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HomeMy WebLinkAboutHR18-161 - Original - CIGNA - Voluntary Group Life Insurance Policy #FLX-968146 - 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: PROTECTION FOR YOU AND YOUR INSURANCE POLICY THE WASHINGTON LIFE AND DISABILITY INSURANCE GUARANTY ASSOCIATION PREFACE This brochure briefly describes the coverage provided through the Washington Life& Disability Insurance Guaranty Association("Association"). The Association is a nonprofit unincorporated legal entity created by the Washington Life and Disability Insurance Guaranty Association Act, Chapter 48.32A RCW("Act"). Every life and disability insurance company authorized to do business in Washington is a member of the Association. A Board of Directors ("Board"), composed of representatives from member insurers, and the Insurance Commissioner, ex officio, oversee the operation of the Association. The expenses of the Association are paid by assessments made against each member insurer. Persons covered by the Act are not charged for the expenses of the Association or the protection provided under the Act. Coverage is provided for certain life and disability insurance. However, the Association does not cover all such insurance. Coverage that is provided is subject to the limitations and exclusions provided by the Act. The purpose of this brochure is to help you understand the general nature and the conditions of the protection provided under the Act. It is only a summary, however, and if you have specific questions that are not discussed here you may contact either the Association or the Office of the Insurance Commissioner. Washington Life and Disability Company Supervision Division Insurance Guaranty Association Office of the Insurance Commissioner P.O. Box 2292 P.O. Box 40259 Shelton, WA 98584 Olympia, WA 98504-0259 360-426-6744 360-725-7214 QUIKSIl'IONS AND ANSWERS L WHAT INSURANCE POLICIES ARE COVERED UNDER THE ACT? The Act applies to life insurance policies, disability insurance policies, and annuity contracts issued by an insurance company authorized to do business in Washington. The term"disability insurance," as used in the Act, includes not only disability income insurance, but also policies commonly referred to as"health insurance"(which includes long term care policies). Together, all of these policies and contracts are sometimes referred to as "covered policies," a term used in this brochure. 2. ARE THERE POLICIES OR INSURERS NOT COVERED BY THE ACT? The Act specifically excludes certain types of policies or portions of policies, including, but not limited to: The portion of a policy not guaranteed by the insurer; the portion of a policy to the extent the interest rate or crediting rate exceeds the limits in the Act; policies of reinsurance, unless assumption certificates have been issued; policies issued in Washington by an insurer at a time when the insurer was not licensed or did not have a certificate of authority; policies issued to a self- insured plan or program; certain unallocated employee benefit plan annuities protected by federal law; and unallocated annuity contracts not issued to or in connection with a benefit plan or a government lottery. The Act also does not apply to policies or contracts issued by health care service contractors, health maintenance organizations, fraternal benefit societies, self funded multiple employer welfare arrangements, mandatory state pooling plans, mutual assessment companies, insurance exchanges, or an organization that has a certificate or license limited to issuance of certain charitable gift annuities. 3. WHO IS PROTECTED UNDER THE ACT? You are covered by the Act if you are an owner of or certificate holder under a policy or contract (other than an unallocated annuity contract or structured settlement amenity), and: ➢ You are a Washington resident; or ➢ You are not a Washington resident, but only if: the insurer is domiciled in Washington; there is an association similar to the Washington Association in your state of residency; and you are not covered in your state of residency, because the insurer was not licensed in that state; or ➢ You are a beneficiary, assignee, or payee of one of the above, regardless of where you reside(except for nonresident certificate holders under group policies). Owners of unallocated annuity contracts are covered if the contract was issued to or in connection with a specific benefit plan whose plan sponsor has its principal place of business in Washington, or the contract was issued to or in connection with a government lottery and the owner is a Washington resident. A payee under a structured settlement annuity (or beneficiary of a deceased payee) is also covered, if the payee is a Washington resident,or the payee is not a Washington resident, but the contract owner is a resident; or the insurer that issued the annuity is domiciled in Washington and coverage is not available in the state in which the payee resides. Residency is generally determined at the time of entry of an order of liquidation against the insurer. If you move to another state and reside there when such an order is entered,you may still have protection under the law of that state. You should contact the insurance department in your new state of residence to find out about guaranty act protection there. 4. HOW DOES THE ASSOCIATION PROTECT COVERED PERSONS AGAINST LOSS? After an order of liquidation is entered against a company, the Association begins its work of carrying out the propose of the Act, which is to assure the performance of insurance obligations of that company. The Association is authorized to carry out its duties by working with insurance companies in good standing to assume or take over the covered policies. The association may also directly provide benefits and coverage as authorized by the Act. The Association has the authority to collect the funds necessary to provide protection to covered persons against losses on their covered policies. PROTECTION FOR YOU AND YOUR INSURANCE POLICY THE WASHINGTON LIFE AND DISABILITY INSURANCE GUARANTY ASSOCIATION 5. WHERE DOES THE ASSOCIATION GET THE MONEY TO PROVIDE THIS PROTECTION? The Association is authorized to collect money from all life and disability insurance companies doing business in Washington. The funds collected from an assessment are used to pay claims to covered persons and/or to fund the assumption of covered policies by another insurer. 6. DOES THE ASSOCIATION PAY OUT THE MONEY IT COLLECTS RIGHT AWAY OR DO COVERED PERSONS HAVE TO WAIT? The Association generally cannot make an assessment for covered policies issued by a company until after an order of liquidation has been entered against the company, and a reasonable estimate can be made of the amount of money needed. Insurance companies receiving an assessment notice must make their payments within thirty days. Because it takes time for an action to be commenced against a financially impaired insurer, for a Court to issue an order, and for funds to be collected to satisfy the obligations of that insurer, some delay, hopefully short, is unavoidable before payments can be made. Although it is impossible to predict how long this process will take in any given case, an average time period of twelve to eighteen months is not unusual. When necessary, the Association may borrow money to make payments more promptly, particularly in cases that will take an unusual amount of time to be resolved. 7. W1IAT IS THE AMOUNT OF PROTECTION PROVIDED BY THE ACT? The Act provides the following maximum amounts of protection: Life Insurance Death Benefits_...........................................................................................................$500,000 Disability Benefits and Health Benefits (including Long Term Care Benefits)................................. $500,000 Present Value of Individual Annuities ................................................................................................$500,000 Unallocated Annuity Contracts, other than certain government retirement plans (limit is per contract owner or plan sponsor),...... ................................ .................---............$5,000,000 Government Retirement Plans in Unallocated Annuities established under Internal Revenue Code § § 401,403(b), or 457(limit is per participant)............................................................................. $100,000 This protection becomes effective at the time of entry of a Court order of liquidation against the insurer.Of course, if the amount owed under the contract or policy is less than the maximum benefit under the Act, the covered person will be entitled to protection only up to the actual amount owed. Furthermore,the maximum protection available to each covered person remains the same, regardless of the number of contracts through which he or she has a claim. 8. IF A HUSBAND AND WIFE EACH INDIVIDUALLY OWN A COVERED POLICY, IS THE PROTECTION UNDER THE ACT PROVIDED TO EACH OF THEM? Yes. As long as the residency requirements are met, both would be entitled to the protection provided by the Act, up to the maximum amount. 9. WHY DOESN'T MY INSURANCE COMPANY ADVERTISE THE FACT THAT ITS POLICIES AND CONTRACTS ARE PROTECTED UNDER THE ACT? Under Washington law, insurance companies are prohibited from advertising that their policies or contracts may be covered under the Act. You should not rely on coverage under the Act when selecting an insurance company. 10. WHY HASN'T MY AGENT TOLD ME ABOUT THE GUARANTY ACT? Your insurance agent is subject to the same prohibitions as your insurance company. As a representative of the company, an agent must exercise great care when soliciting business and consequently, will generally not discuss the subject of a guaranty act with clients. 11. WHO SHOULD I CONTACT IF I BELIEVE THERE HAS BEEN A VIOLATION OF THE ACT? You should contact the Association if you believe your rights have been violated under the Act. If you are dissatisfied with the actions of the Association, you may also contact the Office of the Insurance Commissioner. CONCLUSION This brochure has been prepared by the Washington Life and Disability Insurance Guaranty Association, Its purpose is to inform the public in a general way of the protections that are available in this state on insurance policies and annuity contracts issued by companies authorized to do business in Washington. The Association does not,by this brochure, endorse any company or its products, but rather seeks to address some of the concerns that you may have regarding the security of insurance policies and annuity contracts. For more information or answers to specific questions you may contact the Washington Life and Disability Insurance Guaranty Association or the Office of the Insurance Commissioner,whose addresses and telephone numbers are shown in the Preface. _...._ ..................... This brochure is prepared by and made available through the Washington Life and Disability Insurance Guaranty Association, which has granted member insurance companies permission to reproduce and distribute the brochure. It is the responsibility of the company, or any representative of a company, reproducing this brochure,to ensure that the use thereof does not violate applicable laws or regulations. I 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. TL-004798 LIFE INSURANCE COMPANY OF NORTH AMERICA 1601 CHESTNUT STREET GROUP POLICY PHILADELPHIA, PA 19192-2235 (NON-PARTICIPA'r[NG) (800)732-1603 TDD(800) 552-5744 A STOCK INSURANCE COMPANY POLICYHOLDER: City of Kent POLICY NUMBER: FLX-968146 POLICY EFFECTIVE DATE: January 1,2018 POLICY ANNIVERSARY DATE: January I This Policy describes the terms and conditions of coverage. It is issued in Washington and shall be governed by its laws. The Policy goes into effect on the Policy Effective Date, 12:01 a.m. at the Policyholder's address. In return for the required premium, the Insurance Company and the Policyholder have agreed to all the terms ofthis Policy. 4'w '-a L( � -k. 4 . � Anna Krishtul, Corporate Secretary Matthew G. Manders, President 'If-O04700 i TABLE OF CONTENTS SCHEDULE OF BENEFITS..........._........... ................................... . ........ ..... ........,........ 1 SCHEDULE OF BENEFITS FOR CLASS 1...............................................................................................2 ELIGIBILITY FOR INSURANCE ..............................................................................................................7 ENROLLING FOR INSURANCE,.,...............................----.... ..... ............... .................... ...... -9 EFFECTIVE DATE OF INSURANCE.................................................................................................,.... 10 TERMINATION OF INSURANCE...........................................................................................................I 1 CONTINUATION OF INSURANCE........................................................................................................12 LIFE INSURANCE BENEFITS...................-......,...................................,................................................ 19 CLAIMPROVISIONS................................................................................................................................22 ADMINISTRATIVE PROVISIONS....................................................................................... ..................25 SCHEDULEOF RATES............................................................................................................................27 GENERALPROVISIONS ..........................................................................................,..............................30 DEFINITIONS..................................................................................................................................... DOMESTIC PARTNER/CIVIL UNION PARTNER RIDER....................................................................34 STATE MODIFYING PROVISIONS AMENDMENT RIDER............ ......-................. ....-........36 SCHEDULE OF BENEFITS Premium Due Date: The last day of each month Classes of Eligible Employees Class 1 All active, Benefited Employees of the City of Kent regularly working the minimum required weekly hours for their job subject to a minimum of 20 hours per week, and the elected Mayor currently in office. I SCHEDULE OF BENEFITS FOR CLASS 1 Eligibility Waiting Period The Eligibility Waiting Period is the period of time the Employee must be in Active Service to be eligible for coverage. It will be extended by the number of days the Employee is not in Active Service. For Employees hired on or before the Policy Effective Date: No Waiting Period For Employees hired after the Policy Effective Date: No Waiting Period LIFE INSURANCE BENEFITS Employee Benefits Amount of Insurance An amount elected in units of$10,000 Guaranteed Issue Amount: the greater of a)or b)below: a) $300,000, or b) an amount equal to the Life Insurance Benefit in effect on the termination date of the Prior Plan Maximum Benefit: the lesser of 6 times Annual Compensation or$500,000 The Maximum Benefit will be rounded to the next higher$10,000, if not already a multiple thereof. Age Based Reductions Life Insurance Benefit for an Employee age 70 and over 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 1 st coinciding with or next following the Employee's attainment of age as specified in schedule above. Continuation Options For Layoff Maximum Benefit Period: the end of the month in which the layoff begins For Leave of Absence Maximum Benefit Period: 12 months For Family Medical Leave Maximum Benefit Period: 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 For Disability for Employees over Age 60 Maximum Benefit Period: 12 months Applicable Coverages: Life Insurance Benefits for the Employee, his or her Spouse and Dependent Children, if any 2 Extended Death Benefit with Waiver of Premium Extended Death Benefit Applicable Coverages Life Insurance Benefits for the Employee, his or her Spouse and Dependent Children, if any Waiver of Premium Waiver Waiting Period 9 months from the date the Employee's Active Service ends Maximum Benefit Period Lifetime of the Employee Applicable Coverages Life Insurance Benefits for the Employee, his or her Spouse and Dependent Children, if any Portability Options For Employees See the Former Employee and Spouse/Domestic Partner of a Former Employee sections in this Schedule of Benefits for the amounts of insurance an Insured is eligible to continue under this option. 