. the Employee has a legal obligation of support of the child; or
c. the Employee is the child's legal guardian.
23
Any provision of the Policy that otherwise excludes any person who is not legally able to marry the
Employee or Former Employee is changed by the following:
In the case of any person of the same sex as the Employee or Former Employee, the exclusion of persons
legally able to marry will not apply for the first 12 months that the Employee's or Former Employee's
state of residence allows same-sex couples to marry.
Except for the above this rider does not change the Policy or Certificate to which it is attached.
LIFE INSURANCE COMPANY OF NORTH AMERICA
lam, .
Matthew G. Manders,President
R,007113
24
LIFE INSURANCE COMPANY OF NORTH AMERICA
1601 CHESTNUT STREET
PHILADELPHIA, PA 19192-2235
STATE MODIFYING PROVISIONS AMENDMENT RIDER
Policyholder: City of Kent
Policy No. FLX-968145
Amendment Effective Date: January 1,2018
This amendment is attached to and made part of the Policy/Certificate specified above. Its provisions are
intended to conform this Policy/Certificate to the laws of the state in which the insured resides.
The Policy delivered under the Group Policy are amended as follows:
APPLICABLE TO CALIFORNIA RESIDENTS:
I. Conversion Privilege for Life Insurance
Insured Employees and Insured Spouses may convert to an individual policy of life insurance for an
amount not greater than the Conversion Amount shown below when the Policy ends,without regard
to any requirement that the person be insured under the policy for a specified period of time, if all of
the following apply.
a. The Insured became Totally Disabled while covered for the Life Benefit of the Policy.
Totally Disabled means the person is unable to perform all the material duties of any
occupation for which he or she may reasonably be qualified based on training, education and
experience.
b. The Insured remained Totally Disabled until the Policy ended while covered for the Life
Benefit of this Policy.
C. The Policy does not provide a Waiver of Premium, Extended Death Benefit Provision or
monthly payments to Totally Disabled Insureds for the Life Benefit.
d. The person meets all other conditions for converting the insurance.
Conversion Amount- Insured's life insurance amount under the Policy on the date the Policy ends
minus the amount for which the Insured is insured under a group policy that provides life coverage to
employees of the Insured Employee's Employer covered under this Policy.The dollar limit that
applies to the amount for conversion at Policy termination does not apply.
The requirement that the Insured be covered under the Policy for the stated number of years in order
to convert life insurance does not apply.
NOTICE: FOR EMPLOYERS LOCATED IN CALIFORNIA, THEY MUST PROVIDE COVERAGE
TO CALIFORNIA RESIDENTS WHO ARE IN A REGISTERED DOMESTIC PARTNERSHIP.
APPLICABLE TO FLORIDA RESIDENTS:
The benefits of the policy providing your coverage are governed primarily by the law of a state other than
Florida.
25
APPLICABLE TO MARYLAND RESIDENTS:
The Group Insurance Policy was issued in a jurisdiction other than Maryland and may not provide all of
the benefits required by Maryland law.
APPLICABLE TO MINNESOTA RESIDENTS:
The following"Continuation of Life Insurance"provision is applicable to Minnesota residents if the
Employer has a minimum of 25 Employees who reside in Minnesota, or the Minnesota Employees
represent at least 25%of all covered Employees under the Policy, and the Policy does not offer
Portability.
Continuation Of Life Insurance—This provision shall not apply to the extent that the Policy provides
for the right of Employees to continue insurance on a direct billed basis following termination of
employment(Portability).
This provision shall apply with respect to Employees whose coverage Linder the Policy is terminated due
to: (i) voluntary or involuntary termination or layoff from employment, for any reason other than gross
misconduct; or(ii) reduction in hours such that the Employee is not eligible for insurance under the
Policy. This provision shall only apply to Employees who, on such date, are Minnesota residents.
This provision shall also apply with respect to Employees whose coverage under the Policy's Takeover
Provision ends, for any reason other than the Employee meeting the Policy's Active Service requirement.