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, subject to a Maximum Benefit of $225,000. Spouse or Domestic Partner Benefits Amount of Insurance Units of$10,000 Guaranteed Issue Amount: the greater of a)or b) below: a) $50,000, or b) an amount equal to the Life Insurance Benefit in effect on the termination date of the Prior Plan Maximum Benefit: $300,000 A Spouse's Life Insurance Benefits cannot exceed 100%of the Employee's Voluntary Life Insurance Benefits. Portability Options For Spouse or Domestic Partner Sec the Former Spouse or Domestic Partner section in this Schedule of Benefits for the amounts of insurance an Insured is eligible to continue under this option. 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. 3 Dependent Child Benefits Voluntary Benefit Option I Units of$2,000 Option 2 Units of$5,000 Option 3 Units of$10,000 Maximum Benefit: $10,000 A Dependent Child's Life Insurance Benefits cannot exceed 100% of the Employee's Life Insurance Benefits. All Dependent Child benefits are Guaranteed Issue. Portability Options For Dependent Children See the Former Dependent Child section in this Schedule of Benefits for the amounts of insurance an Insured is eligible to continue under this option. Annual Enrollment Period For Employees During an Annual Enrollment Period, an Employee currently insured under the Voluntary Life Insurance portion of this Policy may increase his or her Voluntary Life Insurance Benefit, and an Employee who is eligible for the Voluntary Life Insurance portion of this Policy but who has not previously enrolled may become insured under the Policy, as long as the total Benefit does not exceed the Maximum Benefit, by satisfying the Insurability Requirement. Insurance will be effective on the later of the Policy Anniversary following the Annual Enrollment Period or the date the Insurance Company agrees in writing to insure the Employee. For Spouses During an Annual Enrollment Period, an eligible Employee may elect coverage for his or her eligible Spouse. If a Spouse is currently insured under the Voluntary Life Insurance portion of this Policy, his or her Voluntary Life Insurance Benefit may be increased, as long as the total Benefit does not exceed the Maximum Benefit,by satisfying the Insurability Requirement. If a Spouse is eligible for the Voluntary Life Insurance portion of this Policy but has not previously enrolled, he or she may become insured under the Policy, as long as the total Benefit does not exceed the Maximum Benefit, by satisfying the Insurability Requirement. Insurance will be effective on the later of the Policy Anniversary following the Annual Enrollment Period or the date the Insurance Company agrees in writing to insure the Spouse. Insurance Benefits for an Employee, his or her Spouse and Dependent Children may be reduced at any time. A request for a Benefit reduction received during an Annual Enrollment Period will become effective on the Policy Anniversary following the Annual Enrollment Period. Any other Benefit reduction will be effective on the date the Insurance Company receives the completed change form. rL-002025-i 4 Life Status Change For Emplcrvees Within 31 days after a Li Fe Status Change, an Employee currently insured under the Voluntary Life Insurance portion of this Policy may increase his or her Voluntary Life Insurance Benefit as long as the total Benefit does not exceed the Guaranteed Issue Amount without satisfying the Insurability Requirement. An Employee who is eligible for the Voluntary Life Insurance portion of this Policy but who has not previously enrolled may become insured Linder the Policy as long as the total Benefit does not exceed the Guaranteed Issue Amount without satisfying the Insurability Requirement. Guaranteed Issue Amounts are shown above. Insurance will be effective on the first of the month following the Life Status Change. An Employee may increase coverage or become insured for a Benefit in excess of amounts described above only if he or she satisfies the Insurability Requirement. Any excess amounts will be effective on the later of the first of the month following the Life Status Change or the date the Insurance Company agrees in writing to insure the Employee. Insurance Benefits for an Employee may be reduced at any time. The reduced amount will be effective on the date the Insurance Company receives the completed change form. 'FL 008030-1 Former Employee Benefits Amount of Insurance An amount elected subject to the Maximum Benefit amount for Life Insurance Benefits allowable to an Employee, 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 he or she no longer qualifies as an Employee will be effective on the date the Insurance Company agrees 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 Ill, subject to a Maximum Benefit of $225,000. Spouse or Domestic Partner of Former Employee Benefits Amount of Insurance An amount elected subject to the Maximum Benefit amount for Life Insurance Benefits available to a Spouse or Domestic Partner. Any amount elected in excess of the Life Insurance Benefits in effect on the date the Employee's employment with the Employer ends will be effective on the date the Insurance Company agrees 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 111. 5 i i Former Spouse or Domestic Partner Benefits Amount of Insurance An amount elected subject to the Maximum Benefit amount for Life Insurance Benefits available to a Spouse or Domestic Partner. Any amount elected in excess of the Life Insurance Benefits in effect on the date he or she no longer qualifies as a Spouse or Domestic Partner will be effective on the date the Insurance Company agrees 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 111. 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 n.004994(WA) 6 ELIGIBILITY FOR INSURANCE 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. An Employee who is the Spouse of another Employee may not be insured for Voluntary Life Insurance as both an Employee and as a Spouse at the same time. Any Employee, who is eligible for Voluntary Life Insurance, will not be eligible to be insured as a Dependent Child of another Employee. If an Employee is eligible and has enrolled as the Spouse of another Employee, but ceases to be eligible to maintain the amount of insurance for which he or she has enrolled as a Spouse, that Employee may, within 31 days, enroll for coverage as an Employee, in an amount equal to the lesser of(1)the amount of Spouse Voluntary Life Insurance terminating, or(2)the maximum amount of Employee Voluntary Life Insurance for which the Employee is eligible. The Insurability Requirement does not apply. if this amount is not equal to a Voluntary Life Insurance coverage option, it will be adjusted to the next higher available Voluntary Life Insurance coverage option. This provision shall be in lieu of the Policy's provisions, if any, regarding coverage changes following Life Status Changes. If a Spouse is eligible and has enrolled for Voluntary Life Insurance as an Employee, but ceases to be eligible to maintain the amount of insurance for which he or she has enrolled as an Employee,the Spouse may, within 31 days, instead become enrolled as a Spouse of another Employee, in an amount equal to the lesser of(1)the amount of Employee Voluntary Life Insurance terminating, or(2)the Maximum Benefit Amount of Spouse Voluntary Life Insurance for which the Spouse is eligible. The Insurability Requirement does not apply. If this amount is not equal to a Voluntary Life Insurance coverage option, it will be adjusted to the next higher available Voluntary Life Insurance coverage option. A Dependent Child of two or more Employees may only be insured once under the Policy. If an Employee who has elected to insure Dependent Children ceases to be eligible to do so, then the Employee's Spouse may, within 31 days, elect to insure Dependent Children, provided he or she is insured as an Employee. In all cases, "Dependent Child"shall be defined with respect to the Employee who has enrolled dependent children. In all cases, amounts of insurance referred to in these provisions shall be determined before the application of any reductions in benefits due to age. Any amount of Voluntary Life Insurance Coverage which cannot be continued under the above provisions may be subject to the Conversion Privilege. 7 Employee An Employee in one of the Classes of Eligible Employees shown in the Schedule of Benefits is eligible to be insured on the Policy Effective Date or the day after he or she completes the applicable Eligibility Waiting Period, if later. If a person has previously converted his or her insurance under the Policy, he or she will not become eligible until the 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 the Employee's Life Insurance Benefits based on age or a change in class unless those conditions no longer affect the amount of coverage available to the Employee. i Except as noted in the Reinstatement Provision, if an Employee terminates coverage and later wishes to reapply, or if a former Employee is rehired, a new Eligibility Waiting Period must be satisfied. An Employee is not required to satisfy a new Eligibility Waiting Period, if insurance ends because he or she ` is no longer in a Class of Eligible Employees, but continues to be employed by the Employer, and within one year becomes a member of an eligible class. Spouse If an Insured is eligible to elect Spouse coverage, the Spouse is eligible to be insured on the date the Employee is eligible or the date he or she becomes a Spouse of an Employee, if later. The eligible Employee must be insured for Voluntary Life Insurance in order to elect spouse coverage. For the purpose of eligibility, the Spouse must be the lawful Spouse of the Employee and not legally separated or divorced from, or widowed by the Employee. Dependent Child If an Insured is eligible to elect Dependent Child coverage, the Dependent Child is eligible to be insured on the date the Insured is eligible or on the date the child qualifies as a Dependent Child, if later. In no event will a Dependent Child be eligible to become insured more than once under the Policy. 8 ENROLLING FOR INSURANCE Initial Enrollment For Employees Daring the Initial Enrollment Period, an Employee who was insured under the Prior Plan may increase his or her Voluntary Term Life Insurance Benefit under this Policy by one Benefit Level, up to One Benefit Unit Increase, as shown in the Schedule of Benefits, without satisfying any Insurability Requirement. An Employee who was eligible to be insured under the Prior Plan but not enrolled for coverage, may become insured under the Voluntary Term Life Insurance Plan provided by this Policy for a Benefit equal to one Benefit Level, up to One Benefit Unit Increase, as shown in the Schedule of Benefits, without satisfying any Insurability Requirement. See Effective Date oflnsurance provision. If an Employee is not actively at work due to Injury or Sickness, coverage will not become effective for an Employee on the date his or her coverage would otherwise become effective under this Policy. Coverage will become effective on the date the Employee returns to Active Service. An Employee may become insured for an amount in excess of amounts described above only if he or she satisfies the Insurability Requirement. Any excess amount will be effective on the date the Insurance Company agrees in writing to insure the Employee. For Spouses During the Initial Enrollment Period, an eligible Employee may elect coverage for his or her eligible Spouse. If a Spouse was insured under the Prior Plan,his or her Voluntary Term Life Insurance Benefit under this Policy may be increased by one Benefit Level, up to One Benefit Unit Increase,as shown in the Schedule of Benefits, without satisfying any Insurability Requirement. If a Spouse was eligible to be insured under the Prior Plan but not enrolled for coverage, he or she may become insured under the Voluntary Term Life Insurance Plan provided by this Policy, for a Benefit equal to one Benefit Level, up to One Benefit Unit Increase, as shown in the Schedule of Benefits, without satisfying any Insurability Requirement. See Effective Date oflnsurance provision. If an Employee is not actively at work due to Injury or Sickness, the amount of coverage elected during the Initial Enrollment for his or her Spouse will not become effective on the date the Spouse's coverage would otherwise become effective under this Policy. Such coverage will become effective on the date the Employee returns to Active Service. A Spouse may become insured for an amount in excess of amounts described above only if he or she satisfies the Insurability Requirement. Any excess amount will be effective on the date the Insurance Company agrees in writing to insure the Spouse. If an Employee's eligible Spouse is(a)an inpatient in a hospital, hospice, rehabilitation or convalescence center, or custodial care facility; or(b) 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 the dependent is no longer an inpatient in these facilities or confined at home. If such dependent was covered by a Prior Plan on the date immediately prior to first becoming eligible under this Policy, this provision will not apply to the amount of coverage in effect on such date, but will apply to any increase in coverage. '1 1L90H055-1 9 EFFECTIVE DATE OF INSURANCE An Employee who is required to contribute to the cost of this insurance may elect insurance for himself or herself and an eligible Spouse or Dependent Child only by authorizing payroll deduction in a form approved by the Employer and the Insurance Company. The effective date of this insurance depends on the date and amount of insurance elected. If an individual elects coverage within 31 days after becoming eligible to enroll, or for any increases, the Guaranteed Issue Amount will be effective on the latest of the following dates: 1. The Policy Effective Date. 2. The date payroll deduction is authorized for this insurance. 3. The date the Employer or Insurance Company receives the completed enrollment form. If Employee or Spouse coverage is elected in an amount that exceeds the Guaranteed Issue Amount or an enrollment form is received more than 31 days after becoming eligible to elect coverage, this insurance will be effective on the date the Insurance Company agrees in writing to insure that eligible person. The Insurance Company will require the eligible person to satisfy the Insurability Requirement before it agrees to insure him or her. If coverage for a Dependent Child is in force and another Dependent Child becomes eligible, coverage for that child is effective on the date the child qualifies as a Dependent Child. If an eligible Employee is not in Active Service on the date insurance would otherwise be effective, it will be effective on the date he or she returns 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. I L004712 10 Takeover Provision Special Terms Applicable to Previously Insured Employees Not in Active Service and Their Dependents Coverage will not go into effect for an Employee, or his or her Spouse and Dependent Children unless the Employee is in Active Service on the date the Employee would have first become eligible to be insured under the Policy. However: 1. if such Employee, and his or her Spouse or Dependent Children were insured under a Prior Plan on the date immediately prior to the date the Employee would have first become eligible to be insured under this Policy had the Employee satisfied the Active Service requirement, and 2. if such Employee, Spouse or Dependent Child dies, the Insurance Company agrees to provide a Death Benefit only equal to the lesser of: a. the amount due under this Policy (had the Employee satisfied the Active Service requirement), or b. the amount that would 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 terms will end on the earliest of the following dates: I. the date the Employee meets 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 the Employee first becomes eligible under this Policy; or 4. the last day the Employee, Spouse or Dependent Children would have been covered under the Prior Plan if coverage of the Employee, Spouse or Dependent Children under that plan was still in force. r�ooyoza-i TERMINATION OF INSURANCE An Insured's coverage will end on the earliest of the following dates: 1. the date the Employee is eligible for coverage under a plan intended to replace this coverage; 2. the date the Policy is terminated by the Insurance Company; 3. the date the Insured is no longer in an eligible class; 4. the date coinciding with the end of the last period for which premiums are paid; 5. the date an Employee is no longer in Active Service; 6. for an Employee, Spouse and Dependent Child, the date the Employer cancels participation under the Policy; and 7. the date coverage for the Employee ends, for any insured Spouse and Dependent Child. 