For those Employees subject to this provision, life insurance coverage may be continued under the Policy
for 19 months or until the date that the Employee becomes covered under another group policy,
whichever is shorter. Coverage provided under this provision will also end if the Policy is terminated.
The premium required for continued coverage shall be the premium under the Policy applicable to the
Employee's class and amount of coverage. The Employer may charge an additional amount, not to
exceed 2%of such premium, for collecting premium contributions from former Employees. The
Employer shall notify the Employee of the right to continue and the required premium contribution. The
Employee may elect to continue within 60 days of termination by paying the required premium, and may
continue coverage in force by paying the required premium,without demand, on a monthly basis, as of
the first of each month,to the Employer. Coverage will end at the end of any month in which the
Employee has failed to pay premium to the Employer.
If continued coverage remains in force at the end of the 19 month period, or on termination of the Policy,
the Employee may choose any conversion right then available under the Policy.
In the event the Employee dies during the 60 day right to elect period without having become insured
under another group policy, or dies white continued coverage is in force,the death benefit will be paid to
the beneficiary chosen by the Employee under the terms of the Policy.
Continued coverage will include eligible dependents who were covered on the Employee's date of
termination, provided the dependent remains eligible as a dependent of the Employee. In the event that
the dependent ceases to be eligible, the dependent may choose any conversion right then available under
the Policy.
26
APPLICABLE TO NORTH DAKOTA RESIDENTS:
The Suicide exclusion, if any, is limited to one year from the effective date of insurance. The suicide
exclusion with respect to any increase in death benefits which results from an application of the insured
subsequent to the effective date, if any, is limited to one year from the effective date of the increase.
APPLICABLE TO OREGON RESIDENTS:
NOTICE: MUST PROVIDE DOMESTIC PARTNER COVERAGE FOR OREGON RESIDENTS
APPLICABLE TO VERMONT RESIDENTS:
To the extent the Policy provides insurance coverage to a spouse,the identical consideration must be
applied to same sex marriages and Civil Union Partners.
1. Civil Union Partner means:
a. A person with whom the Employee has a registered civil union under Vermont law which
imposes obligations on the parties substantially similar to marriage. Such person will continue to
be recognized as a Civil Union Partner unless and until: (1)the civil union is dissolved under
applicable law; or(2)either the Employee or the Civil Union Partner marries another person.
2. Spouse means:
a. "Lawful spouse" and includes a lawful spouse of the same sex.
b. This also includes a partner to a civil union recognized under Vermont Law,
Signed for the
Life Insurance Company of North America
Matthew G. Manders, President
'C[.-ooaaw oo
27
UNDERWRITTEN BY:
LIFE INSURANCE COMPANY OF NORTH AMERICA
a Cigna company
Class 1
03/2018
Cigna..
�.✓� Jig � O T Agenda Item: Consent Calendar - 7H
TO: City Council
DATE: November 21, 2017
SUBJECT: Contract Renewals for Medical, Dental, Vision, Basic Life, Voluntary Life,
and Long Term Disability Insurance - Authorize
MOTION: Authorize the Mayor to approve renewal of the City's contracts
for medical, vision, and dental benefits with Premera, Vision Service Plan
(VSP), and Delta Dental for three years, and Kaiser Permanente (formerly
Group Health) for one year, and to approve switching from Standard
Insurance to Cigna for a new 3-year contract for Basic Life, Voluntary Life,
and Long Term Disability insurance, subject to approval of final terms and
conditions by the Human Resources Director and the City Attorney.
SUMMARY: The City of Kent contracts with Premera Blue Cross, Delta Dental of
Washington and Vision Service Plan, to be third party administrators to process
medical, dental, and vision claims, and provide access to their networks of doctors,
hospitals, dentists, optometrists and ophthalmologists. The City is self-insured for
these programs and wires funds to cover the weekly claims cost for medical,
prescription, dental, and vision expenses. The City also contracts with Kaiser
Permanente for the City's insured health maintenance organization. After conducting
separate request for proposal processes for each of these services, staff recommends
renewal of these contracts with the current vendors.
After holding a request for proposal process, and discussions with the City's
Healthcare Board, staff recommends a move from our current vendor for long-term
disability services and basic life, AD&D and voluntary life insurance to Cigna.