11 CONTINUATION OF INSURANCE If an Employee is no longer in Active Service, he or she may be eligible to continue insurance. The following provisions explain the continuation options available under the Policy. Please see the Schedule of Benefits to determine the applicability of these benefits on a class level. Continuation for Layoff,Temporary Leave of Absence or Family Medical Leave If an Employee's Active Service ends due to a layoff, Employer approved unpaid leave of absence, or family medical leave of absence, insurance will continue for up to the Maximum Benefit Period shown in the Schedule of Benefits, if the required premium is paid. Continuation of Life Coverage During Labor Disputes If an Employee's Active Service ends because of a Labor Dispute and his or her premium for Life Insurance Benefits under the Policy is paid either by the Employer, in whole or in part, or by the Employee through payroll deductions,then the Employee may continue his or her Life Insurance Benefits. The Employer will send written notice of the right to continue coverage to each insured Employee at his or her most recent address as on file with the Employer. To continue coverage,the Employee must pay premiums directly to the Employer, who will remit the premiums to the Insurance Company. 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, the Insurance Company 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, the Employee 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. 12 Continuation for Disability for Employees over Age 60 If an Employee becomes Disabled and is 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 the Employee is no longer Disabled. 2. The date following the Maximum Benefit Period shown in the Schedule of Benefits. 3. The date coinciding with the end of the last period for which premiums are paid. 4. The date the Policy is terminated by the Insurance Company. Amount oflnsurance If an Employee dies while he or she is Disabled and coverage is continued under this provision,the Insurance Company will pay a Death Benefit equal to the amount in effect on the date the Employee 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. The Insurance Company will pay benefits only if due proof of the Employee's continuous Disability is received within one year of the date of the loss. "Disability"/"Disabled" means because of Injury or Sickness the Employee is unable to perform all the material duties of his or her Regular Occupation; or is receiving disability benefits under the Employer's plan. "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. Extended Death Benefit with Waiver of Premium Extended Death Benefit If an Employee becomes Disabled and is 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: I. The date the Employee is no longer Disabled; or 2. 12 months after the end of Active Service. Amount oflnsurance If an Employee dies while he or she is Disabled and coverage is extended under this provision,the Insurance Company will pay a Death Benefit equal to the amount in effect on the date the Employee 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. The Insurance Company will pay benefits only if due proof of the Employee's continuous Disability is received within one year of the date of the loss. "Disability"/"Disabled" means because of Injury or Sickness the Employee is unable to perform the material duties of his or her Regular Occupation; or is receiving disability benefits under the Employer's plan. "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 Waiver of Premium If such an Employee submits satisfactory proof that he or she has been continuously Disabled for the Waiver Waiting Period shown in the Schedule of Benefits, coverage will be extended up to the Maximum Benefit Period shown in the Schedule of Benefits. Such proof must be submitted to the Insurance Company no later than 3 months after the date the Waiver Waiting Period ends. Premiums will be waived from the date the Insurance Company agrees in writing to waive premiums for that Employee. After premiums have been waived for 12 months,they will be waived for future periods of 12 months, if the Employee remains Disabled and submits satisfactory proof that Disability continues. Satisfactory proof must be submitted to the Insurance Company 3 months before the end of the 12-month period. Amount of Insurance If an Employee dies while he or she is Disabled and coverage is continued under this provision, the Insurance Company will pay a Death Benefit equal to the amount in effect on the date the Employee 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. The Insurance Company will pay benefits only if due proof of the Employee's continuous Disability is received within one year of the date of the loss. Termination of 6Paiver Insurance will end for any Employee whose premiums are waived on the earliest of the following dates. 1. The date he or she is no longer Disabled; 2. The date he or she refuses to submit to any physical examination required by the Insurance Company; 3. The date he or she refuses to participate in a Rehabilitation Plan for which the Insurance Company determines him or her to be eligible; 4. The last day of the 12-month period of Disability during which he or she fails to submit satisfactory proof of continued Disability; 5. The date following the end of the Maximum Benefit Period shown in the Schedule of Benefits. "Disability/Disabled" means because of Injury or Sickness an Employee is unable to perform the material duties of his or her Regular Occupation, or is receiving disability benefits under the Employer's plan, during the initial 9 months of Disability. Thereafter, the Employee must be unable to perform all of the material duties of any occupation which he or she may reasonably become qualified based on education, training or experience, or is 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. 14 Rehahilitation During a Period ofDisahility If the Insurance Company determines that a Disabled Employee is a suitable candidate for rehabilitation, the Insurance Company may require the Employee 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 the Employee's participation in a Rehabilitation Plan and to approve a program as a Rehabilitation Plan. If an Employee fails to fully cooperate in all required phases of the Rehabilitation Plan and assessment without Good Cause, 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: I. 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. "CL 009745.!,moW!l d b, I IAONM 1 15 Portability Options For Employees The Employee must apply to the Insurance Company and pay the required premium. If the Employee continues coverage, Spouse or Dependent Child coverage may also be continued by the Employee. The 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 the Employee's termination of employment or membership in an eligible class under the Policy; or b. during the time that the Employee has to exercise the Conversion Privilege. Coverage under this option may not be elected at a later date. When applying for this option, the Employee 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 Insured's estate. When coverage is continued under this option,the Employee becomes a Former Employee. The Spouse becomes a Spouse of a Former Employee. The Dependent Child becomes a Dependent Child of a Former Employee. If the Former Employee later acquires a Spouse or Dependent Child, he or she may elect coverage for them. The Former Employee must apply to the Insurance Company and pay the required premium. Coverage for the Spouse or Dependent Child will be effective on the date the Insurance Company agrees in writing to insure them. The Insurance Company may require that the Spouse or Dependent Child 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 the Insurance Company cancels 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. 16 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 the Insurance Company cancels 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. 17 i 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 under 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 the Insurance Company cancels coverage for all Former Dependent Children. b. The end of the period for which premiums are paid. C. 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. 'TF (104916 ue rtiedl[1od by'f L 009380 18 DESCRIPTION OF BENEFITS The following provisions explain the benefits available under the Policy. Please see the Schedule of Benefits for the applicability of these benefits on a class level. LIFE INSURANCE BENEFITS Death Benefit If an Insured dies, the Insurance Company will pay the Life Insurance Benefit in force for that Insured on the date of his or her death. TL on730 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 the Insurance Company not to be eligible for Accelerated Benefits. Terminal Illness Benefit The Insurance Company 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 ofTermfnalIllness For the purpose of determining the existence of a Terminal Illness,the Insurance Company will require the Insured submit the following proof. I. A written diagnosis and prognosis by a licensed Physician; and 2. Supportive evidence satisfactory to the Insurance Company, including but not limited to, radiological, histological or laboratory reports documenting the Terminal Illness, The Insurance Company may require, at its expense, an examination of the Insured and a review of the documented evidence by a Physician of its choice. Such proofs must be submitted to the Insurance Company within the period of time provided in the Proof gfLoss 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 the Insurance Company, 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. 19 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 Li Fe 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, the Insurance Company may require the written consent of the Insured's Spouse. Exclusions Applicable to Terminal Illness Benefit A Terminal Illness Benefit will not be payable: 1. 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 Termination oflnsurance 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 the Employee or 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. TL004748a W A 20 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 the Insurance Company offers to persons of the same age in the amount applied for, except the Insured 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 the Insured has 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: I. submit an application to the Insurance Company; 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 the Insurance Company 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. 21 Extension 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 tinder 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 the Insurance Company; 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 the Insurance Company, he or she will not be eligible for this Conversion Privilege unless the prior coverage has ended. TL,009)40 CLAIM PROVISIONS Notice of Claim Written notice, or notice by any other electronic/telephonic means authorized by the Insurance Company, must be given to the Insurance Company 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 the Insurance Company, 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 the Insurance Company of a diagnosis of a Terminal Illness on which claim is based must be given to us 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 the Insurance Company was given as soon as reasonably possible. Claim Forms When the Insurance Company receives notice of claim, the Insurance Company will send claim forms for filing proof of loss. If claim forms are not sent within 15 days after notice is received by the Insurance Company, 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 the Insurance Company, of the nature and extent of the loss. Claimant Cooperation Provision Failure of a claimant to cooperate with the Insurance Company in the administration of the claim may result in termination of 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. 22 Insurance Data The Employer is required to cooperate with the Insurance Company in the review of claims and applications for coverage. Any information the Insurance Company provides 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 Written proof of loss, or proof by any other electronic/telephonic means authorized by the Insurance Company, must be given to the Insurance Company 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 the Insurance Company, 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 the Insurance Company, must be given not more than one year after that 90 day period. If written proof of loss, or proof by any other electronic/telephonic means authorized by the Insurance Company, is provided outside of these time limits, the claim will be denied. These time limits will not apply while the person making the claim lacks legal capacity. Written proof,or any other electronic/telephonic means authorized by the Insurance Company, 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,the Insurance Company 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 installments 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. 23 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: (l)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 the Insured's death may, at the Insurance Company's option, be paid either to the Insured's beneficiary or to the executor or administrator of the Insured's estate. If the Insurance Company pays benefits to the executor or administrator of the Insured's estate or to a person who is incapable of giving a valid release,the Insurance Company may pay up to $1,000 to a relative by blood or marriage whom it believes is equitably entitled. This good faith payment satisfies the Insurance Company's legal duty to the extent of that payment. Change of Beneficiary The Insured may change the beneficiary at any time by giving written notice to the Employer or the Insurance Company. The beneficiary's consent is not required for this or any other change which the Insured may make unless the designation of beneficiary is irrevocable. No change in beneficiary will take effect until the form is received by the Employer or the Insurance Company. When this form is received, it will take effect as of the date of the form. If the Insured dies before the form is received,the Insurance Company will not be liable for any payment that was made before receipt of the form. Physical Examination and Autopsy The Insurance Company, at its expense, will have the right to examine any person for whom a claim is pending as often as it may reasonably require. The Insurance Company may, at its 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 the Insurance Company, 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. 24 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 the Employee lives 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 The Insured will have the right to choose any Physician who is practicing legally. The Insurance Company will in no way disturb the Physician/patient relationship. 