Although all core contract terms have been resolved with these providers, the City and
the providers are still in the process of winding up final contract language. These
vendors also have their own lengthy internal approval process, so authorization is
sought now to get approval for next year's budget cycle.
EXHIBITS: Memo to the Operations Committee
RECOMMENDED BY: Operations Committee
YEA: Boyce, Ralph, Thomas NAY: N/A
BUDGET IMPACTS: Premera - $1,345,000 for a three year contract; Delta Dental -
$165,330 for a three year contract; Vision Service Plan - $56,100 for a three year
contract; Kaiser Permanente - $420,000 for a one year contract; and Cigna -
$705,000 for a three year contract.
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�I
HUMAN RESOURCES DEPARTMENT
F4ENT Marty Fisher, Director
Phone: 253-856-5270
Fax: 253-856-6270
Address: 400 West Gowe
Kent, WA 98032-5895
DATE: November 7, 2017
TO: Operations Committee
FROM: Laura Horea, HR Benefits Manager
SUBJECT: Medical, Dental, Vision, Basic Life, Voluntary Life, and Long Term
Disability Insurance Vendor Contracts
SUMMARY: The Benefits Division of the Human Resources Department conducted
separate Request for Proposal processes for 1) Medical, dental, and vision
insurance, and 2) Basic Life and Accidental Death & Dismemberment (AD&D),
Voluntary Life and Long Term Disability insurance between April and August 2017.
All bids were reviewed by the Human Resources Director, the Benefits Manager,
and discussed with members of the City's Healthcare Board.
Medical, dental, and vision insurance bids were received from Premera, Aetna,
HMA, Regence, Kaiser Permanente (formerly Group Health), Delta Dental, and
Vision Service Plan (VSP). United Healthcare declined participation.
Our current providers, Premera, Delta Dental, and VSP are recommended to renew
for additional three-year contracts and Kaiser Permanente for a one-year renewal,
based on the strength of their plans, overall costs, customer service, discounts, and
overall administration and billing accuracy.
Basic Life and AD&D, Voluntary Life and Long Term Disability insurance bids were
received from our current vendor, Standard Insurance, and also from Cigna and
Mutual of Omaha.
The recommendation is to move from our current vendor, Standard Insurance, to
Cigna for long-term disability services, basic life insurance, AD&D, and employee
and dependent voluntary life insurance for the following reasons:
• Savings of approximately $100k per year in each of the three years of the
proposed new contract; and
• Increase in employee basic life insurance coverage from 1 x salary up to
$50,000 to 1 x salary up to $150,000.
Employees will have the opportunity to purchase additional voluntary life
insurance for themselves and their family members at a significantly lower
rate than is available through Standard.
Staff has received excellent feedback regarding Cigna from current customers
about their billing accuracy, systems, overall administration, and customer service.
Locally the City of Kirkland just moved to Cigna for these services.
All other contract features are identical to our current offering from Standard.
I
REQUEST FOR MAYOR'S SIGNATURE
*+ KtNT Print on Cherry-Colored Paper
Routing Information:
(ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPARTMENT)
Approved by Director_
Originator: Laura Horea Phone (Originator): 253.856.5290
Date Sent: 4/16/18 Date Required: 4/19/18
Return Signed Document to: Laura Horea Contract Termination Date: 12/31/2020
VENDOR NAME: Date Finance Notified:
CIGNA (Only required on contracts 09/28/17
$20,000 and over or on any Grant)
DATE OF COUNCIL APPROVAL: 11/21/17 Date Risk Manager Notified:09/28/17
(Required on Non City Standard Contracts/Agreements)
Has this Document been Specificall Account Number:
Authorized in the Budget? YES NO
................a_
Brief Explanation of Document:
CIGNA contract - covers Basic Life, Basic AD&D, Voluntary Life and Long Term Disability
--
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Received: �1f'�' Routed Through The Law Department
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Approval of Law Dept,: t f(
Law De et. Comments:
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Recommendations and Comments:
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`Date Returned:
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