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 the Insured's coverage amount is reduced due to acceleration of his or her Death Benefit, his or her premium will be based on the amount of coverage he or she has 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. Changes in Premium Rates The premium rates may be changed by the Insurance Company from time to time with at least 31 days advance written notice. No change in rates will be made until 36 months after the Policy Effective Date. An increase in rates will not be made more often than once in a 12 month period. However, the Insurance Company reserves the right to change the rates even during a period for which the rate is guaranteed if any of the following events take place. l. The terms of the Policy change. 2. A division, subsidiary, affiliated company or eligible class is added or deleted from the Policy. 3. There is a change in the factors bearing on the risk assumed. 4. Any federal or state law or regulation is amended to the extent it affects the Insurance Company's benefit obligation. 5. The Insurance Company determines that the Employer has failed to promptly furnish any necessary information requested by the Insurance Company, or has failed to perform any other obligations in relation to the Policy. If an increase or decrease in rates takes place on a date that is not a Premium Due Date, a pro rata adjustment will apply from the date of the change to the next Premium Due Date. Reporting Requirements The Employer must, upon request, give the Insurance Company any information required to determine who is insured,the amount of insurance in force and any other information needed to administer the plan of insurance. Payment of Premium The first premium is due on the Policy Effective Date. After that, premiums will be due monthly unless the Employer and the Insurance Company agree on some other method of premium payment. If any premium is not paid when due, the plan will be canceled as of the Premium Due Date, except as provided in the Policy Grace Period section. 25 Notice of Cancellation The Employer or the Insurance Company may cancel the Policy as of any Premium Due Date by giving 31 days advance written notice. If a premium is not paid when due, the Policy will automatically be canceled as of the Premium Due Date, except as provided in the Policy Grace Period section. Policy Grace Period A Policy Grace Period of 31 days will be granted for the payment of the required premiums under this Policy. This Policy will be in force during the Policy Grace Period. The Employer is liable to the Insurance Company for any unpaid premium for the time this Policy was in force. 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. Grace Period for the Insured If the required premium is not paid on the Premium Due Date,there is a 31 day grace period after each premium due date after the first. If the required premium is not paid during the grace period, insurance will end on the last day for which premiwn was paid. If benefits are paid during the Grace Period for the Insured,the Insurance Company will deduct any overdue premium from the proceeds payable under the Policy. Reinstatement of Insurance Coverage may be reinstated without satisfying the Insurability Requirement, if an Employee's insurance ends because he or she is on an unpaid leave of absence and he or she applies for Reinstatement within 31 days of his return to Active Service. After an Insured's coverage has ceased, 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. The Insured is eligible under the Policy. 3. A written request for reinstatement and a new enrollment form are sent to the Insurance Company. 4. The required premium is paid. 5. The Insurability Requirement, if any, is satisfied. CGUU4]2U 26 SCHEDULE OF RATES The following monthly rates apply to all Classes of Eligible Persons unless otherwise indicated. FOR EMPLOYEE BENEF1FS Voluntary Life Insurance Monthly Rates are based on units of$1,000 Under Age 20 $.06 Age 60 -64 $.73 Age 20 - 24 $.06 Age 65 -69 $1.40 Age 25-29 $.06 Age 70 -74 $2.50 Age 30 -34 $.08 Age 75-79 $3.70 Age 35 - 39 $.09 Age 80 - 84 $6.61 Age 40 -44 $.13 Age 85 - 89 $6.61 Age 45 -49 $.23 Age 90 -94 $6.61 Age 50 - 54 $.35 Age 95 and over $6.61 Age 55 - 59 $.61 A change in rates due to a change in the Employee's age will become effective on January 1 coinciding with or following the Employee's birthday. FOR SPOUSE OR DOMESTIC P.ARINER BENEF1I S Voluntary Life Insurance Monthly Rates are based on units of$1,000. Under Age 20 $.06 Age 60 -64 $.73 Age 20-24 $.06 Age 65 -69 $1.40 Age 25 -29 $.06 Age 70 -74 $2.50 Age 30 -34 $.08 Age 75 - 79 $3.70 Age 35 - 39 $.09 Age 80 - 84 $6.61 Age 40 -44 $.13 Age 85 - 89 $6.61 Age 45 -49 $.23 Age 90- 94 $6.61 Age 50 - 54 $.35 Age 95 and over $6.61 Age 55 - 59 $.61 Spouse rates are based on the spouse's date of birth. A change in rates due to a change in the Spouse's age will become effective on January I coinciding with or following the Spouse's birthday. FOR DEPENDENT'CIIILD BENEFITS Voluntary Life Insurance $.20 Per$1,000 27 I FOR FORMER EMPLOYEE BENEFITS Monthly Rates are based on units of$1,000. i Under Age 20 $.153 Age 60 -64 $2.461 Age 20-24 $.144 Age 65 -69 $4.065 Age 25-29 $.153 Age 70 -74 $6.143 Age 30 -34 $.177 Age 75-79 $9.792 Age 35 -39 $.190 Age 80 -84 $15.523 Age 40 -44 $.243 Age 85 - 89 $24.106 Age 45 -49 $.384 Age 90- 94 $36.119 Age 50- 54 $.726 Age 95 and over $51.278 Age 55 -59 $1.347 A change in rates due to a change in the Former Employee's age will become effective on the Policy Anniversary coinciding with or following the Former Employee's birthday. FOR FORMER SPOUSE OR DOMvs-ric PARTNERS OR SPOUSE OR DOMESTIC PARTNERS OF FORMER EMPLOYEE BENEFITS Monthly Rates are based on units of$1,000. Under Age 20 $.153 Age 60 -64 $2.461 Age 20 -24 $.144 Age 65 -69 $4.065 Age 25-29 $.153 Age 70 -74 $6.143 Age 30-34 $.l77 Age 75 -79 $9.792 Age 35 - 39 $.190 Age 80 -84 $15.523 Age 40 -44 $.243 Age 85 -89 $24.106 Age 45 -49 $.384 Age 90-94 $36.119 Age 50 -54 $.726 Age 95 and over $51.278 Age 55 -59 $1.347 Spouse rates are based on the spouse's date of birth. A change in rates due to a change in the Spouse's age will become effective on the Policy Anniversary coinciding with or following the Spouse's birthday. 28 FOR FORMER DEPENDENT CHILD BENEFITS Rates are based on$25,000 per Month. U rider Age 20 $2.377 Age 45 -49 $9.777 Age 20-24 $2.777 Age 50 -54 $16.377 Age 25 -29 $2.977 Age 55 -59 $23.477 Age 30-34 $3.600 Age 60-64 $38.250 Age 35 -39 $4.177 Age 65 -69 $54.077 Age 40-44 $6.200 Rates are based on$50,000 per Month Under Age 20 $4.750 Age 45 -49 $19.550 Age 20-24 $5.550 Age 50 - 54 $32.750 Age 25 -29 $5.950 Age 55 -59 $46.950 Ago 30-:34 $7.200 Age 00-64 $76.500 Age 35 -39 $8.350 Age Cis -69 $108.1.50 Age 40 -44 $12.400 A change in rates due to a change in the Former Dependent Child's age will become effective on the Policy Anniversary Date coinciding with or following the Former Dependent Child's birthday. 'IL 04719 29 GENERAL PROVISIONS Entire Contract The entire contract will be made up of the Policy,the application of the Employer, a copy of which is attached to the Policy, and the applications, if any, of the Insureds. 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, the Insurance Company will adjust all benefits to the amounts that would have been purchased for the correct age. Policy Changes No change in the Policy will be valid until approved by an executive officer of the Insurance Company. This approval must be endorsed on, or attached to,the Policy. No agent may change the Policy or waive any of its provisions. Workers' Compensation Insurance The Policy is not in lieu of and does not affect any requirements for insurance under any Workers' Compensation Insurance Law. Certificates A certificate of insurance will be delivered to the Employer for delivery to Insureds. Each certificate will list the benefits, conditions and limits of the Policy. It will state to whom benefits will be paid. Assignment of Benefits The Insurance Company will not be affected by the assignment of an Insured's certificate until the original assignment or a certified copy of the assignment is filed with the Insurance Company. The Insurance Company 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. Agency The Employer and Plan Administrator are agents of the Employee for transactions relating to insurance under the Policy. The Insurance Company is not liable for any of their acts or omissions. Ownership of Records All records maintained by the Insurance Company are, and shall remain, the property of the Insurance Company. 11.004"126(WA) 30 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. Accident An Accident is a sudden, unforeseeable event that causes bodily Injury to an Insured while coverage is in force under the Policy. Active Service An Employee will be considered 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. 1. He or she is actively at work. This means the Employee is performing his or her 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 the Employee 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. An Employee is considered in Active Service on a day which is not one of the Employer's scheduled work days only if he or she was in Active Service on the preceding scheduled work day. Annual Compensation An Employee's 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 an Employee applies 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 the Insurance Company written notice of the change and the required premium is paid. Dependent Child A child who meets the following requirements. l. A child from live birth but less than 26 years old; 2. A child who is 26 or more years old, primarily supported by the Employee and incapable of self- sustaining employment by reason of mental or physical incapacity. The term "child" means: a. a stepchild born to the Employee's Spouse and who is living with and financially dependent upon the Employee; b. a child for whom the Employee is the court-appointed legal guardian and who resides with, and is financially dependent upon the Employee. Employee For eligibility purposes,an Employee is an employee of the Employer in one of the "Classes of Eligible Employees." Otherwise, Employee means 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 an agent of the Insured for transactions relating to this insurance. The actions of the Employer shall not be considered the 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 the Employee's eligibility class. 31 Initial Enrollment Period The period in the calendar year when an eligible Employee who was hired on or before the Policy Effective Date may enroll for the first time for Insurance Benefits under this Policy. This period must be agreed upon by the Employer and the Insurance Company. Refer to Initial Open Enrollment under the Enrolling for Insurance section of the Policy. Injury Any accidental loss or bodily harm which results directly and independently of all other causes from an Accident. Insurability Requirement An eligible person will satisfy the Insurability Requirement for an amount of coverage on the day the Insurance Company agrees in writing to accept him or her as insured for that amount. To determine a person's acceptability for coverage,the Insurance Company will require evidence of good health and may require it be provided at the Employee's expense. Insurance Company The Insurance Company underwriting the Policy is named on the Policy cover page. Insured A person who is eligible for insurance under the Policy, for whom insurance is elected, the required premium is paid and coverage is in force under the Policy. Life Status Change A Life Status Change is an event recognized by the Employer's Flexible Benefits Plan as qualifying an Employee to make changes in benefit selections at a time other than an Amoral Enrollment Period. If there is no Employer sponsored Flexible Benefits Plan, or if it is no longer in effect, the following events are Life Status Changes. 1. Marriage 2. Divorce, annulment or legal separation 3. Birth or adoption of a child 4. Death of a spouse 5. Termination of a spouse's employment 6. A change in the benefit plan available to the Employee's spouse 7. A change in the Employee's or his or her spouse's employment status that affects either person's eligibility for benefits 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 an Employee, an Employee's spouse,the immediate family (including parents, children, siblings or spouses of any of the foregoing,whether the relationship derives from blood or marriage), of an Employee or spouse, or a person living in an Employee's 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. 32 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 sponsored by the Employer 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 Any physical or mental illness. Spouse The current lawful Spouse of an Employee. 33 AMENDATORY RIDER DOMESTIC PARTNER/CIVIL UNION PARTNER COVERAGE Policy No. FLX-968146 Effective Date: January 1, 2018 Eligible Classes to which this Rider applies: All Classes 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: I. 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 I 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 iE 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. 34 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 Matthew G. Manders,President T1oa71 111 35 LIFE INSURANCE COMPANY OF NORTH AMERICA 1601 CHESTNUT STREET PHILADELPHIA, PA 19192-2235 I STATE MODIFYING PROVISIONS AMENDMENT RIDER Policyholder: City of Kent Policy No. FLX-968146 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: 1. 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, YOU 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. 36 APPLICABLE TO MARYLAND RESIDENTS: The Group Insurance Policy was issued in ajurisdiction 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 under 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 18 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 18 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 while 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',,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. 37 APPLICABLE TO MISSOURI RESIDENTS: A�al�ble to Voluntary Life Insurance Benefits If an Insured commits suicide, while sane or insane,within I year from the date his or her insurance Linder the Policy becomes effective, Voluntary Life Insurance Benefits will be limited to a refund of the premiums paid on the Insured's behalf. The suicide exclusion applies from the effective date of any additional benefits or increases in Life Insurance Benefits. Except for any ainount of benefits in excess of the Prior Plan's benefits,this exclusion will not apply to any person covered under the Prior Plan for more than one year. If a person was not insured for one year under the Prior Plan, credit will be given for the time he or she was insured. If a Dependent Child commits suicide and is survived by other Dependent Children covered under the same certificate, no refund of premiums wilt be paid. 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 A . /� Matthew G. Manders, President In,aoa000 W 38 LIFE INSURANCE COMPANY OF NORTH AMERICA PHILADELPHIA,PA 19192-2235 We,City of Kent,whose main office address is Kent, WA,hereby approve and accept the terms of Group Policy Number FLX-968146 issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA. We acknowledge that benefits will be provided in accordance with the terms and provisions of the policy,which will be the sole contract under which benefits are paid. This application is tofbe signed. Signatur"cl:� ,,4 - Date ""'V.."'7 ^ - 1 .........,. t& aftj Title: City of Kent TL-004778 �.✓� 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. This page intentionally left blank. �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 -- EC B Received: �1f'�' Routed Through The Law Department s area to be completed by th aw Department) � � � � � , f � �� � �p Approval of Law Dept,: t f( Law De et. Comments: Date Forw2 q': Shaded Areas To Be Comp 1eted, iofstraition Sta f f` Received: and r, f�x' � Recommendations and Comments: os .Disposition) per y p `Date Returned: - ry e, wmm ocmmmn mFuae 9F my^.ww Amm iv.wem